Monday, August 31, 2009

Yes I'd like health care. Affordable health care.

I am finding myself horrified by the national discussion on health care and health insurance.  I am not an expert on health systems, insurance systems, medical treatment, and similar elements that make up a health care system, nor are most Americans.  This is complicated stuff.   But I am an average, middle-aged guy with an elderly parents and in-laws,  young adult children beginning to raise their own families,  and a wife who like me faces her own changing health.  I am pretty average in that I have worked all my life at jobs since I was sixteen and I've seen my ability to maintain health care coverage steadily decline.  This past year,  I've been paying $200 a month toward a much larger health care premium.    I am lucky because I have had good health so far,  and my annual checkup and tests and occasional other small maladies have been routine.   I am lucky because,  even having to make that payment each month,  I have the assurance that I have some protection in the face of a more serious health situation.   This does not seem much to expect here in the Twenty First century in the richest nation on Earth.   But hundreds of millions of other Americans don't have this protection or service.   In fact,  I probably know more people who have no health protection than those who do.   And that number has steadily increased in the past half dozen years.   Why?  Because the "insurance" cost has increased so rapidly.   
Seems to me that having protesters in the streets bearing signs that say "No Health Reform" is astonishing in such circumstances.    In large part,  I believe that those protesters do not have a clear or honest picture of what is being discussed.   The loud chatter about "sideshow" issues like the so-called 'death panels' has made a sensible discussion really difficult.   
Are there really people out there who don't want to have affordable health care for themselves?  I doubt it.  
As I think about what I know,   several things surface.  One big piece is that we really are talking about two separate questions.   One is the question about the health care delivery system itself---how it works now and how it could be improved.   The other is the question about how the  funding of health care is done which includes the component of "insurance" to cover the risk that we may face a "big" illness and the component of "service" which addresses the cost of buying services such as a doctor visit, a prescription, a lab test,  and so on.   These things often get tangled in together in people's minds and that makes it harder to have a sensible conversation.
Looking at the piece of the puzzle that falls into the "insurance" category,  we can be pretty certain that two broad factors drive what happens.   Insurance companies rate risks using actuarial statistics,  'the likelihood that a given person will get sick or need certain kinds of care'.   Those numbers are pretty hard to argue with although the particular blend they are folded into may be 'tweaked'.   But in the big picture if a company examines the risk for an insured population that reflects the makeup of the whole American public it would be higher than the risk for an insured population that is limited to younger people with healthier habits etc.   The other big factor in the insurance equation is that health insurers like other American corporations are going to add a percentage of profit to return to their shareholders into the costs they are charging us, the insured.   
In a system where the marketplace drives decisionmaking,  insurers are likely to choose to limit who they will insure to the least risky,  or to offer insurance to most risky at a vastly higher price.   I don't think that this is what happens now because there are some public (government) constraints on the market and because there are also some non-profit competitors in the marketplace.   However,   the reality is that many people with higher risks don't have health care coverage because of that actuarial equation.   And ultimately,  this is a form  of corporate, not government, rationing of health care.   If you have money,  you are more likely to have care.  If you don't you may die from lack of care,  even though your malady may be treatable.
If part of the government's purpose is to protect our rights to "life, liberty, and the pursuit of happiness" I'd argue that some guarantee of access to health care is necessarily included.  That does not mean that the government is responsible to provide all services to all people--but access to some level of health basics like vaccinations, examinations,  and similar services seems reasonable.   We have the government providing that now to elderly people through Medicare.   While Medicare can be criticized,  as can any program,  the majority of people eligible for it take advantage of  it.  And few of us are distraught about whether it's appropriate or not.   Why should the calculation be different for five year olds or fifty years olds?   I miss the logic.

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