Moral health diagnostics
Some recent letters in the Dispatch have requested that some positive opinions and facts on the Affordable Care Act (ACA) should be published. This is understandable because by my count, in the last four months, there were a total of 17 columns solely about the ACA in the editors’ or “Guest Opinion” columns; all were negative.
A fundamental flaw in these opinions is that they were written as if there are no problems that the ACA is intended to fix, and therefore no solutions were offered other than “Repeal it and start over.” But what the “start over” consists of is never stated. At the same time there is hand-wringing about our debt when all the other developed countries of the world deliver universal care at 60 percent of our per capita cost and get better overall results. Also the marked cutbacks in mental health services have been related to recent gun violence. The foundational issue is not the ACA per se, but the moral and economic reality that if we delivered universal care at the rate Canada or France do, we could improve our revenue/spending balance by almost a trillion dollars a year. In this context, the basic question is, “Is it moral not to try for something better?”
Most of the health care systems of the world are close to one of four different models: 1. Single government payer to government-employed professionals (England). 2. Single government payer directly to private providers (Canada); 3. Employer and employee financing through insurance company payments to private providers (Germany); 4. Out-of pocket only payment (Cambodia). The U.S. system is a patchwork of all four models, represented in this order by: The active military/VA, Medicare/Medicaid, employed adult citizens under age 65, and the 15 percent (45 million) uninsured group of U.S. citizens. In the U.S., the insurance model No.3 has the highest world per capita bureaucracy and subsidizes the out-of pocket group 4.
The three primary goals of most serious U.S. health reform proposals are to close the gap of coverage in the uninsured “working poor” by giving them an “affordable” option; eliminate bad policies that exclude preexisting conditions and allow arbitrary coverage cancellation; and decrease total average per capita cost. Left unaddressed, any opinions on the ACA implicitly reject these as constructive goals.
In the above context it is fundamentally important to understand two things. First, many if not most, liberals prefer a single payer solution like Canada – No. 2 – as the most economically efficient universal coverage model. Second, the universal mandate with insurance exchanges like those of the ACA was a conservative plan recommended by the Heritage foundation in 1989, which was subsequently used in arguing against the 1993 Clinton plan. At the time, Sen. John Chaffee (R-RI) authored a bill with these essentials. The Romney plan is similar. The Ryan-Republican plan to privatize Medicare had insurance exchanges. President Obama chose the ACA model rather than the type 2 (Canada - HR 676) model based on the erroneous assumption that many conservatives would accept it. It could work not only because conservatives endorsed the model, but also because it is a combination of Germany’s system and the Canadian system.
But Republican Rep. Tom Cruz and his team will have none of it. Histories of the failure to pass universal coverage in1993 and subsequent conservative strategies indicate that the biggest concern of the far right is not a possible change of doctors, death panels, etc., but that the ACA will work well and thereby significantly shift the political electorate. Besides, more government service runs against a core conservative ideology. For political gain, it is worth gambling the lives of uninsured Americans. When a chief political aim is to make a presidency and a potentially effective health plan fail, 45 million people without insurance representing 40,000 annual preventable deaths are not a significant strategy deterrent.
Conservatives argue for supremacy of a free market. K.J. Arrow, a Stanford University Nobel Laureate economist debunked the market theory means of controlling health care costs almost 50 years ago. Fifty years have proven him correct. Physicians, not patients determine what tests and treatments are done. Increasingly expensive high-tech equipment and procedures plus compensation competition for recruiting the best-trained professionals push charges up. The existential threat of disease puts the medical patient in a much more compliant position than most professional or business relationships.
There has been nothing except the free market to restrain rising charges. Gas and electric companies have to apply for rate changes from a government agency, and medical providers have to do the same in Germany.
Winston Churchill once said, “Americans usually get things right, but only after they have tried everything else.”
Recently a highly respected economist said that escalating health care costs represent a much bigger threat bankrupting the country than any or all of the entitlements because the latter are much easier to objectively deal with. But slogans such as “liberty,” “American exceptionalism,” and “common sense” make many Americans look contemptuously at what other countries do better. Meanwhile, like the monkey with his hand stuck in the bottle because he would not release his grasp on a peanut, we may be walking ourselves into bankruptcy with unfettered capitalism-based health care designed primary by and for those who can afford it at the expense of those who cannot.
Any opposition “victory” that might come by ending the ACA would be pyrrhic for health care because it would be a second moral failure of the constitutional and medical ethics distributive justice mandates.
The 20 additional years of a free-enterprise system since the 1993 failure did not slow increasing costs, increase coverage, or increase our overall world health rankings. Along the way there has been no alternate Republican plan and there will not likely be one.
Regarding the 17 or more Dispatch editor and editor-selected guest opinions on the ACA, readers must judge the difference between broadly constructive reasoned analysis and narrow ideological political propaganda. Most newspapers have some of both.