Everyone weighs in on the health care debate--it's became a national pastime--so why not massage it some more?
Blue = Single payer universal health care
My take on the problem is not unique, but I do notice that almost nowhere in the media are the key underlying--and crucial--issues really being addressed. The problem is expressed in what I take to be three major areas:
1 Budgetary constraints
2 Cost of services
3 Conflicting priorities
They're interdependent, of course, and can't be addressed discretely apart from one another. But it's helpful, I think, to point out some obvious facts, and to try to see the dilemma in a non-partisan way.
First, universal health care is a relatively new phenomenon. It's been around for a little less than a century, though in its present forms it's only been around for a few decades.
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Green = Public universal health care through other means
Grey = No universal health care
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There are basically two issues with universal care: Level of care, and degree of inclusion. Also, health care availability and quality varies according to context: Universal care in an "undeveloped" country is really no care at all. Quality care involves expense: Research, modern sophisticated technologies of treatment, comprehensive training and certification and licensing of providers and facilities--these are all expensive things. Modern medicine is a highly developed estate. In 1900, for instance, medical "care" was many times simpler and less effective than it is today, and was as a consequence much, much cheaper.
Second, there's been a geometric increase in world population since 1900. It's quadrupled, approaching 7 billion people in 2010. The world's actual resources haven't grown by a single molecule in that century; what that means in real human terms is that the world is actually over four times poorer, on a per capita basis than it was in 1900, because that many more individuals now depend upon the earth's bounty, and the rate by which we're using it has increased geometrically as well. Everyone knows this growth rate is unsustainable, but almost no one talks about it publicly. "We'll find new ways of addressing these problems, science will make advances, the growth rate will naturally moderate," and so on. The cost to feed, cloth, shelter, employ and care for each human individual is a staggering burden on the planet.
The price tag attached to every person's long-term care, severe fatal or chronic disease or malady, given the contemporary approach to treatments, is far, far beyond society's resources to afford. If, for instance, we sought to deliver sophisticated, comprehensive medical care to each individual in the world today, there not only would be no money left for anything else, the world's economy would crumble under that weight. Acknowledging this fact is the first step in realistically addressing any so-called "solutions" to the world health crisis.
It's generally acknowledged that the Third World's health problems won't be solved, can't be solved, until or unless its burgeoning population can first be brought under control. Conquering infant mortality, and extending life-expectancy have been wondrous accomplishments on one level, but the resulting success of human increase is the flip-side of the coin of our advance as a species. Successfully overcoming the natural curtailments of our numbers, has meant that we've rapidly accelerated our exploitation of the world's resources to meet the extraordinary demands placed upon it. The demand for health care--like the demand for food, materials for shelter and textile, and energy--has risen far faster than our actual ability to meet that demand, and today it is far beyond anyone's wildest ambitions.
Probably the main reason that national health systems have "worked" in certain countries, is that those economies have not been overburdened by other priorities, specifically military expenditures. As a share of national product and expense, universal coverage easily trumps every other priority. Indeed, there are those who believe that the national health model has only been a brief open window of opportunity, and that eventually these systems, as popular as they may have seemed up to now, are destined either to fail, or to result in compromised delivery.
To take an example: If, say, the world were to have limited its use of petroleum to levels that were typical in 1935, the "horizon" of world petroleum reserves would probably have been 3-5 centuries. Today, with all known reserves, and at the steeply accelerating rates of consumption, it's unlikely that oil, as a predominant source of energy, will last much beyond the current century, at which point it will already be running out.
Are there sufficient possible "economies" of scale or application that could stem the increase in medical care costs in the short term? Even if we limit the discussion to the "civilized" economies of the West, it's unlikely that this will ever happen. Either the quality of care will decrease, or the numbers of those whom society deems eligible for care will decrease--or both. We're already seeing that insurance companies are "dumping" policy-holders in order to control costs. There's a troubling margin in for-profit insurance companies, but this is merely a footnote to the problem. The government already has shaken the society down: Need-based health care has been around for half a century, in the form of Medicaid, for instance. The amount of confiscated capital in the health insurance industry is just a tiny fraction of what it would cost to provide real universal comprehensive care. This is what the Republicans are fighting against: If our country opts to "entitle" all the uninsured and underinsured populations today, eventually the cost will far outdistance our ability to pay for it. Indeed, as history has shown, any publicly underwritten health policy has had the effect of driving up costs rapidly. This is what conservatives mean when they talk about capital transfers or confiscations: If the bottom 25% of the population, in terms of income, becomes lawfully entitled to comprehensive federally funded ("free") health coverage, the burden of that expense will inevitably fall, at least to a proportional degree, upon the rich and the corporations. The medical industries could effectively starve the Federal and State budgets of the entire nation in the long run; and in the short run, they would shoulder aside virtually every other budget priority, including military and defense spending.
Also, in the short term, budgetary priorities are showing just how meager the fruits of our economy will appear, once we start measuring them against the theoretical promise of universal coverage. During the Bush II Administration, money that might have been devoted to funding universal coverage was spent instead on foreign military adventures, and awarding tax breaks to the rich and the corporations. We have spent a trillion dollars on these wars since 9/11, a dead loss to the American taxpayer, since our petroleum interests, which might have been the only sensible reason for our Iraq invasion, came to nothing: The Chinese have been securing oil leases all over the world, without firing a shot.
True estimates of the eventual cost of universal coverage, under our highly sophisticated and advanced medical care system in America, are staggering. Ten trillion dollars by 2015? More! The fight over what burdens this will place on our Federal budget will get bloodier as time goes on. Why are the Republicans so partisan about holding the line against universal coverage? Because they realize that as the middle class shrinks--as America loses more jobs, and as its economy declines in real terms compared to China, India, etc.--the burden of taxation will fall increasingly upon their constituencies (the rich, the business interests, and foreign debt holders). What is happening, today, is that China and Arabia are lending America the money to run its government programs. Each new obligation we add to the burden means America--its economy--becomes that much more dependent upon the pleasure of the holders of our paper. At some point, too, America's position as the primary consumer of commodities begins to decline; when the Chinese and Indians realize they have no reason to prop up a failing giant, will they have any reason not to call in those obligations, or to stop lending to us altogether? On balance, then, our declining economy will mean that our ability to care for our own population will also decline. In several senses, Americans have been living on borrowed time over the last three decades. Nearly every indicator points to a lower standard of living for the great majority; and that includes health care, as well. Rather than "controlling health care costs" we will end up choosing whom to exclude, whom to privilege. The criteria for that will inevitably be cost. The marketplace ultimately will decide.
Debt obligations aren't open-ended. Faith in institutions, no matter how "big"--does have limits. Our Federal government will never be "too big to fail." What is the tipping point at which our ability to "sell" our debt becomes untenable? When do "U.S. Bonds" get reduced to "junk status"? When unemployment rises to 20%? When we close our public schools? When we stand down our uniformed forces? How far are we from a general national collapse, based on the amount of debt we seemed determined to take on? Can you think of any reason why China--probably the most selfish nation in the world today--would be inclined to "help" America if we fell into a deep 1930's style depression? The only argument I've ever heard is that they "depend to an inordinate degree" upon American markets for their goods. But if that market were to dry up, what then?
The world's resource balance is not open-ended. Our ability to provide comprehensive health care isn't either. The ultimate rebalance against the world's ability to provide for its excess population will result in human suffering on a frightening scale. Nationally, we can look elsewhere with remorse upon the millions of humans who suffer from hunger, disease, and early miserable death. Because we refuse to control our populations, this is the unavoidable consequence; the fact that it's happening "elsewhere" allows us the comfortable complacency of believing that there don't have to be any losers, that it's not a zero sum game. Expressed in terms of health coverage, it may appear as an illusion of priorities--if only we could be smarter about allocation, everyone could be saved. But the hierarchy of priorities--the bell-curve of who gets what, across the spectrum of nations and economies--will eventually involve choices.
But there won't be any good choices.
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Addendum 3/3/10
I wish I believed that the government could organize and administer health care, while controlling costs. The government system model is being tried in several countries presently, but the jury is still out on how successful those models will continue to perform in the long term. But the point of my post isn't to set up a dialectic between "private" and "public" administration of coverage. My purpose is much larger, and may be pointlessly conceptual.
To restate: The earth's population has literally outrun the resources (both natural and "human") needed to support it. That shortfall notably includes medical care. Our view of American health care seems to be controlled by a couple of spurious assumptions: 1) That it would be possible, given the available resources, to deliver health care to every American, without somehow compromising every other budgetary priority, and 2) The amount of "profit" to be derived from any "for profit" social insurance system provides enough excess margin to make up for any shortfall in the cost of running a universal system.
If we extend the context to include the vast numbers of uncovered individuals in the so-called Third World, it becomes clear that global universal health coverage is truly unattainable. With the growth of the so-called "global economy" we're seeing that our traditional American historical insulation from other participants in the world economy is evaporating: The world economy truly is a zero sum game. Everyone can't be rich--and as population grows, the numbers of those who stand to be excluded grows, not just in terms of separate nations, but in terms of discrete classes of patrons.
America has a capitalist economy. Socialistic revisions of that system have been made, which moderate certain of its more destructive effects. It may well be that the American health insurance industry could be nationalized. That would allow us to claim that we had universal coverage, but it wouldn't generate more revenue. If we went on a pay-as-you-go basis, the budgetary compromises would end up looking exactly like the "arbitrary" measures private insurance companies engage in, i.e., some treatments, and some individuals would end up being deferred, or denied.
The idea that the only thing standing between the present situation, and a fully functioning universal health care system, is the elimination of the profit motive, is a serious delusion. What we could end up with would be a two-tiered system in which the rich would still acquire high-level treatment, while everyone else would be thrown into a third-rate system with compromised quality all down the line, because the cost to insure and treat the bottom 25% would easily drag the rest of the population down.
In my view, the real culprit in all this is the decline of the American middle class, with the resulting decline in real per capita income, occurring at just the moment in our history when health care costs are climbing rapidly.
Take the auto industry. America's on the verge of losing all automobile production to other national economies. The loss of that capital--and the fruit of that capitalization--is staggering. Millions and millions of jobs lost, buying power gone, and all the things which that capital once afforded--including good health care policies.
Gone.
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