Almost all of the health plans unveiled so far could be called "The Insurance Company Protection Act of 2007". Across the political spectrum, from Medicare Part D, through Governor Schwarzenhagger's plan, through the EPI's "open medicare for a fee" plan, none of them touch the real problem of health care in the United States. That problem is that we use Medicare as, essentially, an annuity for the middle class, and as a means for the states to shift income taxes to the Federal level, and that our private health insurance companies have huge administrative overhead to engage in cherry picking of the available population to make large profits.
The problem then, is not that 49 million people are uninsured, it is that we are diverting the national effort that it would take to improve outcomes and insure everyone, and pouring it into health company profits, which are directly related to keeping people out of the health system, and using the effort freed up to provide more non-essential, read cosmetic, surgery and health care.
Any plan which does not take this on, is not really a health plan, but a prozac program.
The situation should make everyone realize how stuck in the age of Reagan the political elites, the pundit elites and the policy elites are. This is not limited to the American Enterprise Institute, but is seen in Democratic health care plans. The fear of taking on the insurance companies and the upper middle class interest in subsidizing high end health care at the expense of general health care is palpable.
It would be easy to design a better medical program than medicare, particularly the misbegotten medicare part D. However, it is clear that there is a huge political panic wave about doing the one thing which needs to be done: shift national effort away from keeping people out of health care, and into improving outcomes. This is why almost all available plans are funded by some form of regressive taxation, with some amount of subsidy on the very bottom. A level of subsidy that will be hated almost immediately by people with just barely better than awful health care plans, because those just on the other side of the bubble will be getting just a bit more, but will be paying much more for it. As with every other perceived "welfare" benefit, it will drive the white, particularly southern unorganized, working class further into the arms of psuedo-free market jargon and cypto racism.
The problem is not that millions are uninsured. The problem is that half of the country is underinsured, with the bottom of that being "emergency room and bankruptcy" as their health insurance plan, and there is not enough general continuous health care left after heroic intervention and high end ife enhancement.
The problem then is poverty rationing. Just as African Americans and the very poor were kept out of the mechanized economy until the Kennedy-Johnson push to end poverty, so too is the bottom of society kept out of the health system, and for the same reason. We do not, currently, have the resources in the correct form to bring them in. Other nations do, not just because they have insurance plans, but because they have health systems geared to doing it.
Since a "bottom up" approach will create unprofitable demand, there will be little incentive for the health system to adapt. Instead, it will quote the price, shovel its most marginal resources down to the bottom, and mark up the price for everyone else.
Hence if there were a time to think big - to think in terms of planning and a continuous process to shif national effort - that is to say, old style liberalism that thought about the economy holistically - this is it. Strangely the Republicans have had a more holistic understanding of economics than the liberals have had. One might, and I do, abhor the militarization of the American economy, but one cannot say that it is not a sweeping attempt to shift natioanl effort from some projects to others. The problem is that the numbers don't quite add up, and the product that it produces - failed states in the middle east and its peripheries - is one that only terrorists and expansion minded theocracies really like.
Increasing demand for basic health services - which is what expanding the pool of people with access will do - must, repeat must, be coupled with some mechanism to increase the number of people to care for them, and reducing the cost of caring for each one. This is where regressive taxation of the pitiful income stream these people have makes no sense. Even if there were no subsidies, the people uninsured do not have the drmand to pay for such a shift, and their meager amount of consumption, even if sharply limited, would not dramtically change the picture.
They simply don't use that much in the way of skilled knowledge labor and heavy capital. Now the military, on the other hand, uses the kinds of sophisticated electronics, high end design, and skilled knowledge work required. One can't turn a store clerk inot a doctor, but one can take the production devoted to cruise missiles and devote it to medical imaging systems.
This should be liberalism 101 - increase general demand, and balance this by taxing inflationary demand or luxury demand. In short, tax high end cosmetic surgery, and use the money to pay for more doctors. Tax high fat diets, or ban it outright, and use the money to pay for more nurses. Tax high end assisted living and nursing homes, and use the shift in effort to build more modest, but acceptable, long term living and assisted living communities. Tax luxury goods such as limosines and personal jet aircraft, and use the money to develop appliances that can be used by older people. This was obvious 20 years ago, and it is obvious today.
To think economically is to think in terms of trade offs. To bring the uninsured into the fold, we need to shift the design of the health delivery system away from heroic intervention at the end of life, and towards sutainability through out life. We must trade stents that don't do much for heart attack victims that didn't need them, and towards more doctors who can diagnose preventable or limitable diseases. Instead of a deficit culture approach of keeping dead people alive at enormous cost, we need a surplus culture approach which keeps people healthier, and which has the infrastructure to make possible a continuous interaction of indiviaul and health system.
Of the assorted plans, the simplest are clearly the best - Medicare for all, in one step or in several, and mandating participation in it. Not medicare access for the poor, not $5000 dollar "hospital protection plans" at punishing cost for people on the edge of bankruptcy. Slice the bottom half off of what insurance companies provide, for everyone, and then let the companies compete over supplemental insurance, long term care insurance, and heroic intervention above and beyond what the society can afford on a general basis. Don't just bargain with the system, find a market incentive system that will shape activity to providing continuous health care.
This shouldn't be hard, but it seems to be, with a thousand interests trying to do everything but address the most obvious problems - the actuary problem of an aging population, and the perverse incentive to a health system which shovels a third of its money up the smoke stack of administration, and half of what is left on projects which generate the least amount of utility.
We can give good health care to everyone, but at the moment, we are paying insurance companies blood money to separate the quick and the dead. Putting bandaids on the back end will not alter these problems, but will, instead, cost money, and will not solve the middle class health care crisis - in fact it will exacerbate it as more pensioners are kicked off of their health care rolls and more middle class plans raise prices even more as they compete for yet scarcer resources. They don't even address it, in fact. Rampant health inflation couples the problem of uninsurance, it is why the uninsured are uninsured, because there is no arbitrage to be had for their employers to offer it.
A plan then must be composed of three elements:
1. Shifting of the profits of insurance companies into expanding the general health delivery system. This means more doctors, nurses, hospital beds, clinics and health sustaining programs such as immunization.
2. Shifting demand from luxury goods to "late life" consumer goods. Something as simple as a way to wash cloths or wash dishes without having to bend over is currently very expensive. In an aging industrialized world, this is folly.
3. Taxing corporate profits - currently at record shares of the economy - to pay for the uninsured's access to this expanded health system. The poor don't have the money, and should npt be hit up for it even in theory. A society which cannot give minimum wage workers a raise in 10 years, is not one that should be telling people near the bottom of the wage ladder that their small paychecks are going to be the source for insurance plans.
Thus the standards must be:
1. Continuous
2. Sustainable
3. Universal
The rush to create universality first, heedless of continuous and sustainable, shows that guilt amd greed, and not enlightened slef-interest, are driving this first round. The middle class health crisis is the one which is making voters angry. Yes the uninsured bother them, particularly if they are in the pool of risking being uninsured, but the fact that they are not getting raises, even in upper middle class jobs, and are seeing increases in medical insurance costs and increases in deductibles and out of pocket costs, is what is making them angry.
A holistic approach solves both the problems of the poor, without inflicting regressive taxes and onerous mandates on them, and the problems of the more affluent.