17 January 2008

Health care: a shared responsibility

Reponsibility without authority in your work is the worst of all worlds. In health care too -- and yet that's exactly where we are right now. No wonder we're so stressed. The guys with the authority, the health insurance companies, have but little responsibility. Their responsibility is to their shareholders, and they're doing just fine in that department, thank you very much. Individuals, on the other hand, are told time and again that it's up to us to find that job with good benefits, to exercise and eat healthily (amidst all the conflicting advice from experts -- wine or no wine? Coffee or no coffee? Fish or not too much fish? Vitamin C helps with colds or doesn't it?), to understand insurance policies that even lawyers can't make heads or tails of (that's the point), to hire advocates to look out for our interests with providers and insurers (or to tell our insurer that we're close personal friends with Michael Moore) -- and so on.

The public knows we need reform, but what kind of reform? That scary single-payer? Mandates forcing everyone to buy insurance from the same people who seem to be at the root of the problem? Expanding access to SCHIP? Insurance market reform? HSAs? The Commonwealth Fund released a survey of Americans' views earlier this week. Ezra Klein and the media largely picked up on the question that showed 68 percent of Americans favoring mandates forcing individuals to buy private insurance (with the government helping those who are unable to afford it).

There's more to the survey, however, beginning with the fact that support for mandates included soft support:

There is stronger agreement that financing for health insurance coverage for all Americans should either be paid mostly by the government or else be a responsibility shared by employers, government, and individuals:

Most single-payer supporters, by the way, would probably answer that question along with the majority -- that costs should be shared by employers, the government, and individuals -- as is true in most countries with guaranteed health care. Personal responsibility is an important part of the single-payer message.

Note that the portion believing that the government should "mostly" pay for health care costs is 15 percent of the total, versus 6 percent who think those costs should be "mostly" paid by individuals.

One more chart from Commonwealth Fund -- which is a treasure trove of charts in powerpoint and pdfs formats. This one shows the percentage of Americans who think there should be a business mandate:

Quite a bit higher than the numbers in favor of an individual mandate. When single-payer groups around the country have written single-payer bills and proposals (like the one modeled here in Colorado), they typically discover what we did -- that to pay for the program it's necessary to collect contributions (a tax, premium, whatever you want to call it) not only from individuals but also from businesses.

The business task force to the Colorado Blue Commission for Health Care Reform told commissioners that they could live with a 4 to 6 percent tax in order to fund health care. That would be far more affordable than the average of 10 to 12 percent they now pay -- and the quotes of 25 percent that smaller businesses with older employees regretfully decline, leaving their employees uninsured. The task force told the commission that they'd been surprised to learn the truth about single-payer during their meetings, and that members had said they could indeed support a single-payer plan. They just thought it needed to happen at a national level rather than a state level -- something with which HCAC disagrees.

Back to what kind of reform is needed. Health care is a devilishly complicated subject, encompassing many variables. It's no wonder that most people hope that the experts will hand us a solution, no wonder that folks are misled by ideologues and obscenely wealthy special interests. But consider this. At the National Congress for the Un- and Underinsured last month there was exactly one speaker among dozens who unambiguously called for single-payer. David Himmelstein, MD, told the crowd of health policy professionals and academics that single-payer financing for health care is the only sustainable, workable solution that will give Americans the kind of quality health care we want.

There was also exactly one standing ovation at this entire conference of health care policy wonks.

It was for Dr. Himmelstein.

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