The Open Mind II: Riposte

by A. Jay Adler on October 21, 2009
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Ensuring Healthcare or Insuring against the Loss of Health?

I’m not a pundit, but I play one on my blog, and, it must be said, for a good deal less money than the television variety, though I could pretend to the same priceless knowledge in all fields. Let me teach Peter Orszag a thing or two about healthcare financing. Allow me to analyze the flaws in the numbers of the Congressional Budget Office. Watch me put the spank on David Gratzer.

I think not.

There an army of people (two, in fact) more qualified than I to analyze a national economy’s money flow, and that of several nationwide industries’, in order to argue for this adjustment in the tax code or that in eligibility, producing x amount of cost benefit or y amount of health system apocalypse. Some of them do it for an interested party, some for government and think tanks, some from arm chairs. Some of the cushion dwellers may actually know a thing or two. I wouldn’t bet against it. I’ve got a cushion of my own. Pick your favorites and believe them, because that is all that most people can do. It’s a representative democracy for a host of reasons, and that’s one of them.

A policy vision will appeal and make sense to you or not. Elements of plans will seem reasonable or ridiculous. Take the idea of taxing “Cadillac” plans at the insurer level, to encourage employer-consumers to price shop for more cost-effective plans. Do not trust your tax preparation to proponents of this idea. Through my employer, I happen to be a beneficiary of just such a luxury vehicle. Or I was. My employer and my union, with the voted endorsement of the membership, have very recently agreed to end our self-sustaining plan in order to participate in a plan representing a far larger pool of educators. The writing – and, if nothing else, educators can read – was on the wall. The costs were unsustainable. The change will produce substantial annual savings to be utilized elsewhere. Our benefits, though not insignificantly diminished, are still far better than most. Now we are in a Buick Regal. One doesn’t need to be Paul Krugman to see that the tax on the insurers would produce higher premiums and/or reduced benefits to the insured – and on what planetary basis do proponents of this tax believe that businesses are not already seeking to lower their burdensome health insurance costs, by price and benefit shopping, as did my employer, as well as my union?

However, I prefer to play a different role. I like to examine how we argue about matters. I like to look at fundamental assumptions. After all, the self-acknowledged non-experts need a basis upon which to place their trust, with the understanding that almost no one deserves it, but somebody has got to get it.

To begin, what’s this about “Obamacare”? As a student once said to me a long time ago, “Why you gotta take it there? Why’s it gotta be all that?” With all due consideration to mi amigo en el discussion, this strikes as a bit of reflexive, partisan demonization. Many elements in society have been seeking healthcare reform for a very long time. The failed effort at it was a centerpiece of the Clinton administration. Many names – that of Kennedy, for instance – are far more associated with the history and the policy initiatives of healthcare reform. Perhaps the greatest criticism leveled against Obama from those on his own end of the political spectrum has been his disinclination clearly to commit himself to a fixed set of policy reforms. So why Obamacare?

One doesn’t need to have been glued to any variety of LCD over the past near ten months to have observed the intent of various forces on the right to embody in Obama a full range of conscious, unconscious, and hysterical fears. Some of this effort has been politics as usual, some, perniciously, has not, and not all of the efforts are related to each other. But personalizing the current, multiple plans produced by the two houses of congress via the usual sausage assembly of conflicting and even undermining political interests as Obamacare does nothing to further or enlighten debate, and serves only to prejudice the mind and disable objective consideration. Favor the longstanding liberal drive for reform or not, it is not embodied in Barak Obama, it does not emanate from him, it is not expressive of his special influence, however one perceives it. It is the expressed desire of many tens of millions of Americans. Obama is not the fearsome leader of this movement. He is a follower chosen to play a temporary leadership role. But Obamacare does manage to conjure for a primed audience a dark and frightening agenda.

One of the too rarely considered distinctions in the current debate – how words do matter – is that between health insurance reform and healthcare reform. Now let’s be clear that whatever bill passes – and it seems nearly certain that something will pass – it is likely to truly please no one. It won’t be any of the models that genuine proponents of reform really want, and it will contain a variety of components that those who have always actually opposed reform, and who sought to water it down and to protect the interests of the insurance industry, will complain are, in fact, in toto, destructive to the system. That said, SW cites John F. Opie correctly remarking that risk and coverage are the two fundamentals of insurer’s business model. “Tamper with either of these,” says Opie, “and you destroy the business model of insurers.”

Oh, dear. Wouldn’t want to do that.

One needn’t be a socialist, and can even believe mightily in the creative and innovative engine of private enterprise, and still pause to consider the essential nature of the enterprise to insure. Insurance is gambling dressed in civil finery. Actuarial tables are card counting. Unlike gambling, insuring can perform a useful social function (if one wants to discount the social usefulness, in personal pleasure, of non-addictive gambling), but there is no reason to accept without consideration the notion that because a thing can be insured, it should be insured (anymore than the notion that it is a social good that because something can be securitized – like a pool of subprime mortgages – it should be securitized, and then, further, that security insured against loss). I’ll bet a buck against your house your spouse croaks by the end of the hour. Oh, no, I meant I’ll insure him. I’ll offer you the value of a house, say two hundred thou, if he does, and you make a premium payment of a buck an hour.

SW writes, “Our insurance system hides the true cost of insurance and has engendered the belief that medical care is, or should be, essentially free.  A variant is the shibboleth that ‘healthcare is a right not a privilege.’” I agree. The insurance system also hides, though its longevity and ubiquity, the question for many people of whether it is intrinsic to the concept and practice of healthcare that people be insured for it at all. In small, sparsely and dispersedly populated, technologically less advanced, or poor societies, or in combinations thereof, people’s medical fates are perforce an individual risk. Those economically raised above the norm can attempt to manage that risk more successfully than do others, health insurance being one form of risk management. Overcome all of those obstacles to group interest and cooperation, as has the United States and most other wealthy nations, and one has the opportunity to substitute for the short, nasty, and brutish reality of the only empirically demonstrable right – to meet one’s end – the, not entitlement, but enlightenment of a joint effort to protect life as long as possible against natural or accidental close. It is fundamental to the notion of the nation-state that it is organized for the mutual protection of its members against aggressive threat to life, both external, through a military, and internal, through policing agencies. It is commonly agreed that these functions are properly authorized, if not fully a function of, some level of government.

There is no reason why a society should not consider the appropriateness of conceiving healthcare – protection against those natural and accidental threats to life – in a similar manner. Having achieved a sufficient level of affluence, and overcome those natural obstacles to joint effort, a society can contemplate the cost of such an endeavor and the required distribution of resources to various essential sectors – research, equipment manufacture, pharmaceutical, delivery, and so on. But it is in the very conception itself that it exclude no one, and one is hard pressed, having conceived healthcare outside the constrictions of prevailing practice and assumption, to discover any essential or even useful role for insurance. Insurance company marketing costs and profits develop no component of care and add no value to it. Once the decision is made that the mutual benefit of healthcare will be assumed as a joint effort, developed through policy in any number of possible formulations, those who can crunch the numbers to determine the available and future dollars available need not consider their flow through insurance companies or the useless percentage remaining with them.

That’s a conception. Reality will not remotely match it, no to start, maybe not ever – not because the concept is inherently unrealizable, but because of the forces arrayed against it. That is in the nature of the political process. Our founders thought the checks and balances of not only government branches, but of contending forces was productive of stability. Maybe so. Demonstrably not always productive of coherent policy. Among the strengths of a well-run business is the capacity, in management structure, to see a business plan, wholly envisioned, through to its coherent realization. Democracy, imperfectly and democratically, offers little such opportunity. The political reality is that opponents of healthcare reform would never allow such a coherent vision to be enacted unmolested. Proponents must pass what they can achieve, and build on it. Waiting fifteen years again for another bite at the healthful apple is not an acceptable option. Historical studies have shown that almost all nation’s adopting some form of universal health system have done so not by any sweeping reconception and institution of a new system from the ground up, but by adapting change to existing structures. That seems bound to be the course in the United States.

Shrink says, “There are reasons people from around the world come to America for care that they cannot receive at home.” Indeed, we have the some of the best, and most expensive, healthcare in the world. If one can afford it, one may come for it. The advantages of affluence have never been in question. But no one comes to the United States for the healthcare system. If SW does not think the healthcare system is discriminatory, it is, it seems clear from his argument, because he doesn’t think variance in access is discriminatory. Most Americans disagree. Everyone knows, too, that the emergency room for non-emergency care is neither cost-effective nor productive of long term health.

The variance in access is not just demonstrable in the nature of the care sought and delivered, but in the care that isn’t. When I worked in support of universal healthcare in Minnesota in the early nineteen nineties, I heard countless stories from parents who purchased no insurance in order to pay the rent, and sometimes none for their children either, for which they felt great guilt. No care there but for emergency rooms, and sometimes – who knows to what detrimental end – not. Regular readers of the sad red earth know that several weeks ago I suffered a severe blow to the head in a biking accident very far from home (accounting, no doubt, for an array of recent dsfunctions.) Because of my excellent health insurance, I didn’t hesitate to go to an emergency room, where I was given a CT scan. All, thankfully, was well, though my skull hurt for over a week, and that was with a helmet. I received just two days ago a copy of the bill to my insurance company for the ER visit – over $4400. Under other circumstances, unemployed or low paid and uninsured, I don’t go to the ER. I can’t afford it. I take my chances because I think I must, and I suffer the hematoma and die.

One doesn’t get the protection of the military or the police based upon an ability to pay. One’s life is protected as part of the social contract, without exclusions. So it can be through a different conception of healthcare. Supply and demand are fundamental to markets. But markets are neither the sum of human life nor the structure of reality. They’re not Kant’s noumenon.

SW says “Obamacare treats the healthcare pie as a zero sum system.” Well, we know it is five different congressional plans to which Shrink refers, not Obama anything. But then he writes,


1) Affordable

2) High Quality

3) Universal

Pick two of the three…

That formulation is the whole zero sum pie right there.


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