Arguing about health care
eridani@scn.org
Effectively convincing people who haven't spent much time thinking about health care policy requires countering the blather that the likes of Harry and Louise have been using to make people in the US afraid that however bad the current situation is, change is too scary and government is bad anyway. The market is good, no matter what problem you are addressing. A way to effectively counter this attitude occurred to me after listening to Dennis Kucinich speak in Seattle. Talking about his universal health care plan, he said, "The market has failed!" three times, with an invitation to the crowd to join in, which people mostly did. He was, of course, preaching to the choir. This is a slogan that will cut no ice with the "market good, government bad" crowd, and it caused me to think about the various ways in which it could be taken.
Obviously, what Kucinich meant was that the market has failed to deliver health care, but the statement taken plain could also be seen to refer to markets in general. In that case, anyone who bought a computer ten years ago and has upgraded recently (and who almost certainly doesn't spend any time on being a health care policy wonk) is going to think "What on earth is this idiot ranting about?"
Clearly the markets for health care and the market for computers are pretty different. If you ask free market believers what governments should be doing, they will often say something like "Roads and police and firefighting are legitimate government occupations because that is infrastructure." What we need to do is to present a good case that health care is infrastructure too. Almost no one will argue that government should have no role in creating and maintaining infrastructure, other than a few Libertarian hard cases whose arguments are ignored by average citizens anyway. Health insurance paid for by individual is extremely expensive, and people who pay that way commonly feel ripped off because after they pay, they never see a penny of it. But if health care is infrastructure, it is analogous to police and fire protection. These services are also expensive, but do people feel that if their houses don't burn down and they don't get assaulted or robbed, the property taxes paying for these services are a ripoff? Should the expenses for these services be paid only by the people who are immediately served by them? Obviously not.
The slogan "Health care is infrastructure" beats "Health care is a right" as well. The latter makes people think of endlessly inflating entitlements that will drive the country into bankruptcy and still not satisfy everyone. Saying that health care is infrastructure not only directly and inevitably implies that health care is a right, but it gets people thinking about the issue in the most productive manner, namely as active citizens responsible for helping to determine public policy.
The reality is that health care providers and firefighters are very similar in an economic sense. Computer makers want to sell more computers, and people always want more memory, more bandwidth and more speed, but people would rather not get sick and rather not have their houses burn, but want effective help fast should those things happen. Imagine a city with three or four fire departments, paid for by dozens of different employer insurance schemes plus a few subsidized plans for the poor which a lot of low income people earn too much money to qualify for. A real mess, right? The firefighting equipment has to be duplicated several times, and the private insurance is always shifting around with employment patterns.("Whaddya mean you won't send a truck out? My employer turned in the new insurance paperwork last week!" "I'm sorry sir, but you must still be with Company X. We don't have you in our records.") And you'd also have a bunch of sorryass parasites sitting around trying to calculate which zip codes are likely to have the most fires, so they can stick their unlucky inhabitants with higher fees. Also each company would adjust prices dramatically upward to include profits as well.
Since no city in real life is actually stupid enough to have several different fire departments, there is no way of comparing that hypothetical situation with the current state of affairs in the provision of health care. But this was not always the case. There used to be private fire departments, and markers designating fire protection eligibility can still be found in antique shops. If your neighbor's house caught fire from the cinders of your fire, your personal firefighting service would just let the other house burn. If there was a dispute about coverage, competing services would often spray more water on each other than on the fire. Before the revolutionary war, that well-known commie rat bastard Benjamin Franklin put a stop to this practice with America's first public fire department in Philadelphia.)
We do know what happens to health care prices in towns with more than one hospital compared to towns of similar size with only one hospital-namely that the more hospitals, the more expensive health care is. And it's perfectly obvious why-if you think about the proper economic analogy, namely that of the fire department. And it's exactly the opposite of what happens with restaurants, barbers and computer manufacturers-more of those means better and cheaper products and services. Since firefighting is paid for as a public investment, they'll go to a house of $100,000 assessed valuation just as rapidly as one with a million dollar valuation, even though the property taxes are higher in the latter case. People in wealthy areas may have some overall service advantages, but the difference is trivial compared to the difference between people with and without health insurance.
Competition actually degrades performance directly as well. The single most important factor in determining your chances of surviving a complex operation is the number of those operations previously performed in that hospital. Divide the number of operations by the number of similar facilities in town, and you have calculated the relative incompetence factor. The same goes for firefighters-they keep their skills up by practicing on buildings slated for demolition that have been set on fire, or on fire towers which have serious restrictions as to where they can be located. Therefore there are limited numbers of these, and dividing them up among competing departments would mean that everyone would have lower skill levels. Compare this with computers, where sales and product improvement efforts mean more computers are made and sold. Somehow you just can't sell people on the virtues of having more heart attacks and house fires, so more competitors means less real-life practice for everyone.
In one respect, public payment for health insurance is more like paying for roads than firefighters. Just as roadbuilding is paid for by the public but almost always contracted out to private outfits, medical providers would continue to be private operators even though publicly financed. Road maintenance is done by both public and private employees-how you decide between the two options is by putting the matter up to public debate and arguing about it. (This is called "activism" these days, although it used to be just plain old "citizenship.")
That firefighting is a public business leads to putting arguments of how to pay for it in the public venue. Service providers will always want to do less work for more money, and service recipients want more service for less money. No conceivable social arrangement can alter that basic fact of life. What happens is that unions and professional organizations argue about the solutions in public, bond issues and tax rates are proposed, and everybody comes to a compromise arrangement. And there is no reason to think that the same process won't work with health care providers. You can't cover everything and pay everyone what s/he thinks s/he deserves, so you put all the arguments on the public table and come up with a compromise.
And this segues into other public policy areas as well. In the case of firefighting, there are building codes and enforcement to argue about, fire safety and extinguisher training, smoke alarm requirements, etc. In the case of health, there is urban design (making walking and biking easier, for instance), health education and awareness, arguing about how to evaluate various technologies for proven results, etc. By comparison, making matters of computer design subject to this kind of public dispute would be unbelievably stupid.
And finally there is the question of how do we afford single payer. Establishment opinion says that the Kucinich proposal is outrageously expensive compared to the proposals of other candidates. Of course they fail to mention that we would no longer have private insurance expenses, that out of pocked expenses would be dramatically reduced, and that we would continue to have the government funding that we now have. The fact is that we are already paying for universal health care-we just aren't getting it. Suppose your electric bill is $400 and you don't have that much. And suppose that you check your back yard and find out that someone is tapping into the line between the power provider and your house, siphoning off as much as they can get by with. All of a sudden the fact that you don't have $400 isn't the main problem any more.
The health care plans of all the other candidates (note that Sharpton and Braun just advocate single payer--they have no specific plans posted on their sites) are in fact more expensive than that of Kucinich, because they all assume that we continue to spend what we are already spending, but should add more to that total in order to further subsidize private insurance companies, who would continue to drain off funds in the pipeline flowing from the public to health care providers. For those who like equations, those plans would cost out as
Total proposed health care spending = Current spending + incremental proposal extra expenses - x, where x is whatever unknown amount of savings would be produced by the plan. (Extending preventive care, no matter how incrementally, can be expected to produce some saving.)
Kucinich plan = current spending only - x.
So remember boys and girls-HEALTH CARE IS INFRASTRUCTURE!
For a nice analysis of Canadian Single Payer with references, see below.
http://www.geocities.com/stewjackmail/pdf/uhc-canus.pdfA note on cost control--an analogy is controlling the movements of a herd of cattle. You can do the sensible thing and build a fence around them, allowing them to move freely within the confines, or you can hire a passle of cowpokes with sets of reins controlling each cow individually. The former is what Canadians do with global budgeting, and the latter is what HMOs and insurance companies do in the US. It's obvious which system gives providers and patients the most choice.
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