Map of life expectancy at birth from Global Education Project.

Monday, November 07, 2005

One step forward and two steps back?

I don't know how much attention it's getting in Peoria, but the game is afoot here in the People's Republic to reduce the number of people without health insurance, maybe even to something like zero. This has been tried before, back when Michael Dukakis was Governor, and the strategy then was broadly similar to the Democratic strategy now: require employers to cover their employees. Then as now, there were built-in "cliffs": cut-off points in numbers of employees at which the mandate kicked in or became more onerous. I forget the details from the late unlamented Dukakis plan but I described them for the current plan a few days ago.

Meanwhile our present Republican governor wants to create a minimalist policy, with high deductibles and co-payments and limited benefits, and require people to buy it. He figures it will be relatively cheap, maybe a couple of hundred dollars a month. Then he'll close down our so-called "free care pool," which is financed by a surcharge on insurance premiums and used to pay to keep the uninsured poor from bleeding to death in hospital doorways, and use it to subsidize the cost of the crappy insurance for low-income people. The idea is that the "free care" money will no longer be needed once everyone is covered.

There's a commonality between the plans because not everybody works full time, obviously, and the 5% payroll tax on small businesses don't provide insurance in the Democratic plan is equivalent to very crappy insurance at best. Note that whether the employer opts to pay the tax, or buy the insurance, it's coming mostly out of workers' pay, not the boss's profit, which in most small businesses is not much by the way. One reason I know this is because I used to manage one. (See Hometown Homeland Security.)

Creating a crappy insurance policy and forcing people to buy it with what otherwise would have been their rent money appears to be the big new "liberal" idea. Stuart Altman, who I know and certainly respect, defends the crappy insurance concept:

I do believe that advocates for comprehensive healthcare are actually hurting the poor, even though they say they are helping the poor, because we have made it so expensive that no one can afford it.

Ahh, no Stuart, you have fallen into the bottomless pit of assumption. Your remark makes sense only if we presume that any redistribution of resources from rich to poor is impossible. And as Dr. Altman knows better than anyone, and has advocated throughout his professional life, the only way to really control health care spending is to establish universal, comprehensive insurance and then make socially responsible decisions about how to allocate limited resources -- as every other affluent country does. Apparently he has thrown in the towel, which is terribly sad.

Anyhow, two people who really know which end is up on all this are Alan Sager and Deborah Socolar at the Boston University School of Public Health Health Reform Program. They deconstruct the crappy insurance solution here. (This link still seems to work as of Monday November 7, but it's a Boston Globe archive story so it may shut down soon.)

I know, I know, doing any better may be politically unrealistic, don't let the good be the enemy of the slightly less horrible, maybe incremental change will lead to better things later, yadda yadda yadda. How about this: let's wrest the country away from the corporate fat cats, the insurance companies, the drug companies, the hospital chains, and their lobbyists. Let's have a second American Revolution.

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