Jay Lake (jaylake) wrote,
Jay Lake
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[politics] Interim report on the healthcare thread

The healthcare feedback has been very interesting, both in the public comments and the moderated thread. There's a bunch of points I could cherrypick to take note of, and I'll cite a couple, but perspectives on healthcare from this reading audience seem to boil down to a few basic things. I'm going to lay them out here without much editorializing. (That will probably occur, just in a different post.)

Points which made me think about things I hadn't carefully considered:

  • Health insurance as it's generally understood in the US today is actually a combination of pooled buying (for routine, non-emergency/non-catastrophic expenses) and risk-based insurance (for emergency/catastrophic expenses). Contrast health insurance, which usually pays for annual physicals, with automobile insurance, which doesn't pay for oil changes or new tires. The significance of this observation to me is not about the value of preventative medicine (this was already clear), but rather that the term "insurance" is itself something of a misnomer.


  • Rationing of healthcare takes place now through the economic mechanisms that select who has access to health insurance. This rationing is a result of passive, rather than active, social policy, in that it is a known and well-understood consequence of decisions in labor law and the job market which themselves are not directly aimed at managing access to healthcare via the funding mechanism of health insurance.


Points which I think are worth considering regardless of where you stand on public vs. private funding of healthcare:

  • The issue isn't access to health insurance. The issue is access to healthcare delivery. In our general political discourse, this has been framed almost entirely as a health insurance problem, but that itself is a social assumption.


  • Our largest public provider of health insurance, Medicare, has admin costs which run about 1/4 the load of market-based insurance. A lot of people of all political stripes are very suspicious of government involvement in health care finance, but Medicare, like the private non-profits, doesn't have the fiduciary responsibilities of return-on-capital which private for-profits do, nor the structural incentive to ration healthcare.


  • End of life care is very, very expensive, with poor outcomes. This skews healthcare spending badly. We view death as a medical failure in virtually all circumstances, when in fact it is a natural, perhaps the most natural, part of life. (I can say that as a matter of philosophical conviction, but if my loved one were in the ICU, I don't imagine for a moment that I'd be the least bit interested in a "common good" argument that they shouldn't have every conceivable medical effort expended on their behalf — it's a profound paradox.)


  • Spending on Medicare/Medicaid (ie, public financing of healthcare delivery) exceeds $500 billion per year now. Spending on uninsured patients, including lost compensation to doctors and hospitals, is less than $50 billion per year now.


Dividing lines in people's viewpoints:

  • A number of people seem to be unaware of the difference between "single payer" and "single provider" systems. The term "socialized medicine", which is a highly perjorative label in American discourse, lumps the two together in the minds of many folks. Canada has a single payer system, the UK has a single provider system, and they are very different from each other. If more Americans understood this distinction, the foundational issues surrounding our national argument about healthcare finance and delivery would be much clearer.


  • People seem very afraid of the kind of healthcare rationing which so-called "socialized medicine" will bring. Yet the decline in classic indemnity insurance in favor of HMOs, PPOs and similar managed care plans has introduced healthcare rationing through market forces. If you have a good plan (ie, well funded, high premiums), you have ready access to medical services. If you have a basic plan, you have gatekeeper physicans and long waits.


  • The most basic question seems to be whether you view healthcare as a right or a privilege. From a classically conservative viewpoint, it's not enumerated in the Constitution as a right. From a free-market viewpoint, healthcare is commodity to be purchased and consumed like any other commodity. From a progressive viewpoint, healthcare is a basic human need on a par with food and shelter.


A few data points on my perspective

  • I'm one of those people tied to traditional employment by the need for insurance as a statutory benefit. Private market insurance for my family is very difficult for me to get and very expensive and prone to sudden cancellation due to pre-existing conditions. (I paid $1,400 a month back in 2002, the last time I had to buy it that way.) I'm completely trapped in the current system, and highly vulnerable to any serious disruptions of it. Luckily I'm trapped at a high enough level in the workforce that I can live a comfortable life and make a wide array of personal choices, but, for example, I will probably never be a full time writer, even if my books come to do phenomenally well.


  • During the course of this year, I went on, then back off, a high deductible insurance plan. High deductible plans are meant to separate routine costs from catastrophic costs, with the consumer being presumed to become more responsible in their medical choices. I lost this bet badly. Right after I irrevocably committed to the plan (due to workplace enrollment windows), Mother of the Child had a suspected heart attack. Though the initial ER admission and hospital stay were covered by my old PPO, by March of this year, I'd burned through my entire, very substantial deductible in her follow-up costs. I was out $4,000. Then my employer was bought out by another company and all our plans were reset. the_child had an ER visit four days after I switched to a PPO. My out of pocket costs for that are substantial — I will be out another $2,000 at least if the current denials from the PPO are not overturned on my appeal. (Because she was treated and released without significant diagnosis, they are viewing the ambulance transport as a frivolous expense — this for a child with a head injury who was nonverbal and unresponsive at the time of transport.) So as someone with good insurance, I'm probably going to be out of pocket $6,000 this year. That's been pretty damned stressful as it is. If I were earning an average US income, let alone something near minimum wage, that would have created profound financial distress. I was not irresponsible in my medical choices. Neither of those expenses (MotC's heart problems or the_child's bicycling accident) were a result of poor medical decision making or poor lifestyle choices on my part or theirs, I keep myself and my family well covered under the current system, and I'm still taking that big a hit.


  • As virtually anyone who reads this blog knows, I am a strong liberal-progressive. I have a very broad view of what constitutes human rights, especially in a society as affluent as ours. As a nation, it seems obvious to me that we can readily afford decent healthcare for everyone. As a society, it seems obvious to me that we lack the political and social will to deliver that decent healthcare for everyone.


There's lots more good stuff back in the comment thread here if you find this interesting.
Tags: healthcare, personal, politics
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