Channel Mike

I told my dad that I would let him know about my opinions and positions on what our federal government ought to do, and ought not do, about health care in the United States. This topic is, obviously, huge. There are facets related to providers, insurers, the role of government, conflicts of interest, pharmaceutical companies, the FDA, etc. Health care is gigantic. Arguments for full privatization and for a full government takeover are both valid, but can't both happen. So what should we demand of our government? A hands-off approach? A regulatory approach? A take-over of the system?

Without going into too much detail, I think that a state-run health care system could (not necessarily would) be in our country's best interests. I am fiscally conservative, believing that our government should stay out of our business as much as possible. The big sticking point is always the "as much as possible" part. Conservatives want the government out of their wallets. Liberals want the government out of their bedrooms. I think we all have common ground, here.

The largest unanswerable question in health-care is, "Is health care a basic human right?" Your answer to that question is one based on your own personal beliefs and values. It is a purely ideological question, and demands a purely ideological answer. No cost-benefit analysis can answer it. Science can't touch it. It's all about what you value. And the answer to this one question will help to answer every other question about health care in the context of government control. I could go either way, here. I believe very strongly in the idea that people must be responsible for themselves. I detest the entitlement attitudes that people have today. These beliefs push me toward the privatized approach. But I also see the reality that people will be beset by health problems that are outside of their control and outside of their financial capacity to fix. Do we, as a society, simply let them die? The answer to the "human right" question addresses this dilemma, too. If we believe that health care is not a basic human right, that it is a luxury to be enjoyed by those who can afford it, we as a nation and a government simply let the sick and poor die. If we believe that health care is a basic human right, we have no choice to make the federal government responsible for it. No other entity can be without gross conflict of interest. The federal government is the only entity in this country that has the best interest of the entire population as its responsibility. It is the only entity in this country that can reasonably spend money on a program that will not return profits. Even non-profit health care organizations must break even financially.

I'm tempted to wipe the slate clean and start from scratch, defining health care from the base relationship between a patient and his/her doctor, then expanding from there. But this would be avoiding so much of the reason that we have a debate in our country this decade. There are real problems that must be addressed and avoided. Lets define a few of these problems.

In the American health care system of the early 21st century, the decision-makers are not the payers. The individuals who must choose which doctor they will see, which hospital they will visit, which drugs they will take, and which treatments they will undergo are not directly paying the bill. Insurance companies are paying the bills. This, in my mind, is the single largest contributor to the problems in health care. It doesn't stick out and cause problems directly, but it creates the environment for numerous problems to pop up. In the same way that rights and responsibilities are tied together in other arenas, the right of choosing health care providers and procedures must be linked with the responsibility of paying for them.

The first problem is that people are over-using the health care system. This has gotten better as co-pays have risen steadily. But a patient usually doesn't even have to ask a doctor what a procedure will cost. If it seems important, do it. The insurance will pick it up. It gets much more complicated than this with pro-rated payment systems for the patient, multiple co-pays depending on procedure, and different prices from providers depending on who's paying the bill. But the main thrust here is that if individuals are not paying directly for their health care choices, they'll use more health care. We have not evolved to appreciate long-term costs for short-term benefits.

The second problem is that providers know that ramping up the cost of care will not deter patients from demanding it. So they charge more and more, knowing that the patients deciding to buy the procedure don't care what it costs. This, too, is more complicated than I can cover in a paragraph. Insurance companies are constantly fighting for lower prices, at least to them, on many procedures. And the doctors are forced into a complicated system where they will give on one procedure to stay on the insurers' plans, then have to gouge on another to keep their profits up. After all is said and done, the same amount of money (on average) is changing hands, but in a complicated fashion that requires lawyers and office-staff to deal with. This additional overhead is also driving up the costs of health care.

Continuing with increasing costs, we have another balance to achieve. One one side is the reality that high-priced health care generates revenue and incentive to innovate. Our health care complex is creating new drugs, new machines, and new procedures that are increasing the quality of care for the entire planet. Unfortunately, along with this increased quality comes increased price. The cost of these procedures is prohibitive. Ordinary people simply could never afford major medical procedures on their own. This dilemma tips back to the first question, where do we place the value of this care? Is it a basic human right to have an expensive cancer treatment? Or is this an investment that should be up to the individual being treated? And even if it is a human right, how much of our federal budget are we willing to set aside to provide this care?

The conflicts of interest are numerous. Insurance companies have the main goal of profit. This is indisputable. Except for a few not-for-profit organizations, health insurance is a for-profit venture. They must make profits or their investors flee to other ventures. Without impugning the integrity of any executives, I'll say, without hesitation, that they have a strong financial interest in denying as many claims as they can legally justify. The more claims they can deny, while avoiding expensive lawsuits, the higher their profits.

Doctors, Hippocratic oath aside, could make a lot of money by keeping their patients just sick enough to require frequent visits, and occasionally sick enough to require a procedure or two. I'm not accusing doctors en masse of doing this. I believe that the vast majority of doctors are doing what they believe to be best for their patients. But the conflict of interest is plain. Healthy patients only need doctors once every year or two for general checkups. Dying patients will spend a gigantic amount of money to postpone death for a week or two, then they'll be gone. The real money-makers for unscrupulous providers are the patients who need routine care.

This brings me to the drug companies. If all Americans ate healthy foods in moderation and exercised regularly, not only would they not see doctors as often, but they wouldn't need any of the current top-selling drugs either. Lipitor alone pulled in $12,900,000,000.00 in 2006. Divided amongst the 301 million Americans, that works out to $43 per year for each human in America going straight to Pfizer. They certainly have no interest in healthier Americans. The more Americans with high cholesterol, the bigger the market for the drugs.

So, everyone is fighting for a bigger chunk of the health care pie, and even trying to enlarge the pie by creating drugs for things like restless leg syndrome. The system, as it's setup, will continue to get more expensive, incur more overhead, and grow larger, taking more and more money to operate. How do we stop it? The Republicans claim that we can't do anything without violating the rights of our free-market corporations to make a buck. The Democrats think that providing more insurance for the uninsured will fix it. But from the context I've laid out, neither group stands a chance of improving anything.

The simple solution to any frustrating problem is to just nuke the whole thing and start over. What if we eliminated insurance, medicare, etc. and took the overly-conservative approach? What if we just went with a simple fee for service system? Individuals would have to weigh their own choices for health care. Every transaction would be between an individual and his/her provider. Providers would have to compete on both quality and cost. People without a lot of money would simply get sick and die now and then with too few resources to fight it. This is an archaic system, but still may be better than the system we have today. It would be the responsibility of each person to make sure they are staying healthy. If they were not healthy, it would be their own problem. When they need health care, it is the responsibility of each person to weigh costs against benefits and choose treatment. We would have a much leaner, more efficient system. This would eliminate most of the conflicts mentioned above. But it would also re-introduce the problems that our current system has "fixed." There are reasons that health insurance companies have sprouted up and grown over the last 50 years. They allow people peace of mind that we can have known costs for our health care whether we are healthy or have a car accident or get cancer. The real effects of the health problems are still there, but HMOs, PPOs, and actual health insurance plans spread the risk of catastrophic medical bills over the entire population.

A more complicated solution is to pull back from the laissez-faire system of the right and move fully leftward to a fully government run system. The federal government has a mandate to keep the best interest of the people above the profit-motive of the private sector. There are no other entities large enough, even if one did somehow have the appropriate motivation. I don't buy for one second all of Reagan's ideas about the government being scary and inefficient and wasteful. Of course they are inefficient and wasteful, just like any corporation. Rather than throw it out on that basis, why not demand more efficiencies? At least they won't have CEOs driving the program into the ground and walking away with hundreds of millions of dollars for their failures. The question for any privatization or public takeover is too complex to be dealt with by throwing ideological one-liners back and forth. The decision requires honest debate over the benefits and the costs; and with a public takeover of health care, there would be many benefits, and many costs. The costs would inevitably be higher taxes, but rather than reflexively scream out, we should calculate what we're paying for our health insurance today (roughly $12,000 annually for the average family) and weigh that cost against the tax hike and benefits we could expect from the government. If we could get the same care for $10k, we should applaud the savings rather than complain about the taxes. The biggest benefit of this system is that it would make financial sense to push real preventative health care. By teaching proper eating habits and exercise habits and comparing them with existing habits at regular doctor visits, we could reduce so many of the costs that plague our system today. The biggest downside is that the reduction in cost we would enjoy as consumers would reduce the investment in new technologies and drugs. There would still be investment, but I think the health care industry would become more like the military-industrial complex. Money would be passed through lobbyists more than through real funding of innovation.

It appears from my oversimplifications that our choice is to eliminate it all or give it all to the government. But neither is a real solution. They both have tremendous downsides. Can we somehow have the benefits of insurance, the benefits of high-quality service and products, an abundance of good doctors, quality drugs, and avoid the problems we have now? The only way is to have an independent party referee the whole thing. The feds can either regulate it or own it. I've now at least mentioned the only four alternatives to any system. First, no system, or simple fee-for-service. Second, laissez faire capitalist private health care. Third, completely public government-controlled health care. And fourth, some sort of regulated private system, basically what we have now.

There is little doubt that we currently have a private system with minimal regulations from the government. As much as I hate regulations, I think they're the only option we really have. In today's world, it's inhumane to allow people to die when we have the technology to help. For this reason, purely private health care will not fly. We also have a political climate that prevents the people from trusting our government. For that reason, purely public health care will not fly. The only option left is a private system that is regulated by the federal government. I don't know the overall answers. Like all real problems, any answer has benefits and costs. I hope, though, that we will be able to see through the simplistic sound bites of our politicians. I hope that we'll elect leaders capable of seeing complexity rather than just ideology. Post your opinions here, or send them to your legislators.