"Books Invite All: They Constrain None"
The Angels' Share - 091009

Healthy, Wealthy, Wise: Pick One


2 a : a method for achieving an end 
    * * *
c : a detailed formulation of a program of action
--  Merriam-Webster Online Dictionary


On Election Day last November I wrote, in explaining why I'd not be casting a ballot for any of the presidential candidates, that

Senator Obama has been sufficiently forthright for me to know I cannot vote for him because I disagree strongly with many of his central policies, but I will shed no tears when he is elected, as seems inevitable.  I wish him well in office, and I feel more than a little sympathy for his supporters: anyone investing that much Hope is bound to be disappointed in a world that sadly, campaign rhetoric aside, does not in fact operate on wishes, good feeling and pixie dust.

And I was right, I think.

Tonight's big health care speech was President Obama doing some of what he does best.  He is a very smart man, a politician even more canny than Bill Clinton (which is saying something), and -- teleprompter be damned -- that rare contemporary figure who can give a canned and pre-rehearsed speech without it actually sounding canned and pre-rehearsed. This last counts for a lot with me: I speak publicly whenever I can on legal and insurance topics or anything else anyone wants to hear about, and I would just curl up and die if the presentation wasn't alive as it's being delivered.  When he's on his game, as he certainly was tonight, the President can be restrained and controlled while remaining alive and connected throughout.  As a performance, it gets an entirely unironic A

Still, I remain unconvinced that anything really worthwhile in the long term can or will be accomplished by our Congress when it comes to health care reform.

My fundamental problem with tonight's speech comes down to the definition quoted above.  From beginning to end, the President told us that, on this night of all nights, he was going to offer and describe his "plan" for reform.  If you parse the speech through, however, no such plan ever appears.  There is plenty of talk about what the President wants to achieve -- genuinely desirable ends not far removed from the well-intentioned rash of Facebook status posts last week, on the lines of

[Name of honorable and decent person] thinks that no one should die because they cannot afford health care, and no one should go broke because they get sick.  If you agree, please post this as your status for the rest of the day.

-- but hardly anything practical concerning how we are going to get there. The proper word for the what is not "plan," but "goal," and we can stipulate that the goals outlined this evening are devoutly to be wished. But it is the how that constitutes a "plan" properly speaking and, apart from a slew of "make it so" diktats, there was a rather glaring dearth of hows to be had tonight.

Just take a look at the official cheat sheet for the self-effacingly named "Obama Plan for Stability & Security for All Americans" [Official White House PDF].  At the outset it promises to

  • End[] discrimination against people with pre-existing conditions.

and to 

  • Cap[] out-of pocket expenses so people don’t go broke when they get sick

Good things both, I think we can agree, and certainly features I would like to see in my own insurance plan.  While we are about it, the Plan also promises that we will get essentially unlimited diagnostic and preventive care -- mammograms and flu shots and diabetes tests and the like -- at no "extra charge," i.e., included in whatever premium we (or our employer if we are lucky) are paying.  

But at the same time as the Plan promises to do all these desirable things, it simultaneously promises that we are all going to have access to "quality, affordable" coverage -- which we have to assume is a phase meant to describe coverage that costs no more than, and possibly much less than, what we are paying now.  In fact, the Plan apparently promises that those who are defined as "high risk", i.e., those with preexisting conditions who we know going in are most likely to require expensive future care, will have access not merely to "affordable" coverage, but to "new, low-cost coverage" through the mysterious and only-vaguely-described "Exchange." 

What, in the most basic terms, is wrong with this picture?  

It seems to me that any Plan that mandates that insurers must take on greater risk -- i.e., that they must provide near-unlimited coverage for people that they know from the outset will be needing an extra-high level of payouts for benefits in order to obtain the care that they are entitled to under the Plan -- but that simultaneously implies that those insurers will not be permitted to price their product in proportion to that risk is side-stepping a fundamental problem.  No insurer, public or private, can be expected to pay out more than it takes in.  The doctors, the hospitals, the folks who clean out the bedpans, they all rightly expect to be paid for providing those services.  If the people who need those services the most are the ones to whom we promise "low cost" coverage, some part of the actual cost needs to be borne by others -- and how that doesn't mean an increased cost for those who already have insurance, or for the taxpaying polity as a whole, I just don't see.  If there is enough "waste and inefficiency" already existing in our Medicare programs that its elimination will cover these costs, as the President implied there is, then it is high time we start the show trials of the entire generation of government functionaries who allowed it to happen.  (He said, facetiously.)  

Now I would be the first to admit that I don't know it all, particularly on an issue this complicated.  And I am prepared to believe that the President actually has answers to these practical objections, and to others with which I won't bore us here.  But I certainly did not hear those answers tonight.  I did not hear the how.  I heard talk about a Plan, but the Plan itself went missing.

These are not impossible questions, or so we are told, but they are undeniably very difficult questions. And I regret to say that I am convinced in my heart of hearts that there is no government on Earth, here or elsewhere, now or ever, of this party or that party or any other party, that is actually qualified to produce a credible answer to them.  Matters as they currently stand are bad enough -- I have been paying my family's health insurance from my own pocket for fifteen-plus years, keeping premiums as low as I can via high deductibles and the good fortune of having needed very little in the way of covered care, and the cost is still too high -- but no plan that I have seen coming out of the Congress to date, and nothing that I heard from the President tonight, appears to hold any practical promise of improving the situation for most Americans. The involuntarily uninsured are likely to benefit, I suppose, but the currently insured (especially those who already pay for it themselves) and those who are willingly, or willfully, uninsured -- those who will be subject to the "individual mandate" to which I recall Candidate Obama being ostentatiously opposed -- seem unlikely to come out ahead.

I would very much like to be wrong about this.  Anyone care to convince me that wrong is what I am?


Illustration by Karl R. Rittman of the 857th Engineer Aviation Battalion.



A.C. Douglas

What, in the most basic terms, is wrong with this picture?

What's wrong with the picture is that no-one dare see, much less acknowledge, the elephant in the room: the perversity of for-profit insurance companies being providers of health care coverage. It's a fundamental — THE fundamental — flaw at the center of the health care problem in this country as it ineluctably involves a central and intractable conflict of interests.

Last night, the President yet once again declared that the so-called Public Option is only one part of his Plan. He had to make that declaration because the determined opposition to that option could derail, even deep-six, the entire health care reform bill. The truth of the matter, however, is that the Public Option is at the very heart of the President's Plan, for without that Public Option, true health care reform is impossible. With the Public Option in place, most for-profit insurance companies will, little by little, abandon the game because it will become unprofitable for them to remain players as all for-profit businesses are in business solely to make a profit, and with their disappearance as players, genuine, comprehensive health care reform will at last become a real possibility in this country.


A.C. Douglas


My above, "It's a fundamental — THE fundamental — flaw at the center of the health care problem in this country...."

should have read: "It's a fundamental — THE fundamental — flaw at the center of the health care system in this country...."


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