Saturday, July 25, 2009

The Health Care Debate That Hasn't Happened

Even as someone who generally prefers private solutions to problems over governmental, taxpayer-funded answers, I have to admit that the Democrats, who are largely in favor of health care reform which gives government a larger role in providing coverage to all, have well-beaten the Republicans, who largely favor less of a government role, rhetorically speaking. While support for Barack Obama's approach to health care has been dropping among the public according to some polls, I think that's more because of the economic situation the country and perhaps even more importantly the government is facing. Expecting the government to help fund a universal health care system seems a bit like relying on a homeless guy to help you pay your mortgage. The thought is lovely, but you kind of have to stop and ask yourself, "Can he really afford to do that?" I think there's a lot of skepticism about cost projections related to the various health care reform proposals floating around the Congress -- well-warranted, in my view, considering we've heard for years that Social Security and Medicare are underfunded. Still, if more people had the unlimited faith in the government's ability to fund everything through taxation and inflation that all politicians seem to have, I think the poll numbers would lean more heavily in favor of President Obama and the Democratic Party's approach to solving health care simply because people know the system is broken and want SOME solution -- even a thoroughly imperfect one -- that works for everyone.

Ideally, from my point of view, the solution wouldn't come from the government but from the private sector. Thus far, though, the private sector's solution has sucked. The health insurers have already had a shot to provide health care to all, but it hasn't worked for a couple of reasons. The first is that one's need for health care has little to nothing to do with one's ability to pay for it (or for health insurance). That makes health insurance unlike auto and home insurance right off the bat -- if you can afford to maintain a car or a home, you can likely also afford insurance so that system basically works for most people. Because of this basic fact about the costs of health care, we already have heavy government involvement via Medicaid and Medicare to essentially insure those who cannot insure themselves. Secondly, the insurers have failed the customers they do have by making it hard (if not impossible) for some to get insurance and sometimes denying coverage when it is needed. Technically, the insurers may well be justified from a business point of view for their actions (and, indeed, some might not even be able to stay in business were it not for those actions!), but these practices hurt too many people. Health care is a life and death matter; unethical business practices may always be bad, but when it comes to health insurance their consequences can utterly ruin finances and end lives. If health insurance is all the private sector can offer, then the private sector has failed insofar as health care is concerned.

However, there is another private approach to health care that gets scant attention. Free clinics have long provided free or extremely cheap care to the poor uninsured, and Shriners Hospitals provide free health care to children with specific conditions. Neither solution is universal, but the fact that both exist show the potential of health care as charity. The free clinic model basically requires the existence of a parallel health care industry because the doctors and nurses who volunteer at free clinics get paid for their work on paying customers elsewhere. Simply turning every hospital into a free clinic isn't acceptable -- doctors, nurses, and other health care professionals do some of the most important work in our society and deserve to be well paid for it. However, with a massive infusion of private money in the form of donations and endowments, it is conceivable that health care could become much more a nonprofit service. Sadly, though there are plenty of nonprofit hospitals that exist today, they tend to do very limited amounts of charity care and aren't necessarily cheaper than for-profit hospitals. Still, if enough people got on board with such an idea, health care could be changed fundamentally. Imagine, for instance, that in order to receive profits from an endowment a hospital would have to reduce the average costs per patient per procedure or treatment year over year. Slowly, costs would come down if the endowment's profits were large enough (the endowments would have to be massive and likely heavily weighted towards reasonably safe, fixed-income investments...stock market fluctuations have been the bane of even the large university endowments at institutions like Harvard lately and the Shriners' endowment has also been severely affected). As I see it, there would also need to be a move towards making other aspects of the health care industry nonprofit as well as part of keeping those overall costs down. This revolution is, alas, quite unlikely to happen now simply because health care is too big of a business, but it probably could've occurred earlier in our nation's history. I definitely feel that the private sector "dropped the ball" on health care long ago by foisting the health insurance non-solution on us all; the likely consequence of our collective decision is more government involvement in health care funded by compulsion rather than voluntarily.

Even so, I can't help but feel we haven't really explored the possibilities of private solutions to the health care crisis. For instance, I wonder why sports stadiums often bear the name of sponsors but hospitals don't. Soft drinks may not be the healthiest thing in the world for you to drink, but who wouldn't want to get treated at Pepsi Memorial if you knew your treatment was being partially subsidized by some corporate overlord intent on spreading good will? Given that we have peer-to-peer lending that lets people loan small amounts of money to regular folks through sites like Prosper (unfortunately, federal and state government regulations have really hurt sites like these), why don't we have sites for peer-to-peer health care or even health insurance funding to help those in need bear the costs of the present system? I hate that the health care debate has been reduced to private health insurance vs government interference...there could be all kinds of solutions being proposed and attempted. I wonder if part of the problem is that a lot of people feel that health care SHOULD be a government thing. Henry Ford, for instance, wanted publicly funded roads and refused to support private roadbuilding initiatives though he certainly had the dollars to make a big impact if he had wanted. Major philanthropists may be reluctant to invest in health care knowing that the poor and needy in other countries tend to be considerably worse off than in America -- there's some truth in that, but ultimately suffering needs to be addressed wherever it exists. Hopefully, any health care reform that does occur, be it a private or a public initiative, will effectively reduce suffering...that is the most important thing at the end of the day.

Sunday, July 19, 2009

Obama's Brand of Pragmatism

I never expected Barack Obama to be the type of president who would sit on his hands once elected into office. Still, I didn't quite expect him to be as active as he has been. Compared to the G.W. Bush and W.J. Clinton administrations, the pace the Obama administration has set thus far has been downright frenetic. To be fair, I think most administrations tend to be more active in their first year, but I think it's safe to say that Obama has been trying quite hard to follow up on the issues he campaigned on and to deliver at least some of the change he spoke so much about last year. That's honestly commendable -- he is doing the job the voters sent him in to do -- but at the same time I have to admit I've been surprised to find out that Obama is pragmatic in a different way than I had anticipated.

Here's what I expected to happen after last year's election. Following the transition of power, I felt the president would focus squarely on the most pressing issue of the day which was and still is the economy. I expected other projects -- especially expensive projects -- to be pushed to the background while the government tackled the crisis at hand. To an extent, that did happen as the president crusaded for a large stimulus package which Congress passed despite some Republican opposition. Strangely, though, after the stimulus was passed, the government turned its attention to other things. In my view, this was premature...you can't build a house on an unsteady foundation. With the markets still in chaos, massive numbers of people out of work, and foreclosures rising, I'm not sure the country is really ready to absorb the costs of cap and trade and health care reform. President Obama seems to take a very long-term view of things; he has seemed to me to have anticipated the end of the recession from the very start of his administration. Even the stimulus package was full of long-term investments in things like education and green energy. Politics, however, is often a short-term game. Obama's poll numbers have been going down of late as it has became apparent that the economy isn't going to improve quickly. The extent to which any government can really turn around an economy is limited, especially in a quasi-free market economy, but I wonder if we wouldn't have been better off had Obama followed a different course and played the role of cheerleader more, reassuring the American public, businesses, and investors that everything was going to be better soon and giving them concrete reasons to be optimistic. Instead, the new initiatives Obama has supported have actually scared a lot of people -- there's a great deal of concern about the government's ability to pay for health care reform, about new taxes, and about rising utility costs in response to cap and trade. Of course the opposition would always foment fear no matter when these drastic changes were proposed, but I think the fear effect has been magnified due to the timing. So Obama hasn't quite been as pragmatic as I expected with regards to the economy.

On the other hand, the president has shown another type of pragmatism which has helped make him an effective leader so far. Obama by nature is a negotiator, someone who wants to hear different points of view and who is open to at least listening to others' ideas. He might not necessarily be a politician who can bridge the gap between the two major parties, but he has shown a lot of ability to work with Congress. In his eagerness to collaborate with legislators, though, Obama has also shown a willingness to abandon some positions he embraced during his campaign. For instance, he hasn't been been strongly advocating against making health insurance compulsory for all Americans or against taxing health benefits, both things Congress is considering. His motives may be pure -- he really wants health care reform as soon as possible and so is willing to compromise in order to get things done quickly -- but he's also abandoned a lot of voters who expected him to stand up for the vision for health care he laid out during the campaign. Not keeping your word isn't exactly admirable in my book. If Obama didn't really believe health insurance shouldn't be forced on anyone, he should never have differentiated his position from Hillary Clinton's (an open supporter of compulsory insurance). If Obama didn't think taxing health benefits was unacceptable, he shouldn't have differentiated his position from John McCain's. Probably the majority of voters just want health care reform and don't care about these details -- they'll judge Obama on his effectiveness at getting things done. Ultimately, it IS up to Congress to do the legislating anyway. Still, I expected Obama to use his influence to shape the process and debate more. In the end, he does have to sign the actual piece of legislature that reaches his desk; it doesn't appear that Congress has any concern that he won't sign whatever they deliver, however. I'll certainly take any specific positions Obama endorses during the next election with a giant grain of salt -- clearly, Democratic members of Congress' views are far more important when it comes to actually implementing change.