I keep saying this, but it’s worth repeating: nobody wants healthcare insurance. I keep reading semi-confused articles about it. With the Democratic ACA and the subsequent Republican sabotage, we get lost in partisan positions, but the goal isn’t — or at least, shouldn’t be — to get everyone a shiny new insurance policy.
People want medical care. They want to be assured they’ll get help when they get hurt, or sick, or just plain old. Same for people’s spouses, parents, children, partners, friends… and, well, honestly, even complete strangers. Americans are generally sane and generous when they see people who need help.
OK, most people are generous. For my own personal mental health, I’m going to pretend there are only a few ideologues like Rand Paul who’d be OK stepping around poor people dying on the street.
Medical insurance is the misnamed method we’ve come up with to provide the majority of American healthcare. Most people get insurance from their employers, some are covered under their spouses, and some buy it on their own, but the majority support medical costs that way. There are also large, single-payer systems in Medicare and VA, fifty different state-based single-payer systems we call Medicaid, and plain charity for those left unprotected. (We don’t turn desperate people away from emergency rooms, for example. Yet.) If I missed something, leave me a comment.
Here’s a critical part: in every single case, someone pays for our medical care. That’s true every single time, front to back. That may seem counter-intuitive, but it has to be true when you’re looking at the overall picture.
Look at all medical costs across the population. How are they paid? Some money comes out-of-pocket directly, some from insurance companies (from premiums billed over a population), part comes from government agencies (from taxes taken from a population), part from charity (paid voluntarily from a population), and part from doctors and hospitals who have to write off some or all of a bill (paid by a mix of lost wages for them and higher charges across their remaining patients). Every cent gets accounted for somehow, every time. (That’s how the big picture works. If there are holes, that just means you’ve missed a spot.)
So we’re not arguing about whether we have to pay for all the American healthcare. Someone has to pay every part of every bill. I know politicians love blurring that part, but it’s a closed box; every service we perform is paid from somewhere. I know the details can be unclear, so the real questions are who pays within our country, and whether we’re doing it well. (Lord knows we’ve found lots of really inefficient ways to deliver care.)
Big health problems are bad. Most major illnesses can push an impossible debt onto a family, while making it much harder to keep working. Imagine coughing up tens to hundreds of thousands of dollars. Now try to keep your full-time job when your kid/spouse/parent needs constant, extensive, exhausting support. Even split between a couple or an extended family, it’s a crushing amount of work.
My family wasn’t terribly unusual. My father worked for himself: no sick leave, and no insurance. It was simple: if he couldn’t work, we didn’t earn money. Even something like a broken leg would have probably cost us our home. We were hardly alone that way. For decades, getting hit with a big medical problem was the primary way people became destitute, losing their homes, jobs, and lives of comfort and contentment.
Outside of major medical surprises, everyone gets old, eventually. Sorry to remind you. I know that not everyone needs extensive nursing care at the end, so feel free to pretend it won’t be you. Still, a sizeable percentage will, and I’m still talking about the population.
Here’s an interesting part. For some reason, we make sure than anyone who needs extensive support will have all their accumulated wealth stripped away. Have you priced out nursing care recently? It’s essential help, and the people working there are doing wonderful work.
But good care can cost $20K. A month. If you can only pay $7-12K a month, it’s still OK, if you search around. Below that, though, your care slips into ‘crappy’ pretty easily. And it’s a ‘cash up front’ kind of business. They know most families will run out of money sooner, not later, leaving your spouse/kids/dependents stripped bare. (I originally ended with, “…And tossed into the poor house,” but there’s none of that mollycoddling today!)
So, somehow, they let large institutions suck down a big part of the wealth that middle-class families worked their whole lives to accumulate. Money they’d hoped would go to their kids, mostly. If it was me, I’d be torqued about that, and tempted to follow that money to see where it goes. Apparently, it’s not a big issue for our various representatives. Must be nice to be rich and protected, I guess.
In the end, healthcare remains a ‘shared burden’, and we’ll still spread some of the costs across the population. (I didn’t think that was a tough concept, but supposedly educated people get that wrong.) If we manage those costs rationally, and do the best we can to keep most of us healthy, when things do go wrong, the vast majority of lucky people can help out the unlucky few.
Imagine if you could look at how to do American health care well, and you were starting from a clean slate. First up, research how other groups do the same job. There are lots of good healthcare systems in the world. Find the best examples, using costs per patient, resulting mortality rates/lifespans, or whatever seemed like a good measure. If you were a politician, find which solutions left people the happiest, too, so you can get re-elected. Which ever.
Once you figured out the good parts (and the sucky bits), copy the good parts, avoid obvious mistakes, and try to tie them into a cohesive system. Compromise where you have to. Once you have a workable structure, push out the implementation carefully, fix the bits that weren’t right (nobody gets complex systems perfectly the first time), and after it’s good enough, let it roll. Seems do-able, right?
I know, I know. Sacrilege! French-loving, euro-trash surrender-monkey! He’s a witch! ‘E turned me into a newt! Build a bridge out of ‘im!
Go ahead, Trump: “Rational planning is fake news. Just another witch hunt by the MSM! Sad!! covfefe”
Anyway, so much for my fantasies. Instead, we have Republicans working on Vampire Trumpcare. (The New York Times and Paul Krugman called it that because Republicans appear convinced their AHCA would crumble into dust at the touch of the sun.) The only thing they’re ‘debating’ is how much of the costs they’d shift back from the population onto individuals. By the evidence, Republicans are OK screwing tens of millions of people back into destitution and ruin.
The ACA worked because it spread the costs across the population. Our Republican masters know all this. They’re educated and informed professionals, despite their attempts to pretend otherwise. I know they’re also self-serving, but that’s part of the nation’s design, who assumed our representatives to act in their own interests.
What I haven’t figured out is why Republicans pretend that the new Senate Trumpcare is going to be a smart move, or even slightly good for them. They’ve all faced those angry town hall meetings at home. They’re perfectly aware they’re about to do something legitimately horrible, and it’s a mistake they won’t be able to hide from us. Sure, they’re pretending they aren’t actively sabotaging the ACA, and yet somehow, we don’t seem to notice, but I’m pretty sure the rest of this turd will land squarely in their laps.
Ah, well. Until this thing is revealed, everyone’s pretending that the sun is dark, the moon is green cheese, and water isn’t really too wet. It’s weirdly nonsensical. I know how insulting it is to assume Republican voters act against their self-interests, but right now, I can’t see how the Republican Party isn’t self-destructing in front of me.
It’s like some surreal movie.
I’m here with you. I will live with you in this hellhole, but I must express myself. If you don’t let me gut out this house and make it my own, I will go insane. [growling] And I’m taking you with me!
— Beetlejuice, 1988
And, as always, Democrats declare they aren’t Republicans, all without saying what they’re for. <Sigh>
