So, health care. What do we need?
The United States is a large, relatively wealthy nation. Yet in many respects, we act like a poverty
stricken region, with little intelligent thought given to our population. It
would seem to me that one of the primary responsibilities of a governing system
is to see to the overall health and well-being of its population. But what does
that mean? That everyone gets free food and free health care? Well, no, not
exactly. But it should be the case that
our nation decides that all of its citizens should have access to adequate food
and health care, that food and health care should not be denied to any part of
the population.
People should not become sick or die of malnutrition because
they have no food. People should not die because they cannot gain access to our
system of health care. Note, if a ruling party decides that a goal of its
system of governance is that its entire population should have access to food
and access to quality health care, then that same ruling party must design the
systems and programs whereby such a goal(s) can be achieved.
It is a principle of management that, when one develops an
overall goal for its population, it is the responsibility of the program
managers—the ruling party—to design a complete program that will lead to
achievement of the goal(s). To announce a goal, and then leave the program’s
design to chance, is to act irresponsibly, and to thereby assure that the goal
will not be achieved.
This simple statement appears to describe where we are as a
nation at the current moment.
For decades, we have been experimenting with both health
care and food assurance to no avail. During the Johnson administration, our
nation’s program managers devised a program that would assure access to quality
health care for both its senior citizens and its poor. At least for the
seniors, the program has worked wonderfully well, although it has begun
breaking down as the program’s manager’s delegate increasing responsibility for
the program’s finances to for-profit enterprises that actually hold different
ultimate goals than the program’s founders and ostensible managers.
In terms of food, our system of entirely
private food production and distribution works well to both produce and to
distribute food to all geographic corners. However, access to food is entirely
a one element system—money. The government has (no doubt wisely) decided not to
interfere in the actual production or distribution systems, but rather to treat
access to food as entirely a matter of affordability. If the population has
enough money, the entire population will have access to quality food.
Therefore, the government’s program to assure access to food is a financial one
entirely. The program managers decide how much money individuals need to live
reasonably in any given part of our nation (costs vary by geography). The
coping system is termed Welfare. When incomes drop below certain predefined
levels, the population can apply for and then receive supplements to their
income to guarantee access to food (and lodging). Note that the system will
break down should the program managers (government) decide that the financial
amounts needed by population segments cannot/will not be made available.
But access to health care has always been more complicated. Our system of health care in its earliest
stages was simply on a pay-as-you-go basis, much like food. But, unlike food, health care services
rapidly became expensive to individuals in need of the higher cost
services. And, as more and more people
began obtaining health care services requiring care within hospitals, the cost
of hospital stays began escalating beyond the ability of individuals to afford.
Thus, enter health insurance. An entirely new industry, has now emerged as
a major element in the ability of the “system” to provide adequate access to
the entire population. Initially, health
insurance became an element in employment. That is, if one was employed full
time by a responsible company that company entered into relationships with
insurance companies that would guarantee access to the employees to full health
care. The company and the employees would split the costs of that enterprise,
so that health care did not “break the bank” for either party. It is important to remember that health
insurance is affordable so long as the pool of people covered is large enough
that the costs are spread such that low users subsidize high users, so as to
contain the costs, enabling the entire pool to have access. That is the obvious
system design element that is slowly slipping away, and jeopardizing the entire
system.
Since the entire system was based on employment, it always
contained a fatal flaw. If one segment of the population were unemployed, that
entire segment would lose access. So,
two groups were at immediate risk—the unemployed elderly and the underemployed
or unemployed younger sets. With the development
of Medicare and Medicaid, the government entered the scene by providing the
role of employers in the remaining sectors.
If people were old enough—initially 65—or poor enough (low income
levels) they still might have access to health care. And the concept of risk
pools still prevailed. That is, the healthy elders subsidized the relatively
less healthy elders. Note the cost
sharing depended greatly on government financing. The elders continue to pay
into the system, but the government finances a major part of the overall
system.
Over time, the private sector system that depended on
employment began breaking down, largely because there was no overall system
manager whose job it was to assure the program’s success. For example, many
companies (e.g., WalMart) decided to reduce their cost envelope by hiring
people less than full-time. It had been decided that all employees who were
employed more than 30 hours per week were “full-time”. Employees who were
employed less than that were “part-time” and, therefore, did not qualify for
health insurance coverage. Thus, cost
began to overwhelm access as the ultimate goal of the system. One needed to
contain the costs of health care and, therefore, since the system was being
managed by the private sector, where cost, not access, was the ultimate goal,
cost concerns began eating away at coverage, and segments of the population
began dropping out of the system.
Note, there was no alternative system that would take over
from the private system that was failing at the basic job of providing
access. In other countries, the
government had long since stepped into the role of provider. That is, the
governments decided that access to health care was a universal right, and the
government, through its taxation system would guarantee that right. America had
no such thoughts. We continued on our private sector approach, in which we
essentially delegated to the for-profit sector responsibility for health care
access. The government continued to intervene for the elderly and the poor,
although complaints about the taxation required to sustain that system have
never quit. It is as though our population
either does not understand, or simply does not agree that health care is a
necessity, not a luxury, and therefore should be guaranteed.
As a result, increasingly large segments of our population
have dropped out of the health insurance marketplace, and very large segments
of even our covered population (the elderly for example) are now beginning to
discover that they cannot continue to afford their health care, as it is
currently designed.
So, it would seem that we now require a whole new approach
to health care insurance in this country.
We need an entirely new financial approach that would guarantee the
entire population with effective access to quality health care. That is, we
need to emulate those systems now in use within many/most European nations
(including our neighbor next door).
That must be our goal if we are to become once again a full
member of the universe of civilized nations. Currently, we have dropped out of
that universe.
