The Healthcare Cha Cha

Ours is a representative government. The idea is that the people vote and – whomever the majority votes for based on the ideas he/she promoted which allegedly mirror those of the people who voted for them – “represents” the will of the people.

Which is all well and good except for two things: most voters vote for slogans or attacks against other candidates, not fully fleshed out policies for which they know the domestic and foreign impacts.  Also, once someone has been voted into federal office, that person is now responsible to ALL the citizens of their state/district, not simply the ones who voted for them, while the President allegedly now represents us all in aggregate.  But they don’t act as if they do.

Nowhere is this more apparent than in the debate over healthcare currently raging. But what has been flipped is that the proposals to “repeal and replace” the Affordable Care Act hurts voters who put representatives into office, as well as those who didn’t.

I just posted a Twitter thread that is an oversimplification, but I will repeat it more completely here. And I am sure it is still an oversimplification.

Insurance rates are negotiated based on the “pool of insureds” (number of people covered in total) and the “risk” of how many of those people are likely to have serious medical conditions develop that will require large output in payments to hospitals and doctors by insurers. So what you basically want is as big a pool of people as possible with as many healthy people as possible to get the lowest prices possible for insurance costs.

Block grants to states like those proposed in the latest Graham-Cassidy bill don’t get you there. First, you have 50 individual states negotiating 50 individual healthcare systems for however many people live in their states.  That bodes better for California and New York than it does for sparsely populated states in the middle of the country.  Also, states with a younger, healthier population will be able to negotiate better rates than will states with aging populations.  The inequities among healthcare programs between states will be staggering.

Also, Graham-Cassidy takes the current ACA Medicaid subsidy levels and spreads them over all 50 states, whether they originally opted for this when ACA first came out or not. By doing so at current levels rather than at levels which would have been in place had all 50 states opted in from the beginning, it penalizes states that accepted Medicaid expansion under “Obamacare.”  That is not a fair distribution, in my opinion.

That state government will somehow be more “compassionate” than the federal government in administering healthcare is laughable. State governments have fewer tax dollars to administer programs.  And employees – be they compassionate or “couldn’t care less” – inhabit government at every level.

Finally, I do not “buy into” the notion that this is the last chance we have to get healthcare “right.” This is just the last chance the GOP currently has to “repeal and replace” on 50 votes versus the 60 vote margin usually needed to pass legislation.  They are doing it for the “win,” not because their proposal offers a comprehensive approach to designing healthcare for the country.

Clearly, the largest “pool” of insureds would be the entire population of the country – that’s more than 323.1 million of us. Since that is all of us, this also represents the “healthiest” pool one could put together.  Does that mean it must be “single payer” healthcare? Not necessarily.  It does mean we all participate.

We could have a national Medicare program from which all citizens purchase health care. In recent years, Medicare Advantage plans have shown that people can have choice within a government health insurance program that allows them to select the levels of insurance they want, at prices they are willing to pay, with pre-existing conditions and wellness benefits covered, from companies competing for their business.

This is where the screams of “Social Security is going broke!” start. First, when he was President, Reagan in 1982 raised payroll taxes in anticipation of Social Security’s greater needs due to the impending retirement of Baby Boomers.  For years, Social Security ran surpluses in taxes collected versus dollars spent.  By law, those surpluses must be converted into interest-accruing bonds which the government then borrows and must pay back by a certain deadline.  (In the case of monies borrowed by Bush to fund tax cuts for the wealthy and the war in Iraq – some $708 billion according to Politifact – those interest payments are due in 2020.  However, these types of bonds are not earmarked for specific types of government spending.  The $1.37 trillion attributed to Bush also includes monies used for the financial bailout in 2008.  All presidents going back to Roosevelt have “borrowed” from Social Security at some point, this Politifact article suggests.  All information in this paragraph and the one that follows comes from an August 3, 2015 article by Linda Qui. )

So, the bonds have to be re-payed. This will likely come in higher taxes by 2020 that – unless Ryan gets his dream of a very streamlined, reduced tax system that disproportionately benefits the rich – will come mostly from the wealthy who benefitted from Bush’s tax era cuts.  (If I have explained this incorrectly, somebody speak up and correct me.  Linda Qui, are you there?)

All of this is what makes it so hard to vote and know who to vote for – it’s complicated. Which is why it’s stupid, in my humble opinion, to vote for anyone who does not have policies that are fully developed on the key issues that impact our lives.  This includes costing them out and showing how they will be paid for.

Am I really calling for single payer? If it can be made to make economic sense, then why not?  That is what the GOP is allegedly looking for – economic sense.  And the Dems are looking for “universal” coverage.

But allowing everyone to buy into Medicare – yes, that I am definitely saying deserves a look before we make a decision on what healthcare looks like going forward.

Tying the entire population to some type of insurance structure modeled on the Medicare Advantage system makes sense to me. So far I have seen no proposals that have ever fleshed this option out.  And until we do run those numbers, we have not solved the problem of healthcare in America, no matter how Congress votes by September 30.


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