Monday, July 2, 2012


In 1942, while British armies were pushing back against the German forces in North Africa and the British navy was doing their best to keep the North Sea clear for arms shipments from the US to Russia and the RAF was trying to fight off German bombers, a committee of economists under the direction of Lord Beveridge was asked to do some heavy thinking about what would happen next.  That is, assuming the Allies won the war--which was very much still in question--what should Britain do next?  What kind of society should emerge?  Beveridge's committee studied the issues of poverty, education and health care, and issued a report called Social Insurance and Allied Services.  Among its recommendations was the establishment of a National Health Service.

The NHS still exists in Britain.  Beveridge and his committee did splendid work. In most British national elections, the NHS is a central issue, but the discussion involves how to make it run more effectively, not whether they should dump it, which no politician would be fool enough to advocate.  Health care is considered a right, free to everyone. Brits are generally happy with the NHS. If you go to an NHS clinic, you'll see an office marked 'Cashier.'  But you don't pay the Cashier anything.  The Cashier is there to hand money out--cab fare, for example, if patients need transport home. 

In contrast, the American health care system was never designed or planned or developed at all.  In the post-war period, labor shortages meant companies competed for workers--one way to compete was to offer health care benefits.  Those expanded, and became the main way most people got health care.  Medicare was introduced to help the elderly poor, Medicaid for others in poverty, SCHIP for impoverished children.  The system is jury-rigged, improvised, ramshackle and misshapen.  As a result, Americans pay about double what most western societies pay per capita for basic health care.  Health outcomes are among the worst in First World countries.  

Although health care is a major issue in most national political campaigns, it's probably the one issue that lends itself most to demagoguery and misinformation and name-calling and partisan bickering.  We're talking people's health--the stake are high.  Liberals insist that health insurance companies are tremendously profitable, that preserving their profits is their only priority, that they callously deprive their customers of needed medical procedures, and that their refusal to insure folks with pre-existing conditions is tantamount to manslaughter.  Conservatives argue that health insurance isn't profitable at all, that essentially everyone gets to see doctors if they need to (if only in emergency rooms) and that it's possible to build market-oriented solutions to problems of access.  Cries on the one hand of the evils of murderous indifference, or corrupt and vicious socialized medicine enliven the debate, without really enlightening anyone. The health care debate is about as ugly as political debates ever get.

To his credit President Obama, when he came to office, decided to expend his newly minted political capital by tackling health care reform.  The Patient Protection and Affordable Care Act was rammed through House and Senate, signed into law. Last week, it was also found to be constitutional, though only by the narrowest of margins.  And the internet blew up.

It's hard to sort through all the lies and misrepresentations to figure out exactly what's in the bill, and whether it will do much good.  One example: an internet meme I saw maybe twenty times, saying that 'on page 114' of the health care bill, President Obama specifically exempted himself from its provisions.  Of course, nothing like that appears on page 114, or anywhere else.  It wouldn't make sense anyway; people who currently have health insurance will see no change in their health coverage with the passage of Obamacare.  The President has health insurance.  So do I.  We're both 'exempted.'

What I thought might be helpful would be to address a few issues relating to the health care debate.  I'm really genuinely am trying to be non-partisan here.  Understand: I'm not.  I thought last week's Supreme Court decision was wonderful.  I'm not a big fan of Obamacare, but only because it doesn't go far enough. I like most aspects of the British NHS model. I wish we'd just followed suit, back in the forties when it was possible.

First point: by far, the most effective part of our health care system is Medicare.  It provides the most health care, with the lowest overhead, of any program in the country.  Concerns about 'the government taking over health care' are overstated--the federal government already runs a huge percentage of our national health care, and runs it extremely effectively.

Second point: Obamacare really is very similar in most details to the Massachusetts plan supported by Mitt Romney when he was governor of that state.  Romney's argument was that the Massachusetts plan was never intended as a national solution.  The second half of that sentence, however, is that states are a good place to try out various solutions to problems.  And the federal government can then look at various programs and figure out--and implement- the one that works best.  If Romneycare works, why not apply it federally?

Third point: nobody really knows what Obamacare will cost.  The initial CBO estimates were that it would actually save money.  Subsequent estimates are less optimistic.  There are no certainties--we need to try it and see how much it costs.  It will probably cost more than initial estimates suggested.

Fourth point: it's not true that liberals went with Obamacare because conservatives didn't offer any policies as alternatives.  Lots of conservative, market-driven policies were suggested.  It's just that most of them were silly.  Four separate people recommended that I look at one Cato Institute proposal.  I read it; its first provision was the complete elimination of the American Medical Association.  Sorry, that's not a realistic policy.  The argument is that health care costs would go down with competition.  What those arguments fail to account for is demand.  I-pods go down in cost over time, because demand lessens.  Nobody has to own an I-pod.  That's not true of an MRI. Doc says you need one (or your kids need one), you'll do whatever to make it happen.

Fifth point: Obamacare isn't really all that unpopular.  Provisions to keep kids on their parents' health insurance until they turn 26, or laws saying people with pre-existing conditions can't be denied coverage, or insurance portability, or making sure everyone can have access to health insurance, those are all massively popular provisions. People respond negatively to only one provision, the mandate.  Which happens to be the mechanism that makes the whole thing affordable.  (People also respond negatively to misinformation; government death panels for example.) Things like the national health care exchange strikes me as a good idea; we'll have to try it, but I like the choices it introduces into the debate. 

My neighbor's house just burned down.  He has fire insurance, of course (can't get a mortgage without it), and they're paying to replace his home.  It's been fun to watch ("hey, look, check out their new garage!"). But insurance can do that, because a whole of people pay into it, most of whom live in homes that won't burn down.  With health insurance, it would be rational for healthy people to not buy it until they start to get sick.  But that's not how insurance works.  

So the sixth point is the one I heard most often over the past few days, people angry that they're going to be forced to buy health insurance, taxed if they don't buy it.  It's the 'they're taking away our freedoms!' argument.  And the level of anger to which people have given voice is really quite impressive.

That argument seems to me to miss the fundamental point of 'freedom.'  We have rights, and we have freedoms.  Freedom's a positive thing; we generally have the freedom to make something of our lives.  We have the freedom to worship any way we want to, we have the freedom to speak out on issues, we have the freedom to raise our families and have careers and we have the freedom to goof off, to do whatever we enjoy doing in our free time. What we don't have is negative freedom; the freedom to avoid our responsibilities as citizens.  We do not have the freedom to not pay taxes.  If we want to live in a civilized society, we have to pay for it, and that means taxation.  We do not have the freedom to ignore traffic laws, even when they're inconvenient.

So when people say "why should I pay taxes so poor people can get health care?" the answer is, because that's the price you pay to enjoy all your other freedoms.  We have freedoms, but we also have duties, requirements, obligations.  And we have to meet them.

Is Obamacare a great bill?  No. But it's a start. Let's try it for awhile, figure out inefficiencies and difficulties, and reform it as needed.  Meanwhile. . . .

Meanwhile, this: My son and his wife live in Minnesota; he's in grad school.  His wife is ill--she almost certainly will need surgery.  They are responsible, hard-working people, doing the best they can.  They also don't have health insurance.  We'll help them if they need to.  But that's wrong, for citizens of the United States, in 2012, to have to make basic decisions about whether this pain or this illness is serious enough to risk going to the Emergency room, for my son to worry about whether surgery necessary to preserve his wife's health will bankrupt them for the next twenty years.  Obamacare hasn't been fully implemented yet--it will be by 2014, unless it's overturned, which would genuinely be a tragic mistake for our nation.

Meanwhile, thanks to Chief Justice Roberts, and thanks as well to Barack Obama (two great American patriots), last week was a very good week indeed.


  1. I like your posts. I'm independent with more republican leanings than democrat, but my gut feeling has been in favor of national health care, and this post reinforces it. Keep up the great posts--the only ones I don't read are the sports ones.

  2. One other misconception - prompted by your final paragraphs about your son - is that if you just walk into an emergency room without insurance, people just lay down the palm fronds and give you the royal treatment all for free.

    No, the truth is that even though you will be treated and released (as soon as you're not about to keel over and die) you will then be printed out a lengthy bill representing every doctor and orderly who stepped foot in your room, itemized with every pill and syringe they stuck you with. You will then sit across from several old ladies peering over their reading glasses in front of computers they can barely use who will try to exact from you every dollar you can possibly afford (or not afford). You will then be harassed by mail, phone, and carrier pigeon until they finally write off your bill as uncollectable a few years later.

    Meanwhile the stress of that situation has probably caused an ulcer that will likely put you back in said emergency room once more to start the process all over again.

    1. Well put. It's a miserable experience. Thanks for that perspective.

  3. I think you should know - Australia has a single-payer system, with even higher customer satisfaction ratings than NHS, and nobody has to opt in. Most people do, because - six years ago, when we were there - a family with four children was covered for a year for about 375AUD. You can start using it at any part of the year, you pay for the whole year with your taxes. If you haven't used it at all, and declared you didn't want to at the beginning, you don't have to pay that. I knew people (a couple) who chose that option - but they were definitely the fringe. I'm just saying, it works very well without forcing anyone to buy it.

  4. I think time will tell that your last sentence is very incorrect... Mr obama is not an american patriot and lied about this legislation and gave out deals to get it passed. and justice Roberts is not an american patriot in the sense that he is blatantly ruling against the constitution when it comes to the individual mandate... I think MAYBE there could be an executable socialistic form of health care in this country but not with our current level of corruption in our political system... Doesn't it make you skeptical when "such a great law was passed and the people who passed it say it won't change your healthcare coverage if you have it already?" I thought that was the point of healthcare law being passed was to make it better for everyone. No, what we have here is a power grab of the federal government to tax us. I hope I am wrong but the mandate being upheld as constitutional will likely lead to taxation for any inaction the government in its infinite wisdom deems bad for the collective. I really don't give a damn about much of the rest of the law, it's the mandate that scares the poop out of me.

    1. Well, we'll have to agree to disagree, then. I would respond to one statement: if people are already happy with their health insurance coverage, why should it change? I've got good health insurance, I like my doctors. I like the status quo. The point of the bill was to cover everyone. It doesn't quite manage that, but it comes pretty close.