Selfishness and Sacrifice: An Honest Health Care Reform Debate

Congress is now up its neck in a debate about the nature of health care reform. From out here in the sticks, it looks to me like about a third of the representatives and senators are worried they'll pay a heavy price if they don't produce real health care for everybody, another third are worried they'll get clobbered if they produce anything resembling a tax increase or a cut in health care for the super-covered, and the middle third are worried about both. The most likely outcome, as I see it, is that they will all come to a consensus that the easiest position to defend is to do nothing of consequence and figure out how to blame the other side come election time. And they are probably right. And people will die early or unnecessarily as a consequence. And that is preemptively pissing me off.

Now, I've made it clear that I'm an Obama supporter, but that doesn't mean I'm some liberal version of a Rush Ditto-head. One of my beefs with Obama is that, too often, his attempt to usher in a new era of more polite politics devolves into a situation in which people get to pull the same kind of crap they always have, but they aren't called on it because they are so busy trying to be nice. And I'm not just talking about the Republicans in congress. The stimulus bill was a bunch of pork-laden crap, and there were really good reasons to oppose it, but these weren't the reasons I heard Republicans voicing. I think they were trying to figure out a way to be nice and enter into this new era of politics, so they criticized it for increasing the national debt. Now, the national debt is a real long-term problem, but no one should take a single Republican who was in office during the Bush presidency seriously on that front, since they all approved a couple wars and massive tax cuts at the same time. If the national debt is a serious concern, you whine about it during a debate about an unnecessary war, or you mention that when you're considering tax cuts for the rich. During an economic crisis, you either point to your consistent track record on the issue, or you shut the f--- up. No, the Republicans should have been shouting because the stimulus plan was misdirected. If that amount of money had been turned over directly to tax payers in the form of a progressively devised direct payment, the Republicans could have called it a tax cut. This would have been better for them, since a tax cut for the neediest Americans might open the door to a group who (let's face it) is wising up to the fact that the Republicans have not been working on their behalf for the last thirty years. Big win for them when they are looking to broaden their demographic appeal. Meanwhile, the Democrats could have touted the progressive structure of the stimulus as a sign that they took their mandate to heart, doing what the Bush gang did in spinning the bad polling about moral issues into a right wing mandate, only in reverse. They could have satisfied the far left, who they will certainly disappoint on other issues, and shown the lower-income red-staters just what a progressive tax structure might look like for them: a check. Instead, the Republicans essentially voted against Pelosi, making them look like "The Party of No", and the Democrats pushed through a stimulus plan that heavily favored the "too big to fail" CEOs, making them look like "The Party of Guys with Matching Priuses and Ferraris". Now, imagine a stimulus bill that, a year ago, had taken the form of significant checks, skewed significantly toward the lower and middle class. What do us poor folks do with that? The less responsible go out and buy TVs, tickets to Nascar, whatever. Good: that's some needed economic stimulus. The more responsible buy things like first homes or cars. That makes a significant dent in the housing crisis and helps bail out the auto manufacturers. The most responsible pay off their credit cards and put their checks in the banks, which helps to rescue the balance sheets of the banks themselves. Would it have created as many jobs as giving money to state governments to build roads? Possibly. Would that stimulus have hit the economy more quickly? Certainly. Consequently, it might have created more jobs, and better, more permanent ones, and it also would have prevented those super-massive bailouts for corporations. Now, as congress considers a second round of stimulus, the argument will not be about whether we should do this, because now folks are concerned about their jobs so they will put that money in the bank, and the banks are one of the sectors we've already rescued. Instead, the debate will be about the debt, which both sides have no real moral authority to gripe about. And that brings us back to health care.

When it comes to the health care debate, like Stimulus I, the debate will be about the wrong thing. It will be about whether or not we should have a public option, and the alternative of the status quo will be presented as revenue neutral and economically viable. And that pisses me off.

Now, I know the danger of over-simplifying an issue. We see it every time the issue of abortion comes up. One side tries to paint the other as a bunch of sluts who kill babies as birth control willy-nilly or, alternately, as a bunch of stupid religious zealots keeping women in some kind of chauvinistic sexual bondage when they aren't busy killing doctors. Both these positions might exist on the margins, but they are in such infinitesimal numbers that any popular vote to enact either side's agenda would be a loser. Imagine a ballot measure to charge any woman who had an abortion with homicide and lock her up for thirty years, even if the baby would not have survived and possibly threatened the health of the mother. Beyond the immorality, talk about a budget nightmare. No way that would pass. Or imagine the inverse; some kind of schema of mandatory abortions for some women. Would either initiative even come close to passing without people being deceived by some campaign to mask the true nature of the legislation in ridiculous rhetoric? Of course not. So any debate about abortion needs to be about the two things we're most uncomfortable confronting: the fact that we will have abortions (which we're all uncomfortable with) and we will have unwanted children (which we're also all uncomfortable with). That's a much more complex debate, but it's the one we need to engage in.

The health care debate, on the other hand, needs to be simplified to some degree, to get us away from the wrong argument, so that we can get to the real debate, which will be complex, but far less deceptive and heartless. We live in a country that, despite its economic woes, can afford to provide health coverage to every single citizen. We simply can. We have a system that is increasing in cost at an almost exponential rate, and it will eventually get to a point where we can't afford it. Health care is already one of the leading causes of personal bankruptcies, greatly harms many businesses' competitiveness if not their outright success, and will eventually bankrupt the government as well. And yet, the debate is about whether we can afford universal coverage. That's simply infuriating. We can't afford not to have universal coverage... or we have to change the law so that people without coverage do not have to be served by hospital emergency rooms, and can be allowed to die.

This may sound like a kind of modest proposal, but it's not an exaggeration: as long as our system requires that people with no coverage be provided with care, we have to figure out a way to provide them with coverage and get them to pay in while they are healthy. We already have universal health services. They're just really unequally and inefficiently delivered. People without health insurance don't pay, but they cost a lot. People with the most resources pay for their own care, but do not pay enough to cover the uninsured. That's clearly not sustainable. So we need to decide, will we let the uninsured simultaneously bankrupt the system and die unnecessarily in the process? Or, will we figure out a means by which the people with more resources pay more but receive two pretty significant bangs for their buck; they get to live in a country where their businesses and government can continue to be successful, and they don't have to live in a country where people are dieing unnecessarily all around them?

Now, here's something you will not hear coming out of the mouth of any congressional representative or senator who opposes universal health care, or its little brother, the "public option", or its bastard child, the public co-op: "It is more important that the wealthiest among us maintain both their incomes and the quality of care they've become accustomed to than that the government remain financially viable and poor people live."

They may say part of it out loud. They'll say we must maintain the quality of care. Fine, but if we expand that to everybody it costs money, and if we don't people die and the government goes bankrupt.

Or they'll say we can't afford to insure everyone. Fine, then we need to stop serving everyone at more expense in emergency rooms than we would if they had individual doctors and preventative care, and simply let them die.

They may say we're classists, or socialists, or Marxists, or some new slur for people who recognize that some people make more money than others, if we try to make wealthier people pay more of the cost. Fine, then we can have a flat tax on everyone, which poor people will not be able to pay, and it won;t be financially viable and we're back where we started, or we're back to letting the poor people die. I suppose there's another option there: We could let the poor go to debtor's prisons for not paying their health care taxes, then provide them with care there, driving up the costs for everyone, and create universal health care at a much higher price that way.

Universal health care is not only the one option which prevents a lot of unnecessary death, but, if done correctly, it's also the more financially sustainable choice. Anyone who says anything else is really saying their current coverage, at their current price, is worth more than both the lives of poor people and the quality of their country as a whole. I know the hard-core, Adam Smith capitalists truly believe in the virtue of selfishness, and I commend them for their strength of their conviction, even if I don't agree. I just want someone to marry the courage of their dogmatic adherence to capitalist virtue to the courage to say so publicly and clearly, especially on an issue where the intrinsic winning-and-losing nature of capitalism, the vaunted "creative destruction", results directly in people dieing. These quiet, seemingly compassionate capitalists are a bunch of hypocrites and cowards, and that's the nicest way I can put it.

Now, this kind of bald truth might not fit well in Obama's new, more polite politics, but it has to be said if we'll move to the real debate, which will still be incredibly complicated and will require politeness and decency. See, once we get beyond the acknowledgment that we have to move to some form of universal coverage, we still need to figure out exactly who is going to sacrifice, and how much. Health insurance companies, unless we leave in a bunch of unnecessary redundancy, will have to shrink down to efficient distributors or cease to exist entirely, and that's a significant sacrifice, though it's only from a small group of people. I expect those folks to fight to the bitter end, though they have to be able to see that they're doomed eventually. Doctors will want to make sure they get to maintain their salaries, though many will be grateful they get to spend more attention on treating patients than on haggling with insurance companies. Individuals outside the health care field will want to make sure they still have the options they currently enjoy. That's reasonable, as long as they realize that some fifteen million people have zero options, so they may have to make some sacrifices, too. (Over all, I think this gripe is greatly inflated. Does anyone really think that if only one government run insurance plan existed, their personal physician would not accept it, and would only serve patients who chose to pay out of pocket? Show me that doctor, and I'll show you a cosmetic surgeon.) Individuals will also have to acknowledge that there will be forms of rationing, probably in the form of delays of non-life-threatening elective procedures, though even here I expect some compromise situation can be developed where people can choose to pay extra to have procedures expedited so that everyone receives a baseline of care and the wealthy can get better care at their own expense. Developing the system, and addressing these concerns, will be difficult and will require courage. In fact, the more courageous we are at the outset (closing down insurance companies, for example, rather than leaving them in to add a profit margin to the cost of health care) the better the entire system will be in the long run.

But the one thing that we simply cannot accept is the kind of cowardice that allows Congress to push this off into the future, toward an immoral and unsustainable end. And that, I fear, is exactly what we're going to see over the course of the next month as this false debate is used to push the issue down the agenda. And it begs the question: Why are the people in Congress working so hard to avoid pissing off some of their constituents and losing their jobs, if they really want to make someone else deal with these issues anyway?