What Kinds of Choices Do We Need For Our Health Care?

Most people would answer this by saying that they want to choose their doctor and make decisions about the kind of treatment they get.  If you ask them if they enjoy trying to figure out which of dozens of insurance plans are both within budget and likely to actually reimburse them in the event of illness, you get a very different response.  And of course with insurance provided by employers, there is often no choice offered at all other than turning it down.  The very existence of thousands of private health insurers often eliminates the choice of practitioner entirely--you choose from their preferred provider pool or pay through the nose to go out of network.  Even if you are lucky enough to develop an ongoing relationship with a doctor, it can be cancelled any time if your employer drops your plan, or even if the plan stays the same but the preferred provider list changes.

It is almost a general systems principle that eliminating or strictly limiting choices at the level of infrastructure is exactly what permits the largest variety of choices at the level of superstructure.  It wouldn't be possible at all to have the huge variety of electrical appliances we have today if manufacturers were allowed to make plugs any size and shape they felt like making them.  I have yet to meet anyone who has felt oppressed by having only the choices of 110V or 220V for line voltage.  Yet the congressional architects of current health care reform seem to think that offering a choice of insurance plans is far more important than choice of practitioner or treatment, yet it is those choices which are the very choices that private insurance limits or forbids entirely.

 Good, useful choices     Lots of different electrical appliances     Your doctor, hospital and treatments
 Bad, dysfunctional choices     Making outlets and plugs whatever  size you want     Which hard to understand insurance plan you want to risk enrolling in

In addition to the systemic structural reasons for eliminating choice in health insurance plans, there is an ethical reason to do so as well.  It makes me furious whenever anybody says that people ought to "be able to choose the plan that is best for their families."  This is one of the most morally and ethically vile things that anyone could ever say, because what they are really saying is that some people deserve good health care, and other people are relatively worthless sorts who do not. Families with more money are better than families with less money, who just ought to adjust to the greater odds that they may die or be bankrupted.

All current legislation describing an insurance "exchange" proposes having four different levels, each of which costs more and covers more. That includes the "public option" proposals as well.   Every other developed country in the world, whether they achieve universal coverage with tightly regulated private insurance, outright government ownership of the health care system or the publicly funded privately delivered single payer system, provides a single standard of coverage for everyone with no exceptions. Co-pays and deductibles are far cheaper, if they exist at all.  No age discrimination is allowed, in contrast to the proposed reforms which actually write such discrimination into law.

It's certainly true that all these countries have multi-tiered health care in practice simply because the affluent buy extra bells and whistles for themselves over and above what the government either guarantees or provides to the general population. That is morally acceptable, because only after everyone's basic health care needs have been met in a reasonably comprehensive way should "choice" should come into play in the area of health care. It's like Bill Gates being able to have an expensive sprinkler and fire alarm system that most people could never afford. That doesn't matter as long as everyone gets the same fire engines in the event of fire. Why have our legislators written bills underpinned by the assumption that people with more money should have access to the health care equivalent of modern hook and ladder trucks and the rest of us should get something more like the horse-drawn wagons of a century ago?  Only the cheapest plan would be eligible for subsidies.

According to the online calculator provided by the Kaiser Fountation(1), someone over 60 with a family income in the area of $40,000 be forced to pay $410-$450/month to get only 70% of expenses taken care of with the Basic Plan under HR 3200 (the best of the proposed reform packages).  That includes both the allowable age discrimination and the offsetting subsidy. Under the single payer bill HR 676, individuals would all pay $125/adult/month regardless of age, and businesses would have a payroll tax of 8-10% above a certain (negotiable) threshold. (Note that businesses that self-insure generally are paying significantly more than that now). With the $325 savings per month, even someone at this modest income level could afford a choice of many self-financed gold-plated health care extras.

Conservatives, and Obama himself, say that raising taxes to pay for universal health care is unacceptable.  Just how dim-witted does someone have to be in order to prefer a $450/month "premium" to a $125/month "tax"?  There are probably a few sociopaths around who would cheerfully pay someone to saw off their dominant hand if the other half of the deal was that someone they hated got both hands sawn off, but how many of them could there actually be?

Why not force private health insurance into the business model now used by private life insurance?  If you work, you must pay Social Security tax, and if you die before your dependents reach majority, they get Social Security survivors' benefits.  Despite this mandated government support of orphans with a single benefit level by all workers, a large variety of private life insurance plans are available because some parents want more income for their kids than Social Security provides.  And buying such insurance takes not so much as one thin dime from the kids whose parents can't afford that option.

Hey, Congress!!!  I don't want to "shop" for health insurance in any kind of "market"!  I want to pay a tax to support a trust fund which pays for care when and if I need it, just like I pay my property tax to support the fire department.  In the event of fire, they send a truck out.  Just the truck and people with the training required to put out the fire.  No more or no less than what I would need in that circumstance.  No personal responsibility questionnaires to prove that I've taught my kids not to play with matches, that I have my wiring up to code, that I don't store oily rags in the basement and am truly eligible for and deserving of  assistance.  And especially no tripling of my property tax just for using the service. There is not one single logical reason why a heart attack should not be treated (and paid for) like putting out a house fire.  The cheapest and most efficient way to pay for health care is to pay for it like we pay for any other public good, like schools, roads, libraries, fire and police protection, or any other part of our society's infrastructure.




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