Healthcare in America — The Next Conversation Part 7 – The Elephant in the Room
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- Healthcare for all
Part 7 – The Elephant in the Room
So now we’ve come around the mountain and discovered that we may not need to rebuild the entire healthcare system after all.
We have most of the infrastructure already. We have the people, the hospitals, the medical technology, the knowledge and the need. We are already spending enormous amounts of money on healthcare.
So what are we really talking about?
Insurance.
And that is where I think the real battle begins.
I’m going to admit something here. When I started this series, I said I wasn’t going to make it about politics. I was wrong.
Not because this should become a partisan argument. It shouldn’t.
I’m talking about something bigger than Republicans and Democrats. I’m talking about the political machinery itself and the enormous amount of money and influence surrounding healthcare.
Healthcare should not be a political football. It is too important, and it affects too many people. This country exists because of its people; the people do not exist to serve the political system.
If we ever decide that healthcare for everyone is something worth doing, then it cannot be something that gets turned on and off every time the White House changes hands.
That is why I keep coming back to the idea of protecting the existing programs while we build something new.
It may cost more at first. It may not be the most efficient way to get there. But it gives us something we don’t have if we put everything into one giant system on Day One: a margin for error.
If one piece doesn’t work, we fix that piece. If one funding mechanism doesn’t work, we change it. If one service needs to be redesigned, we redesign it. We don’t knock over the entire row of dominoes.
The Money Is Already Here
This is where Part 5 comes back into the discussion.
I don’t want to pretend that I have figured out the exact tax structure or financing formula. I haven’t, and I don’t think I should pretend that I have. Those are the kinds of questions that people who actually understand federal taxation, budgeting and public finance need to work through.
But I do think we should stop talking as though America has to suddenly find an enormous pile of money that doesn’t already exist.
We already spend trillions of dollars every year on healthcare.
So perhaps the first question shouldn’t be, “Where are we going to find all this new money?”
Maybe the first question should be:
How much are we already spending, where is it coming from, where is it going, and what are we getting for it?
That’s a different question.
It also leaves open the possibility that some of the money already being spent could be redirected, consolidated or used more efficiently.
And there may be other sources of public wealth worth considering as well, such as the public-resource investment idea we discussed in Part 5.
I’m not claiming that oil royalties or a national investment fund will suddenly pay for American healthcare.
I’m saying we should be willing to ask the question.
If a portion of the nation’s natural resources creates wealth, should some portion of that wealth be returned to the people who collectively own the resource?
Maybe.
That’s a discussion for people who know how to design those systems.
My job here is simply to put the question on the table.
And Then There Are the Insurance Companies
If we are going to create a new federal medical insurance program, we cannot pretend the existing insurance industry won’t notice.
They will.
There is an enormous amount of money involved in American healthcare, and private insurance companies are deeply embedded in the way the system currently operates.
I don’t think we should underestimate the fight that would come from that industry and its lobbying organizations.
We’ve seen this before.
Look at the tobacco industry. We knew for decades that nicotine and tar were dangerous. Yet an industry with enormous financial resources fought regulation, influenced public policy and worked to protect its business interests.
I’m not comparing tobacco companies to health insurance companies.
I’m pointing out something much simpler: when enormous amounts of money are involved, enormous amounts of money will be spent trying to influence what happens next.
Dark money, lobbying, campaign contributions and political pressure don’t suddenly disappear because the issue is healthcare.
So what do we do about the existing insurance companies?
I originally wrote that they should partner with the federal government.
I’m not sure that’s the right way to describe it anymore.
Perhaps the better answer is that they should have a choice.
If a private insurer wants to participate in administering the basic federal program, it could compete to do so under federal rules, with structured and transparent fees and consistent requirements. The government program would pay for the service rather than the individual policyholder.
If an insurance company doesn’t want to participate, that’s fine too.
It could continue to sell supplemental coverage, gap insurance and other private plans to people who want additional coverage beyond the basic federal benefit.
In other words, private insurance doesn’t necessarily have to disappear overnight.
But it also doesn’t get to remain the gatekeeper for basic healthcare simply because that’s the way we’ve always done it.
That distinction matters.
The goal isn’t to destroy an industry.
The goal is to change what that industry is being paid to do.
And if private insurance can find a useful role in the new system, let it compete for that role.
If it can’t, then the market will have to decide what happens next.
This Cannot Belong to One President
There is another problem, and I think it may be one of the most important.
A program like this cannot be built around one president, one Congress or one political party.
It would take years to build. Maybe a decade. Maybe longer.
That means the structure has to be designed from the beginning to survive political change.
When I say “independent,” I don’t mean an agency that answers to nobody. I mean an organization with enough structural protection that it cannot simply become a political party favor for whoever happens to occupy the White House or for whichever politicians helped create it.
The people running it should have qualifications for the job. Terms should be structured so that one president cannot simply replace everyone. Its finances should be transparent. Congress should have oversight. There should be rules governing how it operates, and changing those rules should require more than one administration deciding it wants something different.
Independent should actually mean independent.
Not independent until the next president gets annoyed. Not independent until someone decides they need the money for their favorite project. Not independent until a political donor wants a favor.
The program needs to belong to the people who are paying for it and depending upon it.
That doesn’t mean politicians disappear from the process.
It means the basic healthcare structure should be harder to manipulate for short-term political purposes.
Start Small, Learn, Keep Going
I don’t think we can accomplish this in one pass.
We shouldn’t even try.
The idea would be to start with basic medical coverage, build the system, test it, find the failures and fix them.
Then we could add additional services as the system becomes financially and administratively stable. Dental and vision are obvious candidates. Mental healthcare needs considerably more attention. Physical therapy and rehabilitation, specialist care and other services can be evaluated as we go.
The point is not to create a perfect system on the first day.
The point is to create a system that can improve without collapsing.
I’ve been thinking about those domino demonstrations where one little piece starts a chain reaction and, if everything is positioned correctly, the entire thing works.
They look simple when you watch them.
But behind that simplicity is an enormous amount of planning. Every domino has to be in the right place and the sequence has to work.
Healthcare is like that.
We can’t see the entire chain from where we are standing. There will be pieces we get wrong. There will be things we didn’t anticipate. There will be unintended consequences.
So we need safety mechanisms.
If one piece falls the wrong way, it shouldn’t bring down the entire system.
And that brings me back to where I started this series.
I said at the beginning that I wasn’t going to have The Answer.
I still don’t.
What I hoped to do was ask better questions.
Maybe we’ve gotten there.
Because I don’t think the question anymore is simply, “Should America have healthcare for all?”
That’s too easy.
The questions are much harder.
What should be covered? Who should administer it? Who should pay for it? What happens to the systems we already have? What happens to the people who work in the existing system? What happens to private insurance? How do we protect the program from political interference? How do we pay for it without simply pretending the money doesn’t matter?
And perhaps most importantly:
How do we build something that can survive us?
Not just one president. Not one Congress. Not one political party. Not one generation.
Something that can be adjusted, repaired and improved as the country changes.
Because if we are going to call it healthcare for all, then perhaps the commitment needs to be for all of us, including the people who haven’t been born yet.
And that’s a much bigger commitment than putting four words on a campaign sign.
| Healthcare For All, The Evolving Series |
