The heart of a robust system of healthcare beats to a simple tune: Give every citizen high quality care at the lowest possible delivered cost both to the individual and the nation–the latter measured as the percentage of GDP accounted for by our entire healthcare system. A healthcare system that beats to this tune consistently delivers on several goals that determine quality of care: 1) people’s longevity, health and functionality are increasing relative to those of prior generations; 2) the healthcare they receive is convenient, comfortable, supportive honest and effective, and 3) their dignity and privacy are consistently respected. In such a system patients routinely report high satisfaction with the care they are receiving, the quality of their relationships with their primary care doctors and others in the healthcare profession with whom they work; they are not fearful that they will be denied the care they need; they are not swamped with confusing paperwork and contracts for service that make them fear they may be signing their lives away, and they are happy with the outcomes of their preventative healthcare and their courses of treatment.
For the system to function well, it must satisfy these goals within the context of two cost constraints: 1) cost of delivered care must not be concentrated on individuals with high healthcare needs but must be distributed throughout the population, and 2) the system must be organized to minimize the total costs, while maintaining quality, so that the price we all pay to provide excellent healthcare for everyone is as low as possible. When quality is low and costs are high the system is failing. When care is unevenly distributed and quality varies widely, the system is failing. When costs are concentrated on some, causing them to forgo healthcare that they need or lose their shirts to get it the system is failing. Simple, right.
“Yes,” some say, “this is simple in principle, but it’s just a fantasy. You can’t have your cake and eat it too.” Well yes, that may be the case if: the system we’re working with is organized to achieve these goals; we’ve reached the physical limits of longevity and quality of life, and there’s a hard-wall limiting our capacity to innovate in delivering quality and efficiency improvements to the system. In the United States, none of these conditions hold. We’re paying more for less service and we’re living shorter, less healthy lives than our counterparts in many developed countries. Consequently, we can design and run a healthcare system that delivers on all these goals, provided that we design, manage, evaluate and compensate it correctly–and that’s where the Republicans come in. They don’t want these things, not remotely.
Yes, they gesture vaguely in this direction by talking about things like “patient-centered care,” hoping that we will infer from this language that they actually want to bring down the individual and national cost of healthcare, while driving quality up, but nothing could be further from the truth. Their interest lies in concentrating money, power and resources in the hands of the big healthcare industry players, regardless of the effect this concentration has on delivered care, cost and outcomes. They don’t want you to know this, so they are framing a conversation that diverts our attention from these simple, reasonable and achievable healthcare system that serves everyone well without breaking the bank. They do this by talking about “health insurance” rather than “healthcare,” and they market the idea of “universal access,” as opposed to “universal care,” as a means of delivering quality, efficiency, fairness and freedom to healthcare “consumers.”
Republicans want us to talk about insurance, rather than care– because this seemingly small switcheroo provides a big payoff for their clients in the insurance industry–it provides political cover for denying care while increasing insurance industry profits, even as such denial diminishes the effectiveness, the efficiency and the equitability of the healthcare system. Within the “insurance” model Republicans describe, denying people care for pre-existing conditions makes some sense, and they sell this internal logic well. Their argument appeals to our sense of fairness, and to the value we place on personal responsibility. Its a false appeal, but when delivered cleverly, one with emotional resonance.
The argument goes like this. Insurance is about the pooling of risk. This is true for any kind of insurance, auto-insurance, property insurance, workplace insurance and so on. It’s about about buying an option to cover risky bets, like driving a car, whose distribution of results can be predicted on an aggregate basis, but not at the level of the individual. When, however, we know things about a person with certainty, or in a way that alters this individual’s risk profile vis a vis the broader population (i.e. this person has a long history of DUIs) we wisely deny that individual insurance or alter his or her insurance fees to reflect what we know about this specific person.
That Republicans claim, is why we should not require insurance companies to cover pre-existing conditions. They illustrate the point with folksy anecdotes like one I heard last night, where an elected apologist for universal access held forth about a reputed friend of his who had “bursitis.” In this tale, the man with bursitis was unable to secure new insurance because bursitis was a pre-existing condition. The politician claimed that this man said he would be happy to pay for his bursitis treatment, because he was more than willing to take responsibility for his existing condition, but was still denied coverage because, and this is where the tale gets sketchy, under the law they couldn’t offer him a policy without coverage for bursitis.
The politician’s point was that his friend knew he had the condition. There was no risk, because the condition was a given and despite his willingness to take responsibility for this known he wasn’t allowed to. (Boy that sounds like government messing with personal responsibility and common sense.) Now wouldn’t it be better if we could take responsibility for such matters and get the insurance we need. It’s a folksy story, well told, and it goes down smooth. It’s the kind of story that’s not too easy to disagree with as its being told, but this pol, like so many of his colleagues had slipped a Mickey in the drink.
The conditions we care about are not relatively minor (albeit painful) conditions like bursitis, but big things like cancer, diabetes, sickle-cell anemia, Alzheimers, heart-disease, and a host of other high cost debilitating conditions that no average American could adequately treat, especially given rules preventing Government bargaining over price, within their own resources. Allowing insurance companies to deny coverage for pre-existing conditions like these means that millions of Americans will not get the care they need and that they will live shorter, less productive lives with unnecessary suffering for themselves and for their families. (Of course there are other ways outside of insurance to provide health-care, but I’ll get to that later.)
The costs born by such preventable circumstances will not only be carried by the individuals unfortunate enough to have denied conditions, but by their families–in the form of stress, economic loss, and diminished productivity, and by their communities who will have to deal with the social consequences of the needlessly frayed and diminished lives resulting from a policy that invites widespread denial of existing conditions. For a party that claims to be “pro life” and to believe in “family values,” this seems a mite strange, but “you know it would be great if it could be different, but that’s not how insurance works.” End of story. Or is it?
Of course not, this bait and switch story is based on a big lie, a very big lie. The big lie is that the efficient, effective delivery of healthcare at the lowest individual and aggregate cost maps directly and completely onto a profit maximizing health insurance model. It does not. When providing healthcare, as opposed to insurance, what we care about is “pooled cost,” distributed over the population, not “pooled risk.” These are not the same. Pooled cost means that, together, we’re going to pay for the total cost of the healthcare system and to find a way to distribute that cost in our society widely, so that people who have serious medical problems can get the care they need when they need it. When we think in terms of “pooled cost,” we have enormous incentives also to reduce risk, by providing preventative care, support for healthy lifestyles, and innovations in treatment that produce better and less varied outcomes. We also have incentives to cut fat from the system, real fat, like insurance, which only covers “pooled risk,” being used as a poor proxy for real health coverage while delivering billions in unjustified profits to its providers, imposing layers of bureaucracy, bargaining and paperwork that dramatically increase cost to providers and increase the risk of patients confronting uncertainty about what care they can and will receive.
This is not to say that a well designed healthcare system might not include an insurance component. My own view is that a capably organized single payer model that allows for free choice of providers within that structure is the best alternative, but one could imagine other options such as comprehensive care plans offered by competing providers (not insurance companies), who as part of their risk management strategies might insure against catastrophic costs at the level of the group, in essence laying off some of the risk to a larger pool. The critical factor in designing policies and institutions that meet our healthcare needs, foster innovation, distribute care equitably and drive down cost, will be ensuring that the focus of policy reform is on healthcare, not health insurance. Insurance, a tool, not an end in itself. It might be part of a larger equation, but its logic is inappropriate to the situation and should not frame the debate. So how did we get to the big lie in front of the circus tent?
In common parlance we tend to use the term “health insurance” to mean the coverage we need to ensure that we get proper, dignified and effective healthcare promptly when we need it. By insurance we really mean coverage for care, not insurance in its technical sense. Republicans know this, but they are substituting a technical argument about what insurance is for what we actually mean when we throw the term about at the kitchen table. They’re doing it to keep the nominal terms of the debate the same, but to change their meaning. It’s an old trick, and a clever cover for a big lie. In the old days this deft maneuver was called a “chicane,” a “quibble” meant “to prevent justice.” If we want to do right by the American people, let’s concentrate on how to deliver great healthcare to all at a good price and not be taken in by these sellers of an all too dangerous policy elixir.