Reframing the Debate on Health Care

Effectively convincing people who haven't spent much time thinking about health care policy requires countering the blather that the likes of Harry and Louise have been using to make people in the US afraid that however bad the current situation is, change is too scary and government is bad anyway. The market is good, no matter what problem you are addressing. The market has obviously failed to deliver health care, but markets are just as obviously successful in other areas. For instance, anyone who bought a computer ten years ago and has upgraded recently (and who almost certainly doesn't spend any time on being a health care policy wonk) is going to think that markets really ought to bring the same benefits to health care.

However, the markets for health care and the market for computers are pretty different. If you ask free market believers what governments should be doing, they will often say something like "Roads and police and firefighting are legitimate government occupations because that is infrastructure." What we need to do is to present a good case that health care is infrastructure too. Almost no one will argue that government should have no role in creating and maintaining infrastructure, other than a few Libertarian hard cases whose arguments are ignored by average citizens anyway. Health insurance paid for by individual is extremely expensive, and people who pay that way commonly feel ripped off because after they pay, they never see a penny of it. But if health care is infrastructure, it is analogous to police and fire protection. These services are also expensive, but do people feel that if their houses don't burn down and they don't get assaulted or robbed, the property taxes paying for these services are a rip-off? Should the expenses for these services be paid only by the people who are immediately served by them? Obviously not.

The slogan "Health care is infrastructure" beats "Health care is a right" as well. The latter makes people think of endlessly inflating entitlements that will drive the country into bankruptcy and still not satisfy everyone. Saying that health care is infrastructure not only directly and inevitably implies that health care is a right, but it gets people thinking about the issue in the most productive manner, namely as active citizens responsible for helping to determine public policy.

The reality is that health care providers and firefighters are very similar in an economic sense. Computer makers want to sell more computers, and people always want more memory, more bandwidth and more speed, but people would rather not get sick and rather not have their houses burn, but want effective help fast should those things happen. Imagine a city with three or four fire departments, paid for by dozens of different employer insurance schemes plus a few subsidized plans for the poor which a lot of low income people earn too much money to qualify for. A real mess, right? The firefighting equipment has to be duplicated several times, and the private insurance is always shifting around with employment patterns. ("Whaddya mean you won't send a truck out? My employer turned in the new insurance paperwork last week!" "I'm sorry sir, but you must still be with Company X. We don't have you in our records.") And you'd also have a bunch of sorryass parasites sitting around trying to calculate which zip codes are likely to have the most fires, so they can stick their unlucky inhabitants with higher fees. Also each company would adjust prices dramatically upward to include profits as well.

Since no city in real life is actually stupid enough to have several different fire departments, there is no way of comparing that hypothetical situation with the current state of affairs in the provision of health care. But this was not always the case. There used to be private fire departments, and markers designating fire protection eligibility can still be found in antique shops. If your neighbor's house caught fire from the cinders of your fire, your personal firefighting service would just let the other house burn. If there was a dispute about coverage, competing services would often spray more water on each other than on the fire. Before the revolutionary war, that well-known commie rat bastard Benjamin Franklin put a stop to this practice with America's first public fire department in Philadelphia.)

We do know what happens to health care prices in towns with more than one hospital compared to towns of similar size with only one hospital-namely that the more hospitals, the more expensive health care is. And it's perfectly obvious why-if you think about the proper economic analogy, namely that of the fire department. And it's exactly the opposite of what happens with restaurants, barbers and computer manufacturers-more of those means better and cheaper products and services. Since firefighting is paid for as a public investment, they'll go to a house of $100,000 assessed valuation just as rapidly as one with a million dollar valuation, even though the property taxes are higher in the latter case. People in wealthy areas may have some overall service advantages, but the difference is trivial compared to the difference between people with and without health insurance. In addition, the fees would be jacked up even higher to include as much profit as possible.

Competition actually degrades performance directly as well. The single most important factor in determining your chances of surviving a complex operation is the number of those operations previously performed in that hospital. Divide the number of operations by the number of similar facilities in town, and you have calculated the relative incompetence factor. The same goes for firefighters-they keep their skills up by practicing on buildings slated for demolition that have been set on fire, or on fire towers which have serious restrictions as to where they can be located. Therefore there are limited numbers of these, and dividing them up among competing departments would mean that everyone would have lower skill levels. Compare this with computers, where sales and product improvement efforts mean more computers are made and sold. Somehow you just can't sell people on the virtues of having more heart attacks and house fires, so more competitors means less real-life practice for everyone.

In one respect, public payment for health insurance is more like paying for roads than firefighters. Just as road building is paid for by the public but almost always contracted out to private outfits, medical providers would continue to be private operators even though publicly financed. Road maintenance is done by both public and private employees-how you decide between the two options is by putting the matter up to public debate and arguing about it. (This is called "activism" these days, although it used to be just plain old "citizenship.")

That firefighting is a public business leads to putting arguments of how to pay for it in the public venue. Service providers will always want to do less work for more money, and service recipients want more service for less money. No conceivable social arrangement can alter that basic fact of life. What happens is that unions and professional organizations argue about the solutions in public, bond issues and tax rates are proposed, and everybody comes to a compromise arrangement. And there is no reason to think that the same process won't work with health care providers. You can't cover everything and pay everyone what s/he thinks s/he deserves, so you put all the arguments on the public table and come up with a compromise.

And this segues into other public policy areas as well. In the case of firefighting, there are building codes and enforcement to argue about, fire safety and extinguisher training, smoke alarm requirements, etc. In the case of health, there is urban design (making walking and biking easier, for instance), health education and awareness, arguing about how to evaluate various technologies for proven results, etc. By comparison, making matters of computer design subject to this kind of public dispute would be unbelievably stupid.

And finally there is the question of how do we afford universal health care. Establishment opinion says that it is outrageously expensive compared to the current patchwork system. Of course they fail to mention that we would no longer have private insurance expenses, that out of pocket expenses would be dramatically reduced, and that we would continue to have the government funding that we now have. The fact is that we are already paying for universal health care-we just aren't getting it. Suppose your electric bill is $400 and you don't have that much. And suppose that you check your back yard and find out that someone is tapping into the line between the power provider and your house, siphoning off as much as they can get by with. All of a sudden the fact that you don't have $400 isn't the main problem any more.

Health care plans proposing incremental reform are more expensive than universal health care, because they all assume that we continue to spend what we are already spending, but should add more to that total in order to further subsidize private insurance companies, who would continue to drain off funds in the pipeline flowing from the public to health care providers. For those who like equations, those plans would cost out as

Total proposed health care spending = Current spending + incremental proposal extra expenses - x, where x is whatever unknown amount of savings would be produced by the plan. (Extending preventive care, no matter how incrementally, can be expected to produce some saving.)

Universal single payer health care = current spending only - x.

So remember boys and girls--HEALTH CARE IS INFRASTRUCTURE!

A note on cost control--an analogy is controlling the movements of a herd of cattle. You can do the sensible thing and build a fence around them, allowing them to move freely within the confines, or you can hire a passel of cowpokes with sets of reins controlling each cow individually. The former is what Canadians do with global budgeting, and the latter is what HMOs and insurance companies do in the US. It's obvious which system gives providers and patients the most choice.

There is a debate on this issue? Where?

All I am seeing is a barrage of Radical Right-wing Republican issues flying into reality faster than I can keep up with them. My Fascist BINGO card is now full so I have to yell, "Bingo!"

With the Rethugs in control, I don't see much debate or dissent being entertained. I see them reframing the entire system rapidly. The mass media is more of a co-conspirator in that game. Journalism is now cronyism.

It almost seems like a wild goose-chase or a hopeful distraction to continue forward in some sort of political delusion that the bi-partisan system of checks and balances is still in effect.

This has to be framed as infrastructure. When people finally realize that the government exists to provide to all its citizens the things they can't very well provide for themselves individually, but must be done collectively, like roads, civic improvements, education and access to health care, then we might get somewhere.

We also need to dump all politicians who think taxes are their personal cookie jar to reach into for their enrichment. Our treasury is there for the benefit of all citizens, not to make certain elements of the corporate world wealthy.

At least not upon first look. Health care is not like infrastructure...not unless our service, manufacturing, and other industries are infrastructure, as well. The fact that it would undoubtedly be less expensive to have a single-payer system than our present mess, that alone won't support your argument. It might support the argument that health care ought to be publically-provided, but not that it's infrastructure. Infrastructure typically is publically financed. While many hospitals are federally subsidized, as is physician training, that's also not enough of a foundation on which to base your argument...not unless, for example, you also want to say that various corporations that receive state subsidies to locate within its borders, or federal subsidies for one reason or another, are also either "infrastructure," or quasi-public, or something else of the sort. I'm not saying one wouldn't want to say that, but I doubt the general public would presently cozy up to that notion.

The whole "health care is a right" thing also leaves much to be desired, OTOH. Arguing from rights always grounds the argument in the premise of liberal individualism, which, IMO, we must ditch in order to be successful in our campaign to reframe the public debate about health care and the public good.

Most medical expenses are incurred by a comparatively small number of people, just as most people are not likely to have their houses or stores catch fire. It's idiotic not to have a public commitment to providing health care--same for firefighting.

You and I are on the same team, in that we both want universal, single payer, government-run healthcare. That being said, you can't just say something's "infrastructure" just because you want it to be. It works for GWB for unfathomable reasons, but the rest of us should probably stick to better established methods of analysis and discussion.

You can argue that the health system ought to be considered infrastructure. But it certainly doesn't qualify as such at present, given its present extent of privatization. Otherwise, you could also say that, for example, Ferrari dealerships are infrastructure, since most of us don't make use of them, but a handful of us do. That's just silly.

Or, on a less silly and more pertinent note, if you want to call our health care system infrastructure right now, you could also say, right now, that automotive repair shops are infrastructure, as most of us don't need to make use of them very often, but at some time or other, most of us need to use them at least once, and frequently must spend large sums of money in doing so. But you'd not want to say that, would you? You probably wouldn't want to say that unless you believe that all property and services should be communal, and you probably don't want to go that far.

Ben Franklin put a stop to that by introducing a public fire department in Philadelphia. Before that, private companies would fight over who got to put out a fire and often dump more water on each other than the fire.

I'd say that life and death matters more than car ownership or repair--Ferrari alone is a small number of total cars. The money in a household budget for car ownership is totally trivial compared to the cost of having a fire, which would be in the millions if costs were shared out only by those people actually having fires.

A quick calculation looking at UK (first that came up for me on google).

150K fires in the UK (house and chimney fires)
http://www.odpm.gov.uk/stellent/groups/odpm_fire/documents/page/odpm_fire_601429.pdf

59068K population
http://www.unicef.org/infobycountry/uk_statistics.html

0.25% of people experience a house or chimney fire. Dividing the entire expense of firefighting by that small percentage is an outrageous burden. Though people with really big medical expenses are more like 15% of the population, a similar logic applies.

you are trying to come up with a solution/suggestions rather than just bitch about our woes. THANK YOU FOR THAT.

I like your analogy. Some months ago I emailed Ray Taliaferro/KGO after a caller-in ranted about using his tax dollars to help treat someone without health insurance, called it socialism.

My remarks didn't use the words infrastructure, but I was using some of the same ideas you just did. I told the host to tell the caller to rethink what ALL of us pay for these days in terms of services. And he did. :)

All of us pay it forward for fire depts. police, forestry, universities, roads (ahem), Courts, bridges, coast guard, military, schools/education, water treatment, sewage, science/R&D, CDC etc.

Not all of us get the use of any one of these at any given moment but we pay it forward anyway. Is it socialism? No, it's for the good of the community. A little tweaking of where some of our tax dollars go can feasibly bring about a basic health care system accessible to all.

Not ALL of the population will be using the system all the time. Young people and men are notoriously absent from seeking a doctors care; unless they break a leg or something. Some folks would use doctors more, some far less or not at all.

I figure if we had a health care delivery system funded by the gov it could take on one of a couple of different styles. Single payer, based on one's income level--free for those without means to pay. Or it could be incorporated into the infrastructure you speak of where everyone gets good quality care...leaving vanity surgeries like liposuction and face lifts etc to those who will have to pay extra for it.

All of this would have to include dental, vision, and mental health care as well. A person with significant means can always opt to purchase outside of what the basic health care system provides. I like to save up and buy my OWN glasses, not the ones my insurer wants me to buy. Same thing with dental; I let my insurer do the basic stuff then I save up and go to another place and pay for cosmetic dentistry.

I think much of the waste of tax dollars in any program will be found in upper administration's mismanagement. Nip that in the bud and save a few bucks.

Cut down on any number of "Agencies" and Bureaucracies who do little more than suck at the government teat. It occurred to me, when looking around, that civil service and/or government related jobs are the ones BOOMING. Who pays them? WE DO.

It's just common sense that we, as a country, would want our population to be as healthy as possible. We want our people to be able to function, to work, to create, to NOT spread diseases. Preventative care is essential to healthy, productive, and safe communities--to a strong nation.

Well done eridani. I hope we hear more suggestions for a lot of things that have gone off the rails these days, like How do we keep our jobs at home. :thumbsup:

I've been trying to get my road fixed for 8 years!!!

Health Care is the only place in America where we don't care about the cost.

If you have a car problem, it's not uncommon to ask what HAS to be fixed what can wait a while, and how much each option will cost.

We don't do that in health care.

And do I really need someone with 10 years of Med school to remove a wart, or perscribe antibotics?

I'm 40 yrs old, and I can't think of a single injury or illness that required more than EMT level traing, but I have probably racked up a couple hundred hours in from of highly skilled doctors.

Actually, we do care about costs in US health care, but only with respect to particular classes of those accessing the system; Medicaid and SCHIP beneficiaries (sometimes), as well as the uninsured, and those patients who are privately insured who are sufficiently savvy to understand that their insurance co. won't pay (or won't pay much) for X or Y medication or treatment, and therefore request another, cheaper or covered, alternative, are among those groups.

But yes, there is no good method of cost control that is presently being implemented across most or all classes of those accessing the system. And many, if not most, Americans are of the opinion that they personally must get the best medical care possible and any test they think might be relevant, costs be damned.

How do deal with this issue? Well, one can go the route of the present administration: push a system of high deductible health plans and health savings accounts that create a doughnut hole within which consumers are responsible for their health care costs, and above which they're covered, and then delink health insurance from employment so each person/family is individually responsible for procuring coverage.

The first part of this is already happening, and the second is in the works. It will be a disaster. Delinking health insurance from employment is, IMO, a good idea, but NOT the way that BushCo is going about it, with absolutely not a plan in place to ensure that the tens of millions who lose coverage as a result have something on which to fall back, and insisting furthermore that we retain a private insurance system as our primary method of payment.

Controlling costs on the demand side simply will not work. It's certainly not ever worked for us in the past during the present era, and at least one recent study shows that about 90% of all health care costs are incurred by those who spend (far) more than the doughnut hole amount, meaning that, once they've spent past that amount, they have no further incentive to economize. We're not going to see any brake on health care costs. And frankly, I don't think BushCo cares one bit about controlling costs. Rather, it cares about shifting costs off the backs of employers and putting more money in the pockets of insurers.

We need, rather, to control costs on the supply side, via a global budget, as in Canada, the UK, and elsewhere. There, it's certain what will be spent; the question then becomes allocation. But that brings up rationing, inevitably. And that's a discussion that most Americans presently will not tolerate.

Our global budget would be much higher, just diverting what we now spend on insurance company bullshit.

Controlling costs the way we now do is like hiring cowboys with reins controlling individual cows (case review). Global budgeting is putting a fence around the cows and letting them move freely within. Local providers are not going to tolerate getting screwed by their colleagues.

to an interesting thread on this topic at an all nurses forum I belong to.

http://allnurses.com/forums/showthread.php?threadid=84879

Interesting and surprising to see how nurses respond to the idea of universal healthcare.

--for sure didn't want to trade places with their US counterparts.

It continues to heat up. I don't know when you last read this, but one of the guys flaming kukitty has identified himself as a freeper of sorts.

Thanks for the link - sheesh, I always expect more people in the health care field to understand the disparities in health care access and treatment that the uninsured and poorly-insured experience, and am always shocked to discover how many do not (until I remember that they see these folks after they've decided to risk debt or even bankruptcy, depending on their problem, by being seen, and after they've made it past the gatekeepers at the health care provider's hospital, ER or office).

It's very frustrated to be getting my nursing license and then realize these are the kind of people I'll be encountering. However, it's no different than any other job I guess.

I completely agree that this phraseology should go. I winced every time I heard Kerry's ad when he said it should be a right. I think health care is a benefit that should be provided by government to those who are unable to provide it for themselves.

How about public good, like education, transportation, fire protection, etc.

Health care today is merely getting rich off the suffering of others, quite noticeably by $100 plus office visits for 15 minutes with a doctor, hundreds of dollars for life sustaining drugs and supplies, etc.

The quickest way to health care reform is to take the profit out of health care and show that attaining wealth or even prosperity from other's suffering is inhuman and immoral.