Healthcare in America — The Next Conversation Part 4 – So What Would Healthcare for All Actually Look Like?
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- Healthcare for all
So What Would Healthcare for All Actually Look Like?
We talk about healthcare for all as though America doesn’t have any healthcare at all. The talking voices on television can certainly make it sound that way, but as we have seen, we actually have an enormous and fairly robust healthcare system. It has its faults, some of them serious, but it provides medical care to hundreds of millions of people through several different programs, insurance systems and funding mechanisms.
What is lacking is coverage for the people who make too much for Medicaid, aren’t disabled, and are too young for Medicare. Some of them have employer-provided private insurance, some buy insurance through the Affordable Care Act, and some have no insurance at all. This is the group that lives in the middle, between the government programs we already have and the private insurance system.
We have looked at three systems that provide universal healthcare: Germany, the United Kingdom and Canada. All three have entirely different structures, and although government plays a major role in each, they ultimately depend on their respective taxation systems to pay for healthcare. There isn’t one magic formula for universal healthcare, and there certainly isn’t one that we can simply pick up and drop into the United States.
The fourth example we looked at was Norway, which is a little different. Norway is a social democracy that maintains a capitalist, free-market economy, but a large portion of its national wealth comes from oil production in the North Sea.
In 1969, Norway discovered oil in the North Sea, and the Norwegians made a decision that would eventually define much of their future: the wealth generated from that resource belonged to the country, not simply to the people who happened to control the wells. They didn’t spend it all at once. They built a system around it, eventually creating one of the world’s largest sovereign wealth funds and using the proceeds as part of a broader social contract with the Norwegian people.
We will come back to that later, because there is another question worth asking: why do the natural resources of our nation benefit so few people rather than the country itself? But that is another discussion.
For now, let’s get back to us.
We already have Medicaid, Medicare and the Veterans Health Administration. We have employer-sponsored private insurance, the Affordable Care Act marketplaces and millions of people who purchase insurance on their own. We also have millions of people who remain uninsured.
So if we are going to add another layer to cover everyone in between, what do we do about the systems we already have? Do we scrap everything and build one new system that covers everybody, or do we leave the existing systems in place and build something around them?
And when I say everybody, I really do mean everybody. Children, poor people, working people, unemployed people, young people, old people, disabled people and veterans, whether they were physically wounded during their service or came home carrying other consequences of their time in uniform. If the goal really is healthcare for all, then eventually we have to decide what those words actually mean.
Will we finally start treating mental illness as healthcare instead of treating it as somebody else’s problem? What about homelessness and drug addiction? They are citizens too, and they need medical care. How much care would be provided, and where would the limits be? Would there be an annual maximum on what an individual could be required to pay out of pocket, or would there be limits on how much care the system itself would provide?
These aren’t easy questions to ask, and I assure you the answers are going to be even harder to come by.
So when you hear a campaign speech promising “healthcare for all,” you might want to ask a simple question: How are you going to do it? And then perhaps ask the even more important question: Do you actually know?
Should We Combine Everything?
That is the question I started asking myself. If we are serious about creating healthcare for everyone, does it make sense to combine Medicaid, Medicare, veterans’ healthcare and the private insurance system into one enormous program?
There are some obvious advantages. A single system could be easier to manage because there would be fewer separate sets of rules and administrative systems. It could potentially be easier to fund and could make it easier to identify and control waste, duplication and fraud. The same hospitals and doctors could serve everyone under the same basic system, and instead of carrying different insurance cards and dealing with different rules depending on who you are, there could be one common system.
There is also the possibility that combining some of these functions could reduce administrative costs. We already spend an enormous amount of money moving healthcare dollars through multiple insurance companies, government programs, state agencies and administrative systems. If some of that duplication could be eliminated, perhaps more of the money could actually reach the people providing the care.
But there is a downside, and it is a pretty big one.
The same thing that makes a combined system easier to manage could also make it easier for a change in government policy to screw the whole thing up.
That’s a real concern. Governments change, administrations change, Congress changes and budgets change. If everything is tied together into one enormous system, a bad decision at the federal level could affect virtually everybody at the same time.
That raises the possibility that perhaps we shouldn’t combine everything after all.
Maybe Medicare should remain Medicare. Maybe Medicaid should remain Medicaid. Maybe the Veterans Health Administration should remain a separate system because veterans have a unique relationship with the federal government that is different from ordinary health insurance.
Perhaps instead of tearing down the systems that already cover hundreds of millions of Americans, we should build a new system specifically for the people who currently fall into the middle.
In some ways, that would be an extension of what the Affordable Care Act was attempting to accomplish, except rather than simply helping people purchase private insurance, we would create an actual healthcare system designed to provide coverage for the people who currently depend on the private insurance market or have no coverage at all.
That approach would be less disruptive to the people already covered by Medicare, Medicaid and veterans’ healthcare. It would also give us an opportunity to design the new system from the ground up around the people it is intended to serve.
Of course, there is a downside to that approach as well. We would be creating yet another healthcare program, with another funding mechanism, another bureaucracy, another set of rules and another opportunity for waste, confusion and corruption.
So we haven’t solved the problem.
We’ve simply moved it.
And that may actually be the point of this exercise. Before we decide how to pay for healthcare for all, we need to decide what healthcare for all is actually going to look like.
And Then There Is the Money
The next big question we will have to explore is who pays for it.
The short answer is you. It will always be you, because you are the government. That’s a simple answer, and I know it, so don’t start throwing tomatoes yet. Put them in a basket so I can make soup.
The real answer is considerably more complicated, because Americans are already paying an enormous amount of money for healthcare. We aren’t starting from zero, and that is something that often gets lost in the political argument.
We already pay for Medicare through taxes and premiums. We already pay for Medicaid through federal and state taxes. Employers spend money on health insurance for their employees, and employees contribute to those plans as well. Millions of people pay insurance premiums, deductibles and copayments, while taxpayers also subsidize portions of the Affordable Care Act marketplace.
So if we build something new, we aren’t simply adding the entire cost of American healthcare to the existing bill.
At least, we shouldn’t be.
The real questions are much more complicated. Which taxes would fund it? Would everyone pay the same amount, or would people pay according to their income? What happens to the money employers currently spend on employee health insurance? What happens to the premiums and deductibles people currently pay? What happens to the taxes already supporting Medicare and Medicaid? Would some of those costs disappear, or would we simply move them from one pocket to another?
And then there is the question of the states.
Medicaid is jointly funded by the federal government and the states, with the federal government paying a different percentage depending on the state. If a new system followed something similar, the quality or level of coverage could vary depending on where you live because some states simply have more money than others.
On the other hand, if the entire system were federally funded, the argument would immediately be made that taxpayers in wealthier states were now paying for healthcare for people in poorer states.
Fair or not, that is going to be part of the discussion.
The point I am trying to make is that there isn’t going to be an easy answer. We can talk about healthcare for all as a wonderful goal, and perhaps it is. But eventually somebody has to design the system, somebody has to administer it, somebody has to pay for it, and somebody has to decide what happens when it doesn’t work as intended.
So maybe the best course is to leave the systems we already have largely intact and develop another healthcare system specifically for the people who currently fall into that middle ground, the people the Affordable Care Act was designed in part to help but who still depend primarily on private insurance.
That would add another layer of bureaucracy, another funding system and another opportunity for waste and corruption. But it might also be the least disruptive way to move toward universal coverage without putting the systems that millions of Americans already depend upon at risk.
I don’t know yet which approach makes the most sense.
And I’m not sure anybody else does either.
But that is what we are going to explore.
Because if somebody tells you they have already solved healthcare for all, you might want to ask them to explain the details.
The details are where the real healthcare debate begins.
| Healthcare For All, The Evolving Series |
