Tuesday, March 14, 2017

Health Care: how did we get here? Where are we going?

If you're wondering who socialized medicine in the United States, it wasn't Barack Obama. It was Ronald Reagan.

In 1986 Reagan signed the Emergency Medical Treatment and Active Labor Act, which prohibited hospitals from refusing to admit or dumping uninsured patients who arrived in emergency rooms.

This was a good, humane idea. Some hospitals were literally putting people with heart attacks and stab wounds out by the curb to die.

But it also created a spiral in which an increasing number of the uninsured showed up at emergency rooms for treatment either for minor issues that weren't really emergencies, or for major emergencies that would have been much less costly to treat had they been treated earlier.

Literally leaving people to die at the curb is unpleasant, but it is a good deal cheaper than actually treating them.  And aside from the extra costs of emergency room services, the amounts charged to uninsured patients for treatments is often much larger than the amount charged to insured patients for the exact same treatment. This is because insured patients are covered by contracts with prices negotiated by their insurers. Not surprisingly, bill collections against these uninsured folks for these inflated debts generally resulted in poverty, bankruptcies, and very little actual money collected -- per the well established economic dictum, "You can't squeeze blood from a stone."

It's also worth noting here that "poor" in the health insurance debate doesn't necessarily mean "destitute, homeless, on welfare, etc." Most of the poor in this context were the working poor: people working full- or near-full-time jobs that didn't provide affordable health insurance. The truly destitute often were at least partially covered by Medicaid. The working poor were often left out in the cold.

Still, somebody had to pay the bills. One of the reasons the cost of insurance for the insured rose much faster than inflation was because our health care system had to absorb these additional overhead costs.

There were many other contributors to the rapid rise in health insurance costs before the Affordable Care Act (ACA) was adopted in 2010: increasing use of technology, pharmaceutical costs, malpractice lawsuit costs (themselves made worse by the spiraling cost of health care itself), forcing the sick out of the insured pool due to preexisting conditions, etc. But the basic math of covering the poorest people in America in the most expensive way possible is immutable. Eventually, more people become uninsured and the people with insurance have to pay more to cover their costs.

Ultimately, you face three options:

1) Remove emergency-room care. Leave the working poor, the elderly and the truly destitute to die in the streets.

2) Cover those people with some sort of jury-rigged private market and government healthcare approach that balances things like requirements that individuals carry health insurance, financial support for policies that cover the poor, and requirements that insurance companies accept all comers.

3) Expand government insurance like Medicaid and Medicare to cover all of the uninsured. Or perhaps even expand it further to become basic insurance for all Americans.

Ronald Reagan and the US Congress rejected option #1 in 1986 for good reasons. If I need to explain them to you, you probably need to take a deep look inside your dark soul.

It's worth noting that Republicans do have a lot of good reasons to seek a better health care system. Spiraling health care costs are a genuine drag on businesses because of our employer-based insurance system. Those uncontrolled costs also contribute greatly to increased government costs. A better health care system that delivered better (or at least similar) results for less money would be of great benefit to a party that is in favor of business owners and reduced government spending.

Option #2 emerged as the conservative Republican alternative for the emerging health care crisis because #3 -- directly expanding the government safety net -- was at complete odds with a conservative political philosophy. So, creating an alternative based on the private market was kicked around for years.

Then, much to everybody's surprise, Mitt Romney managed to implement exactly that in Massachusetts in 2006 while he was governor. And it sorta worked. It at least made a bad situation better.

After Obama was elected in 2008 he decided to take that Republican approach and expand it to the federal level. This worked in one way, the Affordable Care Act (aka Obamacare) was passed in 2010 and it has succeeded in greatly expanding coverage and slowing the rate of growth of health-care costs. It didn't do these things as completely or quickly as something like a full expansion of Medicaid and Medicare would have. It was also less completely disruptive to the existing health-care model, and that had genuine benefit for a country still suffering from the Great Recession.

There was, however, an unexpected side-effect. The Republican Party's leadership decided that they would benefit from outright opposition to Obama on all things. The debate over the ACA became the prime battlefield for that proposition. To Obama's credit he managed to secure enough Democratic support for a proposal that originally came from Republicans to overcome the unified opposition of the GOP. The Republicans, however, were right that their opposition would energize their base. That led to their Tea-Party fueled victories in the 2010 elections and the subsequent gerrymanders that established political dominance for them in state legislatures and the US House ever since.

Thus was the frame of the debate for the last six years or seven years set, with Democrats uncomfortably but unanimously supporting what most of them thought was a flawed half-measure and Republicans unanimously blasting the ACA's very existence and claiming they could do better without ever producing a genuine proposal. To compound the problem, many Republican controlled states refused to implement the expanded Medicaid coverage, leaving many Americans needlessly uncovered. In the meantime, some genuine improvements to the ACA that could have been made were ground to dust beneath the tracks of the Washington, DC, gridlock of 2011-2016.

So, why did the GOP never produce a genuine health-care proposal of their own in all that time?

Most likely because the Democrats had already passed their proposal. Obamacare was never anything more than federalized Romneycare. If you thought Mitt Romney looked uncomfortable in 2012 trying to explain how he completely opposed a health care structure that he fathered, that's why.

Which brings us to 2017 with the GOP finally in charge of Congress and the White House. What has Paul Ryan and the GOP produced? A bill that makes the situation that existed in 2009 worse, and that now has the Congressional Budget Office (CBO) analysis to prove it. In exchange for throwing tens of millions of people off health care and greatly increasing insurance costs for most other Americans, it offers up massive tax cuts for millionaires and billionaires. As just one note among many items in the report, the CBO does find $3 billion potential deficit reduction for Social Security costs because they estimate that between 17,000 and 29,000 Americans will die needless premature deaths because they will not have access to health care.

I would say this means the GOP's long con on health care policy is finally exposed and this bill is dead, but with Ryan, McConnell, and Trump all on board I wouldn't be in the least surprised if they still try to ram some form of it through. More likely, though, it sputters out somewhere between the House and the Senate, after which the Republican Party continues to loudly blame Democrats for all things related to health care.

We shall see. Darned if I can accurately predict anything politically these days.

What might I like to see for health care in the US? Well, it seems to me that the most useful approach would probably be incremental: maybe an expansion of Medicaid as a bottom-level medical benefit for everybody, dropping the Medicare eligibility age to 60 or 55 to bring healthier folks into that pool, while also providing a higher-level of health care coverage for those who can afford supplemental insurance. It probably doesn't move all the way to a true single-payer system as is seen in other industrialized nations. But somewhere in there might be a recipe for building on what we already have -- keeping some genuine market mechanisms for improving efficiency and quality while not kicking tens of millions of Americans to the side to be bankrupted before dying in the streets.

Of course, that sort of thing would take some level of genuine fact-based policy work and bipartisan cooperation to implement. Those are qualities sadly lacking in Washington, DC, at the moment.

But even that may change one day. And the problem will still be with us for a long time to come.


  1. I commend you for a terrific summary of an almost impossible subject--the sort of thing one should be served certainly by our national print media. Some things simply cannot be reported by talking heads. Even those who understand haven't got a chance to speak long enough to get the fundamentals stated in proper sequence. Terrific.


  2. While I completely agree with A's comment, I have a mionor quibble about your use of the word "conservative" in your Option 2 This is used commonly by Media and most Republicans, though much that is being referred to is not real Conservatism,. Most often, as in the case of the new AHC, it is something more of a kind of Libertarianism, or Aynrandianism, actually. Obamacare was certainly not Socialism, but its replacement is also certainly not conservatism in any real sense. We have accepted the appellation of Conservativism to much that describes GOP actions, but that is actually not the case, and certainly not in this instance. I hope you would understand my point on this, John. I am a stickler when it comes to the meaning in the use of language.