Monday, May 8, 2017

The debate on a national health care system. A few random thoughts

 Ambulances, Ft. Huachuca, 1918.

I should pay more attention to the debate going on about health care than I do.  I really should. It really matters.  I've posted on it a few times, but for some reason it just isn't the burning issue for me that it with some.

Which leads me to my first point. There are some pundits out there declaring that the GOP sponsorship of a new bill, repealing the Affordable Health Care Act, means they're doomed in the mid terms as they're hurting their constituency.  

The pundits, once again, are delusional.

This entire talking point assumes that the entire nation including the rust belt voters have immersed themselves in the topic of medical provision, concluded that a national health care system is needed, and are now debating the best one, and have concluded that was the ACA.  Learning that they personally will loose benefits, they'll become outraged.


The debate on health care on the street level isn't about this at all.  It's more visceral.  And it really deals with how much the government should do.  You can have a visceral negative reaction to something that's good for you.

Take Prohibition for example.  It was a health care success, benefiting those at the bottom of the economic rung the best. So we kept it, right?

No, we repealed it, and the reason we did is we just didn't like people telling us not to drink.  The health care debate is like that.

Which doesn't mean it isn't being treated like the opposite, and doesn't have some of its features.  Demonstrating another point.  When the government gives out benefits its deuce difficult to take them back, and that is something that really should be taken into account whenever that is done.

Free and reduced school lunches, Federal involvement in pre school education, Medicare, Medicaid and a million other programs are such examples.  I'm not saying that they are good or bad.  What I'm saying is that whenever these are debated, they're debated in terms of adjustment, not taking away. Because once you give a benefit, it's really hard to take it back, and soon it becomes viewed as a right.

Free and reduced school lunches, and now breakfasts at least here, are a good example.  When I was attending school everyone, no matter how poor, had food provided by their parents.  If a parent had failed to provide this basic need, they'd have been looked down upon by everyone and they probably would have received a hostile visit from the state.  Now, nobody views this in this fashion and its accepted that the local taxpayers will feed the children of those who can't feed their own.  Is this bad?  I'm not saying that (although there are interesting moral elements of it all the way around). But what I am saying is that good or bad, and in economic times of plenty or lean, it's going to be done. We started doing it, and not doing now seems unthinkable.

Which brings me back to why some folks have true complaints about the Affordable Care Act.

Most people do feel that everyone needs basic medical care.  But what does that mean?  Democrats, in this debate, like to throw in "Women's Reproductive Health" and indeed there are now quite a few people who feel this is a national right.  But what that really means is that the Federal Government is subsidizing sex.  

There's something flat out weird about that, but beyond that a lot of people find that when we reach this particular point we are reaching the limits of what they can tolerate under their own belief set, and they'll push back irrespective of what people like David Frum think about it.  

To some who hold philosophical ideas about the nature of liberty, this entire concept is truly abhorrent.  How can we justify taxing everyone so that some can avoid the natural results of their biological acts?  Does this impinge on a concept of individual liberty as it creates universal responsibility for an individual act?

To other social conservatives this is just childish. The basic argument would be "grow up and take care of yourself if you are acting like adults". And there's more than a little to that.  If people are adult enough to act like adults in this fashion, well, what happens is their problem, this argument would go.

For fiscal conservatives it couldn't be weirder.  Taxing everyone to pay for an individual biological act is bizarre.  It would make just as much sense to tax everyone to pay for food for everyone, and indeed it'd make a great deal more sense.

And of course for some its deeply offensive to their religions, and they're put in crisis by such a bill.

Which brings us to this.  A lot of "affordable care" isn't medicine, but sociology.  When you medicate to prevent the results of a healthy body doing a biological act that's not medicine or it certainly isn't necessary medicine. It's nearly the opposite. And objecting to that makes a lot of sense.

Which, in this particular era, brings us to the topic of how much do we want to cover?  Nobody wants the ill to go untreated.  But do we extend to the margins of science?  Are we going to cover birth control, abortions, cosmetic surgery based on self identity?

If it seems like we haven't really discussed all these things its because, well, we haven't.

And what about costs?

A lot of the reasons that health care is so expensive is that its improved so much over the past half century.  But another is that we don't regulate the price of things in our sort of economy.  We don't really know why things cost what they do.

But we do know, if we are honest, that a national health care system that actually works, and we aren't there yet, will control costs.  People who think otherwise are delusional on this point.  No national health care system that includes everyone will function until taxes are levied to pay for it and costs are controlled by the payer. That's a fact.  And in that sort of system, the money flowing into medical practices and medical industries will have to ultimately decline massively.  And some of this will result in reduced services, probably, and indeed perhaps rationing of one thing or another.

Again, I'm not saying that is good or bad.  I'm saying that flat out is.  It happens to an extent already as health insurers never pay the full rate of anything, nor do government entities like state run workers compensation systems.  But the extent which this would have to occur in a national system is huge.

Which takes me to a prediction. 

At the end of the day, in a nation as big and diverse as we've become, but in an era in which medicine is so advanced and so expensive, we're going to end up with some type of single payer system sooner or later.  We'll have to. We've started down this road, and that's where we will end up.  We're not going back to the pre Affordable Care days, and we're not going to wipe out health insurance and go back to 1939.  So we're going forward, and that means sooner or later we're going forward into one system.  It might be fifty systems mandated by the Federal government, perhaps with health carriers bidding in, or it might be a giant workers compensation type system. But that's what we'll end up doing.  When we get there, there's a good chance that what it provides will be limited by national consensus, or discord.  In other words, my guess it'll pay for all emergency medicine, basic treatment, but if you want birth control pills, your hooters enhanced, or an ugly scar across your chest removed, you'll have to pay for that yourself.

Later rather than sooner, but that's my guess, for good or ill.

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