President Bush vetoed a bipartisan bill expanding healthcare coverage to 10 million children. The president believes denying healthcare to children today is preferable to the possibility of government-run healthcare for everyone tomorrow. His stance betrays two flawed economic assumptions: 1.) that government and corporate bureaucrats are not already heavily involved in running the healthcare system; and 2.) that shifting the government involvement from protecting corporate profits to guaranteeing universal access would lead to economic and medical disaster.
American healthcare is delivered via an uncoordinated patchwork quilt of public and for profit systems. Medicaid covers the very poor. Medicare covers the old and disabled. Managed care companies choose from among the employed healthy who are wealthy enough to pay premiums but not sick enough to require much treatment. The children Mr. Bush feels we cannot afford to insure are among the 47 million Americans who fall into the enormous gaps between government and for-profit systems. CEO William McGuire was paid $124.8 million because his company, United Health Group, could cherry pick from mostly healthy employed Americans. Since healthcare insurance is ultimately a zero sum game, in a very real sense, those $124.8 million represented thousands of denied pap smears, mammograms, cancer treatments, vaccinations, or denied new or renewing patients. Shockingly highly paid CEOs represent an enormous government-created transfer of wealth.
It is no coincidence that drug company lobbyists on Capitol Hill outnumber lawmakers. Big pharma knows the source of its extraordinary profit margins is no invisible hand. Americans pay a third more for the same medications as do Canadians or Europeans even though many of those medications were created with taxpayer-funded research and development because our government guarantees and enforces drug company monopolies for several years after a drug is launched. The premium we pay represents a de facto government subsidy to drug companies, enforced with taxpayer-funded courts and policing agencies and possible because of the absence of a Walmart-like agency with the economic muscle to negotiate lower prices for all of us. (Indeed, the bill creating Medicare drug benefits expressly forbade the government from negotiating lower prices at all!) Intellectual property rights should be protected. But as the President misleads us with talk of "government-run healthcare," let's not forget that we've already got it. I believe the government should protect patients as zealously as it protects patents.
Since the government is heavily involved every stage of health-care delivery in this country, let's stop the posturing and figure out how to make it work for us rather than against us. Those who believe free markets do no wrong and governments nothing right should pack their bags for
The brewing battle over healthcare is really not between advocates of free markets versus supporters of government intervention. Instead the fight is about what the role of an already heavily involved government should be. Currently most of the activity of the government is directed toward enhancing the profitability of the managed care and drug companies. Is it so outrageous to demand that our government shift its focus to protecting the taxpayers who support it while advancing universal access to healthcare, at least among our children?
Currently, those without insurance have no advocate. There is simply no agency, private or public, who takes ownership of this growing problem. To continue to insist that the status quo should work in theory despite mounting persistent evidence that it does not work in practice verges on psychotic. If the current mix of public and for profit insurers could deliver healthcare efficiently and rationally, they would have long ago. 47 million Americans, 90% of them working, 50% of them children, would not lack health insurance. Infant mortality, vaccination rates, and life expectancy at birth would not be markedly worse than those of countries with universal health coverage. There would not be the scandalously higher mortality rate among those without insurance. We would not pay so much more - 16.5% of GDP in 2006 - on healthcare but get so much less.
Let's not forget that access to healthcare, unlike access to a luxury car or a larger home, is ultimately a matter of life and death. We can forgo luxury expenditures; we should never forgo healthcare for our children.
President Bush fears something sinister about a government spending as much on children's health as it spends in 9 weeks in
The apocalypse of American healthcare is now, not in the form of a government bureaucrat deciding healthcare but a profit-driven managed care bureaucrat denying it. The exact details of any solution are less important than our commitment to get it done. It is hard to envision any proposal that would not heavily involve the federal government, at least as a referee. Get over it.
My modest proposal: expand Medicare to cover all American citizens. As a private practice psychiatrist who accepts all major private plans as well as Medicare and Medicaid, I generally elicit surprise when I tell people that Medicare is one of the best plans to work with. They were among the first to go electronic, and they pay promptly and well. You would never know it from Bush's misinformation, but Medicare is far more efficient than any private system. The Medicare administrative costs of about 2% are comparable to the administrative burdens of most national health systems. This is in contrast to private plans' administrative costs of 15%-25%, including compensation of top executives, lobbying, marketing and advertising. The fact that Medicare can deliver healthcare to the old and disabled at a fraction of the cost of private plans means that if the risk pool were expanded to the young and the healthy, the economy of scale savings would be enormous, driving down administrative costs even more.
If universal coverage is too much to swallow, why not at least expand it to cover our children? If those under 18 and over 65 were guaranteed healthcare, we could always work on those in the middle later. Families relieved of the burden of finding and maintaining continuous private insurance for their children would experience huge premium savings on their family policies. Those who develop chronic and persistent illnesses before age 18 could seamlessly shift into a Medicare disability policy as adults. Such a change could end overnight our failed for profit managed care experiment.
Bush misrepresents Medicare and other public programs such as the S-CHIP program he vetoed, confusing government-refereed with government-run. The Veterans Administration is a government-run, centrally planned bureaucracy. Medicare and Medicaid, on the other hand, simply pay a benefit, or supplement a private policy; the benefit can be taken to any participating provider. Such a system offers far more choice than a for profit plan which restrict choice to contracted providers (some pay for out-of-network services, but usually at a steeply discounted rate). The President is simply wrong when he says that Medicare restricts freedom; to the contrary, it allows optimum matching of client to provider and introduces market forces and competition to regions currently carved up by HMOs and managed care companies.
When Bush, a heavy recipient of pharmacy and health insurance campaign donations, speaks of the threat of squeezing out private insurers I wonder if he would have opposed the development of the light bulb because of its impact on the candle industry, or fought the polio vaccine because of its economic threat to iron lung manufacturers. A healthcare system exists not to protect one favored group of workers but to serve patients. Determining the optimum mix of private or public systems should be driven by what works, not who works.
No doubt, we could help many of the for-profit bureaucrats and claims processors get jobs in an expanded Medicare program. Some might even become healthcare providers in the countless clinics that would spring up as millions of previously uninsured or under-insured Americans took their new benefit to the physician of their choice. Consumers and providers will vote with their feet, responding to market incentives and differences in quality of care. Providers will have a strong incentive to provide excellent care and customer service since their patients will no longer be constrained by insurance to see only a limited number of physicians. Hospitals and clinics could downsize their billing departments, reducing overhead and ultimately fees. Emergency rooms, currently the only place where the uninsured cannot be denied care, could focus on those truly in crisis.
Corporations should embrace universal healthcare. Aggregate profits should soar as the liability for current and future healthcare is shifted from individual corporations and shared fairly by all of society. As earnings rise, so too should stock prices, fueling a tremendous bull market. General Motors could focus on making cars instead of providing healthcare, and would no longer be at such a competitive international disadvantage. Many lawsuits motivated by the uninsured desperate to get someone to pay their medical bills would disappear, reducing litigation and insurance costs. Millions of Americans stuck in dead-end jobs could leave if insurance were de-linked from employment. They could start businesses or return to school. Our entire society would benefit from the new outburst of labor mobility as millions of Americans moved into optimally-matched positions. Millions of Americans dependent upon Medicaid or Medicare disability could re-enter the workforce confident they would not lose their healthcare as a punishment for appearing too functional.
If we can afford to spend a trillion on the invasion and occupation of
Since universal health-care coverage is a tough sell in, let's at least agree to cover our most vulnerable citizens. No child should ever go without health insurance, at least not in a wealthy country such as ours. President Bush believes we cannot afford to insure poor children; I believe we cannot afford not to. Indeed, how we treat the least among us is the ultimate measure of the strength of our country. As the bumper sticker says, freedom isn't free, but either is healthcare. Let's stop the ideological posturing and misinformation campaigns and get to work.
