The Health Care Speech Obama Should Give–But Won’t
The Health Care Speech Obama Should Give–But Won’t
The Health Care Speech Obama Should Give
My fellow Americans,
I am speaking to you at a moment of crisis for our nation. We have a choice to make: Whether we, citizens of the richest and most developed country in the world, are going to claim quality health care for each and all of us as a common good; or whether we are going to continue to see it apportioned on the basis of life circumstances, the ability to pay, and the luck of the genetic draw.
This choice involves fundamental differences both of public policy and philosophy. There are those who deny that as members of American society we have any positive responsibilities to each other. These deniers can’t help but admit that human beings, always and everywhere, live in social groups; and yet, they insist that we do so only to maximize our individual economic utility, our opportunities for profit. They see society as no more than the sum of individuals. To most of us that is an absurdly reductionist view of human relations. After all, many other animals rely on complex social structures, and they have no notion of capital, of new markets, or innovative products. They live together for the same reason that we do: because collective society offers benefits and protections that are not available to us as atomized individuals.
This is hardly a radical notion in the field of health care. How many of us believe that acting through our government we should not mandate inoculations for schoolchildren? How many of us think that the FDA’s regulation of drugs and medical procedures is an intolerable infringement on individual liberty?
Yet health care industry’s leaders, as well as many right-wing politicians and media personalities, insist that they are obstructing reform for the purest of reasons: They are merely defending democracy, which relies on free markets. And so it does. We know from bitter experience that when markets are not allowed to function, dictatorship or oligarchy become the only possible forms of government. In almost all cases, market solutions are the best solutions.
But this does not mean that the public interest cannot be a player in the market, or that market forces cannot be regulated in the public interest without destroying democracy. Even the most influential classical liberal thinkers on economics, such as Adam Smith and Friedrich Hayek, have recognized that there are certain social priorities that are simply too important to be left entirely to the market.
We don’t sell public stock in our military, and we don’t run our police and fire departments for profit. We don’t let the market determine (although it influences) the money supply or the prime interest rate, and there is nothing wrong with using the tax code to encourage broadly-agreed, desirable developments, such as green energy production.
So how, then, can we harness the qualitative and innovative benefits of the market for the health care system while making those benefits available to all, regardless of income and pre-existing conditions? How can we eliminate private corporate profits while retaining competition? The answer is a well-designed single-payer system, in which the federal government pays the medical bills of all residents of the United States.
Socialism! The end of markets! I hear the screams of outrage.
Socialism–well, yes. Because such a plan would socialize risk, expanding the pool of those who pay premiums and receive benefits to every resident. Under such a plan, the young and the healthy would subsidize the old and infirm. Horribly unjust, I know, since science has established that the young and healthy are going to stay that way forever.
The end of markets? Well, not really. Government-paid health care does not mean, or does not have to mean, government-run health care. Under my plan, every American would be perfectly free to choose his or her doctor and course of treatment in consultation with that doctor. Doctors would be paid a salary rather than being compensated on a per-procedure basis.
But doctors who performed well would also be rewarded based on a formula independent of political mandates and complex enough to encompass the realities of health care: number of patients seen, the inherent risk of the doctor’s specialty, whether the doctor practices in an underserved location, health care outcomes as compared with average outcomes for similar conditions, patient reviews–all of these, and other things not yet thought of, could be factors. The best and hardest-working doctors would attract the most patients in the health care marketplace, produce the best results, and have the best incomes.
Other aspects of meaningful health care reform would be publicly paid medical education for qualified medical students, researchers, and other health care workers so that the profession is open to all who are bright and dedicated, regardless of financial resources. We need tort reform so that massive and frivolous lawsuits do not continue to drain resources from the system and force doctors to practice expensive, and defensive, medicine. We must have ethics rules that require doctors to disclose their interest when they refer patients to medical facilities in which they hold a financial stake, and meaningfully high co-payments indexed to patient income in order to guard against the tendency of people to consume more of a good than they need when it is free.
No one will be excluded from or denied coverage for a pre-existing condition or for any other reason. We are able to stipulate this because we are talking about social insurance, not private profits. But part of this extra expense will alleviate itself: We will not be paying legions of medical-coders and corporate hit men to find reasons to deny coverage. This is one reason that Medicare’s overhead is 2 percent to 3 percent, and that of private insurance varies between 13 percent and 20 percent. The opponents of health care reform want to talk about cutting waste. So do I.
How would I pay for all this? I’d raise your taxes. You heard me. If I said anything else I’d be lying, and you’d know it. National health care would require somewhat higher personal income taxes. But let’s put that in context. How much are you paying for private insurance now? If you have coverage through your workplace, you have an employer-subsidized payment that ultimately lowers your take-home pay by more than the voluntary deduction amount. If you are self-employed, you are painfully aware of the true cost of for-profit insurance.
Beyond the savings realized through eliminating private health insurance premiums, there would be enormous secondary and tertiary benefits to our health care system and our general economy that would reach the consumer. How many physician-hours, how many resources would be saved if every American went to that recommended semiannual routine checkup, because he or she were covered? How much less does it cost to treat a pre-cancerous condition than third-stage cancer? One thing we do know is that when it comes to medicine, an ounce of prevention is not only more effective, but much cheaper than a pound of cure.
Think, too, of the drag on employers and the economy that the present system of employer-provided benefits entails. GM’s negotiated role as a provider of health care benefits, and the massive costs associated with that, was one of the prime reasons for its collapse–a collapse that continues to ripple through our economy. Japanese automakers do not have this problem; their employees have public health insurance. This has given the Japanese a competitive advantage in the American market, at the expense of the American worker.
LET ME now address several claims of those opposed to reform that, if constant repetition were the standard of truth, would be powerful arguments. We hear over and over again that socialized medicine doesn’t work, that it’s a disaster for our European and Canadian friends, that it would lead to rationing, and that we have the best health care system in the world—why change?
But socialized medicine is different in every country that has it, and some do it better than others. The British National Health Service is widely considered to be one of the worst-run public systems, which is surely the reason that it is mentioned so frequently by those who oppose national health care. But even there, the outcomes of the British system are generally comparable ours, or better. Our infant mortality rate is 6.26 deaths per 1,000 live births while in the United Kingdom, it is 4.85 deaths per 1,000 live births. Part of the reason for this is that poor and uninsured mothers in the United States receive inadequate prenatal care, and therefore give birth prematurely. Our life expectancy at birth, averaged for men and women, is 78.11 years, while in the UK it is 79.01 years.
Infant mortality and life expectancy are susceptible to all kinds of extraneous influencers, so let’s look at a more stable measure of quality in health care delivery: patient satisfaction. Where does the United States, with our private, for-profit system of health insurance, rank among the seventeen most industrialized countries? According to a study by Harvard University, we are fourteenth—with a 40 percent patient satisfaction rate. Denmark, which has one of the most comprehensive socialized medicine programs in the world, is ranked number one with a 91 percent patient satisfaction rate. And Denmark spends about half as much per capita on health care as we do.
The fact is that we don’t have “the best health care system in the world.” We have the best doctors, the best researchers, the best technology, the best universities. But in terms of outcomes and patient satisfaction and in terms of health care availability to the general population, we lag behind many of the countries that the opponents of reform would have you believe are health care disasters. And we spend far more on health care than they do, which is not surprising: We have to generate profits for the private insurance industry.
The opponents of a public system tell you that it would be the end of freedom. I really have to wonder what they are talking about. How free, after all, is someone who has to live in constant anxiety about a health care condition, about a lack of insurance coverage? How free is someone who has lost his home, cashed out his retirement benefits, to treat an uninsurable condition? I believe that people who talk the “freedom” line are not actually concerned with freedom at all, not as I and most Americans understand it. Their idea of freedom is the freedom not to pay taxes, to be unconcerned and isolated from the reality of their fellow citizens. But the state of our health care is our common reality, whether we are rich or poor. Epidemics don’t magically stop at the borders of the rich neighborhoods. We all pay for the lost productivity and preventable diseases of the uninsured.
I’d like to conclude with an illustration of this sort of delusional thinking. The other day I read an article that astonished me. The author wrote about how her physician father received excellent care as his health declined in the hospital where he had spent his career. She speculated that under a public system of medicine, his life might have been deemed “not worth saving” and concludes: “[T]he beautiful thing about American medicine has been its foundational assumption that such lifesaving, humane treatment is everyone’s due. At least until now, there’s been no question about whether someone’s life is ‘worth’ saving; we’ve presumed that everyone’s life is important–not just those of the powerful or the important or the connected.”
Sometimes I really do wonder what world these people are living in. Does the author believe that her father was not powerful, important, and connected? She went out of her way to describe him as a successful and respected doctor at a prosperous suburban hospital: “When he finally retired, the hospital where he had practiced so faithfully for 48 years named its emergency and surgical wing in his honor; the mayor offered him a key to the city; and more than 300 former patients showed up to wish him well at a farewell reception hosted by the hospital.”
Was this a typical patient? Did his experience of medical care really reflect the standard of care available in the American health care system? Including the treatment available for the uninsured or the uninsurable? Does the author believe that no one in America is denied lifesaving care on the basis of ability to pay and that no one is unilaterally cut from an insurance contract because a condition has become too expensive? People in fact die every day in this country because their insurance companies will not pay for brain surgery, kidney dialysis, and an expensive new drug treatment. These are things you cannot get in the emergency room (and, contrary to another cherished right-wing myth, people who can’t pay are turned away from emergency rooms every day in this country.) Just recently, a Johns Hopkins research study found that when hospitalized, uninsured children have a 60 percent higher risk of death than children who have private or government insurance. Does American for-profit medicine really work as if “there’s been no question about whether someone’s life is ‘worth’ saving”?
I can only shake my head in wonder at the self-satisfied isolation of the privileged, whose sole reference point for suffering is their own coddled lifestyle. Should the rest of us be satisfied when our system is judged excellent because the most elite and connected among us have access to excellent care—and the treatment of the less privileged is no part of the calculus?
What I propose to do is to ensure that “lifesaving, humane treatment” as “everyone’s due” really is the “foundational assumption” of American medicine–that this is not just a fantasy and a prerogative of the wealthy. Something to think about, and I hope that you will. Good night–and be well.
Jesse Larner is the author of Mount Rushmore: An Icon Reconsidered(Nation Books, 2002) and Forgive Us Our Spins: Michael Moore and the Future of the Left (Wiley and Sons, 2006).
