Here’s My Problem With…

The debates.  Specifically, the debate about health care.

This is now something like the 47th democratic primary debate, with another 73 to go.  In every debate so far, the topics have stayed basically the same: health care, Trump sucks, electability, gun control, and because it’s only the most pressing issue in the history of the world, hardly any talk about climate change.

I want to focus on health care though, because in every debate so far, much like the topics themselves, the script remains unchanged.  The moderators ask a question and the conversation quickly devolves into liberals vs. moderates.  Medicare For All vs. Medicare For All Who Want It vs. Medicare by Officer Kamala vs. Medicare For Those Who Eat Salads With a Comb.

The moderates on the stage, and the moderators asking the questions, are desperate to get Elizabeth Warren or Bernie Sanders to say that their Medicare For All plan raises taxes.  And I mean, desperate.  More desperate than Bob Saget in Half Baked.  Warren has (correctly) tried to frame this instead about total costs, or expenses.  She argues that expenses will go down, and that’s what people care about.

The larger point she’s trying to make, and that no one else seems to be picking up, is that people don’t care about taxes vs. health care cost.  The total dollar amount is what they care about.  If you pay $100 in taxes and $100 in health insurance, you pay $200.  If her plan passes, you will pay less than $200.  Does it really matter if, say, $180 is allocated to taxes but $0 to health insurance?  Or $199 in taxes?  It’s less, and that’s what actually matters.

Nevertheless, they persist.  They persist in trying to get her to say taxes will be raised.  She doesn’t give in, but she it comes off as if she’s trying to dodge the question.

The problem, though, is not whether your taxes will go up or not.  The problem is not even whether your costs will go up or not.  The problem is that this entire debate is framed in terms of insurance.

What insurance do you have?  What insurance will you buy?  You’re going to kick people off insurance?  What doctors are in network?  What about unions who have negotiated for insurance, you’re going to take that away from them?  WHAT’S WRONG WITCHU?!?!?!

There aren’t really great answers to this, especially in the format of a debate setup.  You’re in a trap, no matter which way you turn.  Medicare For All seems like great branding – Medicare is incredibly popular, and administrative costs are demonstrably lower than private insurance.  So we should just do that for everyone, right?

The problem, again, is that this is phrased in the context of insurance.  What the context should be is health care.  What I believe, and what I think that Bernie and Liz (can I call you Liz?) believe, but are having trouble articulating, is that health care has nothing to do with insurance.  But rather, that the government should provide a baseline level of care to every person who steps foot in the US of A.  Every person here – citizens, non-citizens, those gal darn illegals, even sub-humans like Don Jr. – should be assured (not insured) of a certain level of care.

This would alter, but not eliminate the private insurance industry.  Instead of coming up with money-making schemes like co-pays, HSAs, deductibles and the like, insurance would change.  It would offer things like, ‘Oh you need a hip replacement?  Well if you have insurance you get the Cadillac of new hips.  Otherwise you get the Chevy of new hips.’  You’ll get the new hip regardless, and you’ll get one that will work, but maybe just not one iced-out with 1 karat diamonds.

What is that baseline level of care?  How much health care is the government actually going to provide?  That’s a great question!  I think we can start with ‘Don’t let people die because they can’t afford the treatment.’  That seems like a good foundation.  From there, there’s loads of low-hanging-fruit that should be covered without (much) of a debate – pre and post-natal care, preventive checkups, physicals, and even (gasp!) birth control.  

Eventually, this discussion will get more complex and complicated and of course polarized because this is America after all.  Should Grandma get that new hip, even it’s just a Chevy? Today, in our fee-for-service model, if she has insurance, that answer is almost always yes.  And in my utopian future, it might still almost always be yes.  But it might not. Maybe this is the 4th hip that Grandma has gone through and even if she gets it she won’t be able to walk because of the arthritis in her other leg and she’s got bad lungs and osteoporosis.  Emotionally, that can be a tough call to make.  

Luckily, we have science and data and can use that to help make our decisions, instead of just what’s going to make the most profit for the hospital.  Remember Death Panels?  This is what they’re actually for!  Not to decide when to kill Grandma, but to figure out which treatments and procedures were most effective. So instead of just racking up treatments and procedures that eventually we would all pay for in the form of higher premiums, you actually had people reviewing data and determining what the best course of action would be.  A novel idea, I know.

There’s a whole other discussion some day around the best way to implement this, who should make up the panel of experts, how long do they serve for, etc. etc. etc.  But we need to at least agree on the concept first.

And if Bernie and Liz have to get on the debate stage and tell people that their taxes might go up, then Uncle Joe, Mayor Pete, Kamala the Cop and the Salad Comber have to tell people that they are going to keep your taxes as is, but they’ll just let you die instead.

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