Somewhere along the line, the inside-the-beltway debate has lost sight of the real mandate that we sent a new crop of elected officials to Washington to pursue: to provide a stable means of access to decent health care for the tens of millions who lack it.

The status quo fails vast numbers of Americans. Obviously, many millions simply lack insurance, and the problem starts right there. They are forced to rely on a costly and ineffective hodge-podge of solutions. Famously, our most expensive care-giving mechanism, emergency rooms, is used to provide basic care. Hospitals write off that bad debt and recoup the cost through higher insurance premiums on the rest of us. Or, people get themselves to a doctor, but then fail to take the expensive medication or get the follow up treatment. Health issues accumulate, and costs spiral higher still.

People fail to have insurance for a lot of reasons. Some people make too much money to qualify for Medicaid but not enough to afford insurance. Employers who rely upon low-paid workforces cannot remain competitive if they try to provide health insurance benefits costing $500 a month to people who make $1500 a month. Insurance companies somehow have settled on this practice of pre-existing conditions — perhaps not fully considering that, while they may avoid insuring the next unwell person, they also are retaining the current unwell person, who now cannot leave his job. Or, a person is stuck with sky-high COBRA premiums. Or simply is young and thinks herself immortal and unwilling to insure the risk of medical expenses.

Whatever all the causes, the status quo is clearly askew beyond all measure. We need only reflect on the often-repeated refrain that the US spends the most money in the world to achieve average, at best, health.

So, back to the mandate. How do we provide a stable means of access to decent health care for the tens of millions who lack it?

1. Cost containment. Without this, we cannot both provide access to all and not break the bank. But where is this in the Washington debate? Neither party in Congress is offering any clear-cut cost containment strategies. Democrats have taken taxation of health benefits off the table. Without that, the CBO says, people have no incentive to moderate consumption of healthcare. They also have taken tort reform off the table, another aspect that some analysts believe could hold down costs. Republicans are behind tort reform, but are offering nothing beyond that whatsoever, and tort reform is a small piece of the package. It’s like going on a diet by giving up sprinkles on your donuts.

2. Universal access. Forget about private versus public. One way or another, access to stable healthcare is the moral imperative here. Republican ideas are focused around helping people buy insurance by offering tax advantages for doing so. Not only does that smack of the recently exposed federal mortgage policies (which, oddly, Republicans have denounced, while advocating a nearly identical policy for healthcare — huh??), but also it fails to address the issue. The people who lack insurance skew hugely to the lower income population. These are people making $1500 to $2000 a month. Health insurance for a family of four costs $500, $600, $1000 a month. Giving a tax break worth 15% of that cost hardly puts it within reach. Democrat proposals are better in terms of access, but still will leave many millions on the outside looking in.

Here is what I wish we would hear from President Obama: “I will veto any plan which fails to provide health insurance to all Americans. This may be private, public, or a combination of both. I will veto any plan which increases the nation’s total expenditures on healthcare. Government spending may go up or down, private spending may go up or down, but the total of the two must not increase. Congress, keep working until you have a plan that fits those two simple — but devilishly challenging, I am sure — guidelines. Other than these two parameters, nothing is off limits.”

Hopefully Obama would allow lots of room for Congressional debate, within these parameters. Taxing benefits is not off limits; if healthcare spending does not increase, then by definition whatever Americans pay in taxes for it will be offset by decreased outlays in other ways. Tort reform is not off limits. Reforms of existing health insurance plans is not off limits. How about we scrap the entire costly, antiquated and ineffective VA medical system, and simply issue Medicare cards to all veterans (why do we have a whole separate healthcare system for that purpose, anyway???). How about we allow doctors to make any medical decision they wish to, but we lessen the payment when that decision is contraindicated by large-scale studies? (In other words, go ahead and get the unnecessary Caesarean section if you want to, but don’t expect your insurance company to pay more than it would for a routine delivery.)

That is to say, dig deep, be truly creative, be bold and innovative. The very worst part of this whole debate is that it is mired in staleness, mired in the dismal workings of Congress and government. But it doesn’t have to be that way. In fact, I venture to say, we elected President Obama precisely because he reminded us that it doesn’t have to be this way. So, Mr. President, go punch Congress in the freakin’ nose and get this right.

Advertisements