Health care reform: a wishlist

Reading over Philip Giraldi’s piece at the American Conservative on our no good, very bad health care system, I’m reminded of just how prohibitive health care costs really are for most Americans.  There are a number of reasons for this, of course, but at least part of the reason is the fact that benefits are tied so closely to employers and outside of that partnership you really do find yourself with few options – especially if you’re older, sicker, or poor.

I remember looking at COBRA as an option after I lost a job several years ago.  We’d been living paycheck to paycheck and the costs to buy into COBRA, even as two young, fairly healthy people, were impossibly high, especially given that we no longer had a revenue stream.  My wife was pregnant and a student and not working.  Even when I did get a job, my benefits didn’t begin right away.  So we were left with no option other than  state-provided insurance which we qualified for, thankfully, given that we were totally broke and had a baby on the way.

After a few months we were back on employer-provided-benefits.  This is how safety nets were meant to be – temporary.  Far better than having to rely on the government for the long-term.   Then again, I’d rather not rely on my employer either.  That’s hardly insurance. The loss of a job should not lead to the loss of both income and health insurance.  That’s a rather precarious situation.  And it’s hardly insurance.

I think we can do better than state-run health insurance, of course, and I think we should try to avoid the cost of yet another massive federal entitlement, but I think the hysterics over all of this have gotten out of hand.

A single-payer system (which I know, is not on the table) might even be more efficient than the mess we have now – a heavily bureaucratic status quo that is neither efficient, nor a real market solution, nor particularly fair for those who need insurance the most.  It is the worst of all worlds in many ways, and could certainly stand to be overhauled.   I think health care, whether or not it is a right is certainly an essential piece of a stable and aging society.  (It’s an essential part of my larger philosophy – civilizational conservatism – which requires that societies create conditions that are economically and socially stable, while retaining as much liberty as possible.)

Either way, I think we need to achieve as universal coverage as possible, but I think we should do it right.  Implementation is everything.  Once entitlements are implemented, they become terribly difficult to reform.

What I don’t want to see in health care reform is:

• Retrenchment of the status quo and a continuation of employer-provided insurance as the only viable means of acquiring health care, especially if we remain heavily unemployed.
• Further monopolization of the insurance market or health care providers, suppliers, etc.
• Along these lines, an end to competition both in the insurance and in the provision of health care, driving up costs and decreasing access, innovation, outcome, etc.  (a public option wouldn’t necessarily do this, but certainly without breaking from the status quo a public option could easily perpetuate and increase these trends….)
• Any reform that is fiscally insolvent, cannot pay for itself, or leads to massive deficits or a great deal of new taxes.
• Any reform that does not achieve close to universal coverage.
• Any reform that requires employers to provide insurance, thus perpetuating the status quo.

Regulations and reforms I’d like to see:

• Taxation of employee benefits: insurance should be personal and portable rather than temporary and tied to a job.
• Deregulation of insurers to allow national competition: with proper rules in place, more competition will only help consumers.  And if we’re going to get a national public option, then insurers should be allowed to compete on the same scale.  This way the public option really will be competitive, and not have an unfair advantage.
• An end to “pre-existing conditions” clauses and abuses of rescission.  These smart regulations can be achieved with…
• Two-way mandates: insurers would be required to provide insurance and citizens required to buy it.  In the end, if we want costs to be well distributed across the system, everyone needs to at least have catastrophic coverage, and we should not maintain a system that crowds out those who need it the most.
• Cost-assistance in the form of vouchers.  Any public option should be offset by vouchers to keep it honest, especially if the public option is a national one.  This also helps stave off monopolization.
• Any reform should be fiscally sound and not be a drag on the economy.  Reform should work to bolster the economy, free up businesses to be more competitive, and free up employees to be more mobile and confident.
• An end to protectionism in the health care market, especially in the form of pharmaceuticals which keep costs artificially high.
• Relaxing of medical provider regulations that have led to cartelization of the industry.  You don’t need an M.D. to sew stitches.

Some of these reforms, like two-way mandates, can quickly become pernicious if monopolization occurs.  So many of these also hinge upon one another.  A public option will work better if there are also vouchers; mandates will only work if there are provisions against pre-existing conditions; insurance providers will only remain competitive under these circumstances if the current barriers to real, robust national competition are removed – and so on and so forth.  No bill will perfectly implement every needed reform, of course.

Wyden-Bennett, for instance, does not fit this equation perfectly, but it does a pretty good job.  Now that Reihan Salam is writing at NRO, I can even claim that it’s gained some support there.  And, as Mark Thompson points out, conservatives have many more reasons to oppose HR3200 than they do Wyden-Bennett.

I think in politics there’s always plenty of bad faith to go around.  But there is something fundamentally broken about the process in this country which boils down, I think, to deep and widespread distrust: of the government, of markets, of each other….

Limited government is good for everyone involved, but it takes reasonable compromise and concessions to achieve.  It requires us to relinquish some of this lack of faith, this lack of trust, and open up to real compromise.  Not just middle-grounds, but quid pro quo.  Compromise that takes two good ideas from countervailing ideologies and makes them work together – not just the worst half-baked ideas of both sides lumped together.

Right now, the Senate Finance Bill doesn’t look very much like my ideal health care reform, but that could change.  Better ideas might be hashed out as the House and Senate bills begin their crash course.  Wyden’s Free Choice Act may be adopted.  Insurance, both private and public might be opened up to national competition and regulation, freeing consumers from the very real problem of monopolization in health insurance.  With freedom to exit from our employer-based insurance, we might become more confident as workers and consumers, and bring that confidence back to the market.

For now, we just have to wait and see.

(A similar version of this post appeared at the League of Ordinary Gentlemen some weeks ago.  This is a pretty good summary of where I stand on health-care reform and I thought reviving it from the archives would be good for readers here at True/Slant.)

(Photo via Daylife)