WHAT IS NOT BEING SAID ABOUT HEALTHCARE (AND WHY)
Christopher Ebbe, Ph.D. 6-17
ABSTRACT: As is frequently the case in politics, the current healthcare debate in Congress (regarding the Republican effort to change the Affordable Care Act) is taking place on the plane of action (what should we do?) while the plane of purpose is being ignored. This and similar lacunae are described.
KEY WORDS: healthcare, universal coverage, health insurance
As is frequently the case in politics, the current healthcare debate in Congress (regarding the Republican effort to change the Affordable Care Act) is taking place on the plane of actions (what should we do?) while the plane of purpose is being ignored. This leads predictably to stalemate, since the two sides are speaking from different assumptions about healthcare goals for the country, and these assumptions are not made public. If all participants shared the same assumptions, then the debate could become a discussion of the best way to fulfill agreed-upon goals for healthcare in the U.S. In this essay, these underlying differences will be outlined, and the reader is encouraged to figure out what he or she actually believes about each fundamental assumption.
A key question for the entire discussion is whether a person will pursue his own goals independently of others or will enter into a cooperative agreement with others in order to achieve his goals. This frames a fundamental difference between liberals and conservatives, with liberals more willing to form alliances and conservatives more willing to have people pursue their own goals without help from others. Conservatives see the latter as an actualization of much valued freedom, while liberals are likely to see it as disorganization. This is consistent with liberals inhabiting mainly urban settings, where high levels of cooperation are necessary for urban complex systems to work smoothly and with the majority of conservatives living in smaller settings where individuals have somewhat broader freedom of action (viz., the “red states” that were key to electing Mr. Trump).
Liberals see providing for citizens what they cannot provide for themselves as being natural activities for government (the cooperative association of all citizens), while conservatives are inclined to be satisfied with whatever people can do for themselves. (So far, in our country’s early (frontier) days, what citizens appear to do independently through exploiting our wonderful environment seems quite sufficient, even amazing. As a country we have not yet run into sustained hard times that we cannot escape, and this supports our optimistic assumption that we can accomplish anything we want. (We should of course be very careful in making these kinds of generalizations about liberals, conservatives, etc., but they do give us a rude framework for starting to understand the differences that divide our nation.)
The concept of insurance is frequently misunderstood in the debate, as when people who do not intend to have children in the future ask why they should have to pay for insurance coverage for obstetrics and when people who are certain that they will not have substance abuse problems in the future ask why they should have to pay for coverage for addictions. The answer is that everyone in an insurance pool is paying for coverage for a large number of conditions, only a few of which they themselves will ever encounter. We don’t know which we will encounter, hence the value of such wide coverage. If only people who were going to have children paid for coverage for obstetrics, then each of them would in effect pay full price for their obstetrics care, because no one else would be paying into the costs of that pool of only those who were going to have children. If only people who were going to have open heart surgery paid for that coverage, then they would pay full price for their own open heart surgery. No one can afford by themselves to pay completely for today’s more complex medical services, which is why groups of people form insurance pools to share the cost.
Young people may wish not to pay for insurance because they are less likely to be seriously sick, but if they don’t pay, then this reduces significantly the total number of persons paying, and this raises significantly the insurance price for everyone who is not young. It’s true that young people are subsidizing the care of older people, but they will benefit from this larger insurance pool when they themselves are older and have greater medical costs (at which time people who are younger will be paying for their care). They could, of course, wish not to pay when young, and accept that they will pay considerably more when they are older, but the astronomical costs of most complex medical services means that very, very few of us can afford medical care without a large pool of those who share the total costs and are not sick, with the healthier ones always subsidizing the costs of the less healthy. It’s not a matter of fairness but of practicality. The same applies to people who might wish to buy insurance only when they get sick. They would be sponging off those who had paid all along and not bearing their fair share of the costs of their care and the care of others in the pool.
One more fundamental issue in planning for the nation’s healthcare is how profits affect healthcare. The money paid into insurance plans goes for three different things—the actual healthcare provided to enrollees, administrative costs, and profits. Since Medicare-for-all is an option for our healthcare system (providing services for all citizens through a government structure or corporation that handles healthcare like Medicare does), it is worth noting that Medicare has much lower administrative costs than private healthcare insurance companies, and of course it makes no profits (no money going to investors or owners).
We must weigh the pros and cons of private versus public healthcare systems. Having private systems makes competition possible, and it may enhance the energy of workers working hard to “get ahead.” On the other hand, private systems’ profits and higher administrative costs make enrollees pay more than if there were no profits involved. Public systems can have lower overhead (no profits, no advertising), though if government jobs are too protected, work quality can suffer. We can assume that any time profits are involved, administrators will be torn between taking profits and providing the most healthcare possible to their enrollees. If investors are involved, administrators are certain to ensure their jobs by taking enough profits to keep investors happy. The motives of administrators in public programs are less conflicted, but public administrators do not have the whip of making a profit hanging over their heads to spur them on to do the best possible job.
Universal Coverage
Liberals are eager to have universal coverage, thinking it an appropriate “right” of all citizens in an advanced society. Conservatives are more inclined to think that people should get what they individually earn and pay for. Liberals do not forthrightly say how much universal coverage will cost us all in additional taxes, and conservatives do not admit publically that it is OK with them that some percentage of Americans do not have health coverage (twenty percent?) or get only the most basic medical services.
It would be more honest for those in favor of universal coverage to estimate how much each tax tier of Americans would have to pay in increased taxes to pay for universal coverage (since a significant percentage of Americans (perhaps fifty percent?) cannot themselves fully pay for their coverage (at least for policies that provide “good” comprehensive insurance). This would enable better discussion of whether this country wants healthcare to be a “right” or not, and it would enable a straw vote about how many are willing to pay the additional taxes that are needed to pay for universal coverage. Ask yourself how much you would be willing to pay in extra taxes in order to help those who cannot pay to have health insurance.
Costs
Many people fear that healthcare costs will rise so far that people will no longer be able to receive all needed services, and the cost trends do lend some support to this fear. We all want medical research to continue to find cures and treatments for every disease, but every added service means additional cost for the entire system. There are almost no improvements that have actually reduced costs, so if we want all possible services, and the number of available services keeps on increasing, we will have to pay more and more for that privilege. Achieving greater efficiency in the system by controlling services would almost certainly mean making it feel less welcoming and humane.
Claims that “waste and fraud” can be reduced enough to make healthcare more affordable are almost ludicrous. Even if such reductions could reduce costs by ten percent, most people who cannot pay for their healthcare now would still be unable to pay for their healthcare.
Treatment authorization processes have been tried, in which every element of your proposed care is reviewed by the insurance company or other provider to decide whether that care will be paid for by the insurance or other payer. These decisions were usually made by technicians or masters level persons in healthcare and not by doctors, and companies expected their reviewers to disapprove a fair number of services, thus controlling costs. These reviews were highly unpopular with consumers and with providers, naturally, and they are falling out of fashion now, but it seems to me that some form of restriction on receiving all possible services is the only way that healthcare costs can be stabilized over the long haul at a fixed percent of our gross national product.
The most important factor that will ensure that healthcare costs will continue to rise is our natural, human wish to be pain free and to have someone attend to our pain whenever we have it. This results in many, many unnecessary doctor visits (visits that may make the patient feel better psychologically but will have no other impact on the patient’s complaints—e.g., the amount of antibiotics given for illnesses that are not due to bacteria, and this wish to be attended to and helped will guarantee that the desire for services will always press upward on whatever limit on services, practical or imposed, is set.
Unless there are excessive profits being made in healthcare that can be curtailed, there is no way out of the increasing spiral of costs if we are to have more and more treatments available due to continued research, except by use of some form of rationing (meaning that decisions will be made by organizations or by the government about under what conditions each service will be provided). All services will not be simply available to everyone, regardless of need, pain level, or age. Americans will not like this, but it is unavoidable if we want to keep healthcare spending for the average family from not going higher than, let’s say, one-third of income.
The Republican mantra that competition will lower healthcare cost and therefore premiums is unlikely to be true in healthcare, since rising prices have no effect on demand (people are going to continue to want and try to get healthcare for every ill, regardless of whether they can pay). With this kind of demand, insurance companies have no incentive to compete, if no additional insurance companies are started, and the trend in healthcare is for consolidation of healthcare companies rather than having new entrants. Actions by insurance companies to be more administratively efficient might help some but again, not by more than (I would guess) five or ten percent of the total.
Competition among healthcare providers could only be effective in lowering costs if there were a surfeit of healthcare providers, which we do not have. We do not have enough doctors for the demand now, and the American Medical Association has held back for years on producing more doctors. So, we can bring in more foreign doctors, but if we have no new insurance companies forming, then only if we have doctors sitting in their offices doing nothing part of the day could price competition occur. (We can easily produce a surfeit of ancillary medical personnel, such as technicians, nurses, and aides, but these persons have no role in setting prices.) In addition, people are suspicious that lesser paid doctors will not do as good a job as higher paid doctors, and everyone wants the best doctors possible.
Another “solution” to healthcare costs proposed by Republicans is to allow insurance companies to offer policies that cover fewer medical services, with no lower limit on what is covered. This will enable people to buy policies that cover fewer illnesses and services than under the coverage mandates of Obamacare. They will feel like their healthcare is costing less, but they will be unhappy and think it unjust if they then need services that are not covered by their more affordable policy. Their healthcare will cost less, but they will get less healthcare. Republicans offer this as a means of getting “access to healthcare” for everyone, without making clear that it will provide less healthcare.
Persons with less coverage are going to go to the hospital, regardless of their coverage, when they have serious problems not covered by their insurance, and then we will be back in our current situation where consumers with insurance pay for those without insurance, indirectly, through the higher prices that hospitals charge them so that the hospitals can give a lot of free care. This is another way that we pretend that we are not paying for the poor when we actually are, and if hospitals continue to provide free care, many people will (unwillingly) resort to not having insurance at all and going to the emergency rooms for all needs, which is exactly why it is so important that lots of people who are paying for insurance but not using it continue to have insurance, since that is the only way that insurance can work. No individual who is significantly sick pays enough in insurance to cover his or her own care. Unless we are very healthy, we only get care by having others pay for the majority of our costs.
The cost issue has impact on notions like universal coverage, since covering more people, including many who cannot pay, will cost more. It would help us to weigh our options if we had estimates of how much taxes would have to rise in order to have universal coverage, so that each citizen could “vote” regarding whether he or she is willing to help foot the bill.
Large groups of people (all the employees of a sizeable company; all members of a state Medicaid plan; all members of an Obamacare plan in a given state; etc.) negotiating with large healthcare corporations for a good price on insurance can do better than individuals can, who have no strength in numbers. What do you think of having your whole town be an insurance buying group and getting a good price as a result? If you push for a really low price, you might not like the healthcare you get for that low price, but you could then find another company or renegotiate the price.
Socialism
It is accepted without question by conservatives that government-run healthcare would be inferior to free market healthcare, and they call it socialized medicine to try to use American fear of Communism and Socialism as a reason to reject government healthcare. Actually, a government-run system, especially one that mainly collects taxes and pays providers with that money, can offer just as much healthcare as any private system, if it can collect the resources to pay for the desired level of care. (We do not fear that we have an inferior military just because it is completely paid for by taxes, so why would we fear a tax-supported healthcare system?) Many European countries have just such a system, with universal coverage, and their citizens think that they have good healthcare. (And, interestingly, they spend less on that good healthcare than we do on our troubled system.) There are rumors that we would have to wait too long for surgeries in a “socialized” system, but most people here are waiting now in our own system, often months for non-emergency procedures.
Another fear regarding government-run healthcare is that doctors and others would stop caring about their patients in such a system, because they have “government jobs.” This, though, is up to us in how we structure those jobs. Government workers don’t have to be hard to fire; all we have to do is set up the rules so that they can be fired. And, a Medicare-like system (expanding Medicare for everyone) would probably be paying mostly private practitioners and hospitals, just as it does now, who would have the same incentives that they do now to make as much money as they can.
Another method of limiting costs would be to limit, by law, how much profit (per patient) that a healthcare corporation could make. This is anathema to American business, of course, since they thrive (or think they thrive) on dreams of great profits. In order to justify great profits, it would be reasonable to expect that those great profits should correspond to great healthcare, and having consumer ratings of their healthcare determine corporate profit limits might be a fitting application of democracy!
The opposite side of the socialism mud slinging is the assertion by some that completely market-based healthcare will lose its focus on people and become dehumanized in its efficiency. Any time that investors get involved in a business and demand short-term returns on their money from profits, the ostensible purpose of the organization (in this case, healthcare) may suffer. Most businesses will put profit over consumers. So, think before you endorse “the market” as your source of healthcare. It may still be the best alternative (just as democracy is problematic but still the best choice for government), but it is not without its disadvantages.
Death Panels and Treatment Authorization
Republicans promoted fear of government-run healthcare by naming Obamacare committees that discussed limits of care “death panels.” The whole treatment authorization game that politicians thought could limit care could also be labeled “death panels,” though, since any limitation on care would reduce the total amount of care and therefore could lead to negative consequences for some citizens. The alternative is to pay more and more for our greater and greater healthcare, because otherwise we will always be running into limits. When we reach a point where we can’t pay the mortgage or buy sufficient food, we will presumably stop paying more for healthcare, but we will complain about it vociferously. Our country seems to be moving slowly toward the assumption by most citizens that good healthcare “should” be given to all, so sooner or later we will have to either pay more and more for healthcare or put some limits on what healthcare we can get, given whatever symptoms we have.
Indolence
A fear among conservatives is that if society provides something for its members, those members will not then strive as hard to get it for themselves. Thus, forcing people to work harder to get what they want prevents sinking into sloth and indolence, depending on others rather than being self-reliant. There is some inevitable truth to this psychologically, but the problem could be countered by, for example, insisting that every person receiving a benefit be working (and giving work, even stuffing envelopes or street sweeping, to everyone who “can’t get a job”).
Summary of What Is Not Being Said and What Is Being Distorted
Any insurance system depends on lots of people paying in who do not draw out (do not have a car accident, do not get sick often), so if all citizens are going to be covered, all citizens must pay in if they are all going to get services.
To cover more people who are currently uninsured, the people who can pay must pay a little more. The government has only our money (and no money of its own), so to have fewer uninsured, we will be paying. (We are not being told how much more we would have to pay per person.)
New medical discoveries each make all of us pay a little more, because if new services are available to everyone in your insurance pool, then everyone in the pool will have to pay a little more so that whoever needs those services will be able to get them. If you want access to all services, you must pay more.
Waste and fraud are quite small parts of healthcare costs.
Citizens who can pay for insurance are also currently paying for the free care that hospitals provide to those who cannot pay. As human beings, it seems that we cannot just let people die (or suffer significantly) because they have no insurance, so everyone is going to get some care, one way or another. (We are not being told how much of our payments go to fund care for the uninsured.)
It might sound good for everyone to have “access” to insurance, but if “access” means being able to buy a policy that doesn’t cover very much, you won’t get much care.
You can’t have it all. The Republicans are now promising that you can have better healthcare (more services, happier doctors) and lower premiums, but you can’t. You can’t have all the new services and treatments and not keep on paying more and more. Even in our fairly rich society, if medical discoveries keep on happening, then there will ultimately be some point at which we just can’t pay any more for healthcare and still pay for food, housing, and other essentials. At that point, there will be some form of rationing, probably on the basis of who is likely or not likely to benefit from a given treatment (like fewer organ transplants for people over 75). The Democrats didn’t exactly promise that Obamacare would not cost more to those who can pay, but they knew that it would cost more and just didn’t say it.
Competition may lower prices slightly, but it will not increase the amount of care, since doctors are already motivated to provide as much care as the finances permit, and it will not improve the quality of care, since doctors individually are already motivated (or not motivated) to do the best they can for patients. Healthcare is not like an inanimate product, where workers can be motivated to produce more widgets to keep their jobs or earn more. Doctors are motivated (or not) by some sort of desire to benefit others, and competition does not affect that motivation. Healthcare companies or insurance companies could insist on paying for only 15 minute patient visits, and while this might result in more patient visits, this will not make healthcare better, because doctors and patients both react negatively to being rushed in and out like cattle.
What Do You Think?
The purpose of this brief essay is to point out that in the political debate over healthcare we are not addressing fundamentals that help us clarify what needs to be done. Politicians in general do not wish to address fundamentals because that would reveal their actual personal beliefs and attitudes, which they believe is likely to alienate more voters than it will please. Finding common ground in healthcare is not going to happen by joining together with those who like the same payment methods that you like but rather by finding common ground with those with the same healthcare goals that you have. So, what do you think?
The fundamental questions are—
· Who (besides yourself and your family) do you want to receive healthcare, and how much are you willing to pay so that more people can have healthcare?
· How much healthcare “should” everyone get—every possible service or only as much as one can pay for?
· What should we do about the conflict we have between wanting every service that we need and not wanting to pay more and more for that privilege?
Do you know what your health plan covers and what is does not cover? If you don’t know without finding your plan and looking at it, then you don’t have enough knowledge to appropriately choose a health plan and get a good price on your healthcare. Insurers want you not to know so you will simply throw up your hands and choose one anyway, because not knowing what you really want, you will not put pressure on them to provide it.
Do you want to pay for your healthcare through an insurance pool or just pay for your own care completely by yourself? (Remember that if you use an insurance pool and you are relatively healthy, you will be paying partly for the healthcare of others in the pool. On the other hand, are you prepared to pay $40,000 yourself for open heart surgery that would extend your life for a few years?)
Do you feel OK about paying more for your care so some of that money can be siphoned off by hospitals to pay for the free care they give (and in some cases are obligated to give, like emergency rooms)? Or, would you prefer to know how much that amounts to and pay that in additional taxes to cover that free care (in return for slightly lower medical costs for yourself)?
Should we strive for universal coverage, which means higher taxes? Whose healthcare would you be willing to pay higher taxes for? How much in additional taxes would you be willing to pay to insure everyone in the country–$500 per year? $1000 per year? $0 per year?
Do you want to limit insurance costs by slowing down medical research from finding more cures for more diseases (and be satisfied with what we can do now medically)? The alternative will be higher prices.
Do you want to limit insurance costs by limiting corporate profits?
If you are receiving healthcare through an employer, do you know how much lower your contribution to healthcare is because of the special tax break you and your employer get for getting your healthcare “before taxes”? Maybe 20 percent? Is it fair that you get that break but individuals buying individual insurance don’t get it? What justifies this discrepancy?
Will you be happy to be able, under the Republicans’ current proposals, to buy less costly insurance that covers fewer illnesses and procedures? If you get such a policy and then have an illness that is not covered by your policy, what will you do? Conservatives will tell you that it is good that you are back in control of your healthcare, but you may not be controlling as much as you would like.
Are discounts given by insurance companies to large bargaining groups fair? Is it fair that you get a lower price as an employee of a large company than your neighbor who works for himself?
Will it dehumanize healthcare to make it into primarily a financial transaction instead of being motivated through a wish to benefit others?
Would you like medical providers to compete by throwing more and more advertising at you, which, since it is financially motivated, will inevitably contain half-truths and come-ons? Would you like them to compete by becoming more persuasive about what they are doing for you (even though they are not actually doing anything differently than before)? Just how would you like them to compete? If you say “lower prices,” then imagine what it will be like for doctors to charge (and make) less for doing the same work. Do you think they will feel good about that and sincerely serve you better? Doctors may be paid too much now, but they will not be happy about being forced to take less, and this will not result in better services.
What Is the Solution?
Unfortunately, in my opinion, given the factors discussed so far, there is no perfect solution. We could do artificial things like insist that any new medical discovery not be made available until some other already available service is made less costly, but we would always want to be making exceptions. The only true solution is for us to use less healthcare, which would increase competition among the increasingly idle medical providers (and allow for incorporation of some new treatment discoveries). You could do your part by just not going in for colds or viruses or minor pain, but if human beings are suffering or unable to function as they wish, they are likely to want medical help. So, we are back to the bugaboo of rationing of healthcare. Get used to the idea. Our human ingenuity in discovering treatments has outrun our human productivity’s ability to generate disposable income, and this could only change if there were unexpected discoveries that drastically increased our energy supplies or cut our food costs in half. Enjoy your relatively unlimited healthcare while you can, and think about what is the best way to ensure that you get the care that you need (and, if you care, what is the best way to ensure that everyone gets the most care possible). And, let your Congresspersons know what you want!
Perhaps the most important conclusion to be reached is just that there is no perfect solution. We may do best to stop thinking that there is a way to have all the healthcare we want at a good price and start figuring out what the best we can do is—how we can give the most healthcare of reasonable quality to the most citizens. The reader may detect a slightly “socialistic” bent here, but remember that if good healthcare is not available to a large number of other people, it won’t be available to you either.
SUGGESTIONS FOR LEGISLATORS
You as legislators have the final word about healthcare in this country, and we need legislators that are both honest and committed to moving ahead with the best healthcare we can all agree on right now, instead of using this issue as a battleground on which to wrangle over more fundamental philosophical disagreements regarding government.
Tell the truth about healthcare to your constituents and to the press. There is no approach or plan that will cover more people, provide an Obamacare-level of services, and lower costs all at the same time. Don’t hold out for a plan that will accomplish all three of these objectives, because such a plan does not and never will exist. The logic of this should be clear in this essay. Competition does not work in healthcare as it does in manufacturing, and if it did, most people would not be happy with the thought that their healthcare providers were always scheming behind closed doors to provide fewer services or charge more.
Be openly honest with everyone about your position. If you think that the appropriate level of healthcare spending for the country unfortunately will leave twenty percent of citizens without healthcare coverage (actually having their emergency and other care being paid for by the rest of us through higher charges for our own services), and that is the way things have to be right now, then say so. If you think government-supported healthcare will be terrible, say exactly why it would be any worse than current Medicare. If you want to keep healthcare coverage and costs down so more money will go to consumer spending, say so and explain why this is important in the larger economic picture. Examine your own beliefs about healthcare issues and the reasons why you believe as you do, to be sure that they are reasonable. If they are not reasonable, change them! Do what is best for the country on this one, even if you risk not being re-elected!
There is a re-election philosophy among legislators that the less voters know about your positions, the better, but this degrades democracy. It would be far better for the country if you would be transparent about your positions (even if they are complicated to communicate), even if that risked alerting some single-issue voters to oppose you.
Democrats, don’t hold out right now for universal coverage. You will have to give that up in order to reach an agreement with Republicans about costs. Republicans, don’t eliminate care for large numbers of people already covered under Medicaid expansion. The feedback from “the American people” shows clearly that no one wants to give up the coverage they have for the sake of lowering costs or for the sake of greater competition. You will have to wait until costs become completely impossible for most citizens before any movement on costs can be made (and even then it will have to be cost controls or some form of rationing). Democrats and Republicans, agree among yourselves on a percentage (perhaps progressive) of income, more than which we do not expect citizens to have to pay for their healthcare, and arrange subsidies accordingly.
Democrats and Republicans, move toward even greater democracy by using national referendums to find out how much coverage people want and how much they are willing to spend (and how much they are willing to spend to have more citizens covered).
Work toward a compromise that represents the best that we can come up with at this time, and keep in mind that Obamacare would have been less disruptive if an incremental approach had been followed. A compromise will make it more possible for all citizens to feel that they are in the same boat on this issue, which will promote more good will about future improvements.
Democrats and Republicans, don’t make rationing sound evil. There will come a time, perhaps after you are no longer in office, when some form of restrictions will be necessary, so educate the public now about how their own desires for healthcare, plus continuing advances in healthcare procedures, will lead inevitably to restrictions (barring some future energy or materials discoveries that drastically reduce manufacturing costs).
Democrats and Republicans, design goals and measures by which you can later judge whether the policies now adopted have “worked” or not, and include these in the legislation. Everyone will always be able to make excuses and to claim that these policies would have worked if some person or circumstance had been different after the adoption, but it will help in designing the policies if you know how you would measure it.
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