Universal Health Care

Health care seems to be on everyone's minds right now, and it will clearly be a top issue in the presidential elections next year. President Bush recently came out with a proposal to increase access to healthcare and lower expenses through a system of tax breaks. Wal-Mart went on the record yesterday, with various labor unions, setting a goal of universal health insurance coverage by 2012. Massachusetts and California have now instituted state-wide plans to provide universal coverage (though the Massachusetts plan is having problems, and the California plan is still in the formative stages). Many other states, like my own state of Washington, are pushing for similar legislation.

Back in 2005, I started a discussion on my Xanga blog about entitlements, primarily universal healthcare. I also posted my thoughts on the Massachusetts plan in April 2006.

On Monday, I came across a post on the John Edwards '08 blog touting Edwards' health care proposal. He claimed the support of "the blog world's health care policy expert", Ezra Klein (I've never heard of him, but that's no surprise). Following the link to Ezra Klein's writings led to a very thought-provoking discussion about universal health care on the American Prospect website.

The discussion aims to answer the question: "When it comes to comprehensive health care, what are progressives' core demands?" So, it is explicitly from a progressive-liberal point of view. But, because it is a discussion of "core demands", the discussion is one that all of us can relate to in some way.

Ezra Klein starts it off by laying out four non-negotiables:
* An End to Employer-Based Healthcare. He doesn't specify alternatives, but presumably publicly-funded insurance, tax breaks for individuals for private healthcare, and other systems would be options for him.
* Insurance that Insures. Meaning insurance that has to insure anyone without discrimination. Klein suggests regulation to force the insurance industry to set rates for whole communities as a group, and to accept anybody who applies for insurance.
* Progressive Universality. Everyone should be able to be insured. Everyone should be required to purchase insurance. Insurance costs must not be an unreasonable burden on anybody.
* Scalability. Basically, Klein is saying that whatever we accept now should be able to transition into a full-blown government-mandated income-redistributing social insurance policy in the near future without too much hassle.

Next, Merrill Goozner adds his thoughts to the discussion. He agrees with Klein that insurance must be universal and mandated. However, he disagrees with Klein about the possibility of a good compromise between employer-funded insurance and a full-blown government-run healthcare system. He points out that employer-paid insurance provides income redistribution on a small scale (because all employees pay the same for their insurance, regardless of their income level), a state which would not be likely to carry over to a private-coverage, tax-break system. That's an interesting observation I hadn't considered. Goozner's prescription is to simply go whole-hog to a government-run health system, and accept no substitutes.

He also suggests mandating some amount of spending on "preventive care and public health campaigns" as a way of "effectively controlling costs". I don't think we can count on such basic measures to realistically provide much of the significant cost-control that is going to be necessary. He also says that "[w]e should demand that the health care system stop draining the rest of the economy." I'm not sure, thought, how he proposes to make that happen. His third point, Quality, is the most confusing to me. He advocates offering everyone "high quality care that is the best that medical science has to offer", but says that "[w]hat it doesn't mean is offering everyone Cadillac care", meaning care options that are overly expensive for the benefit they provide. Of course, the huge question of who (presumably some government agency in a government-run system) would make such weighty decisions is left unanswered.

Jonathan Cohn joins the discussion next. He believes that some version of an employer-based system could be workable as part of a universal healthcare solution. He also adds one significant item that Klein didn't mention, and that Goozner glazed over... cost control. However, he doesn't have any substantive recommendations on that very important aspect of the discussion.

Maggie Mahar is the last participant (for now, at least). She focuses straight in on the cost-control side of the question, and frames the issue in terms of sustainability:

Today we need to launch a public debate that tackles a very sensitive question: how do we create a sustainable health care system that offers high-quality, necessary care to all Americans?

Ezra's proposal focuses on the second half of the equation -- universal coverage -- and, on that score, I agree with virtually all of his points. But I would add that we can't talk about covering the uninsured without addressing the next question: How do we pay for quality care, this year, next year, and the year after? How do we create a sustainable system?

Mahar goes on to face the cost issue head-on. She suggests that the source of the problem is in the nature of how we consume health products.

The health care industry is different from other industries because consumers rarely put a lid on pricing -- even if they have "skin" in the game. Everyone is ready to pay more for the newest medical technology because we have been trained to believe that the newest is best. And when it comes to preventing disease, who wants anything less?

She elaborates on this theme in great detail, and (in my opinion) convincingly. She finishes her thought by arguing that if we could cut out the wasteful use of healthcare that has become prominent in our society, that funding universal healthcare would no longer be an issue.

I agree with most of the goals laid out by these authors. I am not optimistic, though, that any effective solutions will be as readily available as they have proposed.

I agree with the authors above that everyone should have a health safety net. I'm not sure I agree with them about specifically what that means, or how much would be included in that safety net.

I am pretty well convinced by this point that, for an insurance system to function, there must be mandatory buy-in. This system will, of necessity, be some form of income redistribution system. Mandatory buy-in is a more free-market way of doing that redistribution than taxation, and I tend strongly toward support of free-market solutions.

I can see the flaws in an employer-run system, but I can also see that it might be the most workable solution, so I am ambivalent on that point (for now).

I am not interested in Klein's view of "scalability", since I am not convinced as he is that full-out government-run health care is the best end result. In fact, I have a strong suspicion it would not be a good way for this process to end. So, while he is willing to aim for a potentially interim transitional phase, I am much more interested in finding a solution that is, as Mahar put it, sustainable, and intended to be sustained.

I agree with Mahar that the cost issue is unavoidable, and is a key to solving our healthcare problems. I'm not sure exactly how to approach the cost issue, but I think the blame falls very widely, on nearly all the participants in our healthcare system.

I've got much more to think through on this, but this post has gotten long enough. In another post soon I'll go into more detail about the problems I perceive on the cost side of the healthcare system. I'm hoping that the comments here will generate other lines of thought and discussion as well.

So, what are your thoughts? Which of the above writers do you relate to the best, and why? What do you think are the most important goals we should set as we work to rework our health care system? Do you think our health care system even needs to be reworked? What other aspects of the problem should we be considering?

Mark