By this stage in the health care debates, most people are aware that roughly 47 million individuals in America do not have health insurance. And many people are further aware that the 47 million statistic is misleading, because roughly 14 million of these individuals are already eligible for (but have not enrolled in) existing government programs, 9 million have incomes over $75,000 and choose not to purchase private insurance, 3-5 million are only temporarily uninsured between jobs, and roughly 10 million do not have the legal right to reside in the country. In the end, this means roughly 10 million U.S. citizens lack meaningful access to health insurance. It has been noted elsewhere that insuring these individuals would cost a lot less than the $1 trillion proposal currently under consideration in Congress, and further that it would not require a dramatic (and costly) restructuring of the U.S. health care system.
I understand and share a number of the concerns expressed here and elsewhere about the current health care proposals, but my sense is that many of our contributors and readers would object even to a more modest expansion of publicly-sponsored health care for the ten million who are chronically uninsured. I think this position is in tension with the most recent statement of the U.S. Conference of Catholic Bishops, which teaches that “health care is not a privilege, but a basic human right,” and lists the following guideline considerations for health care reform:
1) a truly universal health policy with respect for human life and dignity; 2) access for all with a special concern for the poor; 3) pursuing the common good and preserving pluralism, including freedom of conscience and variety of options; and 4) restraining costs and applying them equitably across the spectrum of payers.
My question for our readers and contributors, assuming I am reading them correctly, is 1) Whether they support expanded public health care for the ten million who are chronically uninsured, and 2) If not, how they hope to achieve the goal of universal coverage called for by the bishops absent government intervention.
If you could come up with some alternative to ObamaCare that would really stay limited to that ten million or so people in question then I would support it. Even within that ten million, however, there are a lot of people who could afford health care without undergoing serious hardship but who don’t do so because they would rather spend the money on something else (i.e. people who are young and healthy). As to that group my thoughts are similar to those of Megan McArdle: “If you could reasonably afford health insurance by dropping down to a lower-priced cell phone plan and cutting back on your bar tab, you are not a national emergency.”
If we’re talking something fairly heavily means-tested, I have nothing in particular against putting something out there to cover that “other ten million”.
If that could be packaged with means-testing medicare and social security, I’d become downright enthusiastic.
For me, at least, the big objection is when you start trying to use the predicament of a small number of people to justify putting _everyone_ into some big program.
I would suggest a subsidy of some sort, probably tagged on to the earned income tax credit, to allow people who simply can’t afford health insurance to purchase it. I, like Blackadder, do agree with Ms. McArdle however. In my bankruptcy practice I do find quite a few debtors, most without much in the way of medical bills, who have run up high tabs on self phones and drive far more expensive vehicles than I drive, and who could easily afford health insurance but simply prefer to spend their funds in other ways.
Health care is a basic human right? Health care is something I’m owed simply by virtue of being a human being? Who’s responsibility is it to see that this “basic” right is not denied to me? Where is that person’s obligation in the natural law? What kind of health care am I owed? What is it’s extent? What does the term even mean?
Please delete my brief rant if you think it’s not sufficiently related to, or will only distract from, the point of the post.
FWIW, if universal coverage is really the goal, then I think the best way to achieve that is to make it affordable for everyone. Because of the way our economy works, the only way this is really possible is through competition and deregulation. This is obviously a very general prescription, but it’s all I’m really capable of:)
Well, there seems to be general agreement (Zach excepted) that an expansion of government-provided health care is desirable here (even if not the best of all possible solutions). Apologies for the caricature in the post if that’s how it came across. I have a few more thoughts I’ll throw out just to be contrary:
BA – Since we agree on the larger point here, I suppose it’s just quibbling, but I think Ms. McArdle’s ‘unsympathetic recipient’ illustration is somewhat beside the point, both because a hypothetical (or actual) ‘sympathetic recipient’ could just as easily be produced, and because over and under-inclusiveness are a necessary consequence of every expansion or reduction in government services. The relevant question to my mind is: “what is the best way to serve the common good here?” A substantial over-inclusiveness problem obviously harms the common good because it is a wasteful use of resources, but we don’t have evidence of substantially over-inclusive public health care benefits with regard to these individuals. If anything, the data suggests we have the opposite problem.
DC – I think we’re in basic agreement. It still amazes me that Social security and Medicaid aren’t means-tested. Everyone seems to agree it should be done, but politicians in both parties seem to be terrified of the political consequences. At some point, hopefully, sanity will prevail, but I’m not holding my breath. As they say in finance, the market (and politicians) can stay irrational longer than you (or the government) can stay solvent.
Zach – I left your comments undisturbed (although you are certainly free as a contributor to modify or delete them if you would like). I think your underlying concern about the ambiguities of rights language has some validity, particularly when the ‘right’ involved is, more properly speaking, a duty imposed on other citizens that evolves and takes different forms as a society becomes more prosperous. Nevertheless, it seems clear to me that the underlying concept of the preferential option for the poor is soundly rooted in the teachings of the Church throughout the centuries and the Gospels.
I think it would be best to forego this until the banking system is arighted and the public sector deficit extinguished. For flusher times, i’ll offer the following suggestions; those of you more sophisticated about the technics of tax collection and accounting and who have consulted some academic literature on insurance and medical economics can tell me where I have gone astray:
1. Equalitarian tax reform:
a. Abolition of property taxes and general sales taxes.
b. Generous use of tolls and fees on public services.
c. Conversion of corporate taxes to a flat rate on net profits, without deductions exemptions allowances, &c.
d. Abolition of the current portfolio of payroll taxes
e. Replacement of estate taxes with a tax on gifts and bequests received over and above a lifetime deductable. The deductable should be calculated such that these sort of taxes are limited to about 4% of the population with serious assets.
f. Establishment of a policy that imposts and excises are to be used as instruments of trade negotiations and to change relative prices and induce ‘substitution effects’, not raise revenue. This can be done by distributing the receivables on a roughly per capita basis as a credit against one’s income tax liability.
g. Define ‘capital gains’ as any increase over and above the increase in the GNP deflator since the base year.
h. Rely on completely unadorned income taxes for about nine-tenths of public revenue. Calculate them as follows:
(r x income in cash and kind from ALL sources) – (sum of credits)
[a dollar value credit for yourself and each dependant]
Fix the rate and the dollar value of the various credits such that revenues meet expenditures and that about 20% or 25% of the public pays no taxes but receives a net rebate. The net rebate for each head of household would, however, be constrained by a ceiling calculated as a percentage of his earned income; the ceiling could be relaxed for the elderly and disabled.
2. Scrap public subsidies and provision for commodities for which household expenditures are regular, predictable, and subject to adjustment for amenity (food, rent, mortgage payments, utilities, etc). Turn interstitial social services (the Office for the Aging, the midnight basketball, &c. over to philanthropies).
3. Incorporate philanthropic foundations to assume ownership and management of all public hospitals, clinics, and homes. Members of the foundation would include those on the attending lists of the hospitals, donors, members of the local chapters of the American Legion and the VFW, those on tribal rolls, &c.
4. Gradually discontinue state funding of medical research, bar that in the realm of public health.
5. Consider removing the adjudication of malpractice claims to administrative tribunals who issue awards from a stereotyped compensation schedule, derived from a state fund collected from an annual assessment on practitioners.
6. Systematize extant schemes in place for extending services to undesirable loci by creating an ROTC-like program for medical students and residents at the end of which they would put in five years with the Commissioned Corps of the Public Health Service, accepting deployments to Indian reservations, &c.
7. Enforced savings: each family would have two bequeathable savings accounts, one devoted to medical care and the other devoted to custodial care. The state would make a flat monthly assessment of one’s income with a portion destined for each account. One would be permitted to draw on one or the other to pay for care, and would be permitted each quarter to withdraw for use at one’s discretion any amount over legislated minimum balances. (These minimum balances I would think be fairly high).
8. Public insurance:
a. Each state government defines by legislation a standard insurance contract. The contract would provide for the re-imbursement of providers once the individual has exhausted the contents of his savings account (or exhausted the legislated minimum balance, whichever is lesser). The state government would divide the territory of the state into catchments on which demographic information would be available and with regard to which insurers could do their own research. The state would then assemble qualified insurers every few years to submit sealed bids to be the insurer for the catchment. Low bid wins, and the state government acts as the bag man for the insurance company in question, collecting the community premium by assessing a surcharge of a certain percentage on the state income tax bill of each family in the catchment.
b. The state government would do the same for the provision of insurance for custodial care.
c. The federal government would enact a parallel plans much like the above to cover medical benefits and custodial care of certain clientele (e.g. military families and others in itinerant occupations) and those who have moved into a state in the last three years.
9. Grandfather clauses:
The federal government would add balances to the medical and custodial savings of the elderly, the disabled, and in-theater war veterans for some decades to hold harmless people whose financial planning was dependent on a certain benefits configuration.
10. Private insurance could be purchased at the discretion of the head of household to supplement or supplant benefits in the state’s standard contract. He still has to pay his surcharges, though.
11. State insurance funds derived from assessments on private insurers, to compensate hospitals for emergency care delivered to patients who use insurers with which that particular hospital does not do business.
12. Philanthropy of the formal and informal sort.
On McArdle’s unsympathetic recipient — if one was willing to come up with some reasonable means-testing and stick to it, I think that could mostly alleviate that problem. Assign a subsidy or possibly public coverage ala Medicare to those in that ten million, but only to those who meet a certain threshold of need.
If people don’t have the stomach to leave those who can cover themselves but refuse to out in the cold, one could allow them use of the same program as those who meet the means test, but then dun them for payment via the IRS.
Now, I’ll say, I’m not crazy about public subsidies (for people or enterprise) in general, but I think given the society we find ourselves in at this time we’re probably stuck with using that as a way out of certain problem. I admire groups like the Amish who accept neither social security nor medicare nor insurance because they believe in relying on one another — but we clearly don’t have that kind of community cohesion so there’s no point in cutting our legs out from under us based on the ideal.
I do not care for subsidies for private goods, either. What is (among other things) characteristic of medical care, custodial care, and legal counsel is that over the course of your life you suffer somewhat unpredictable spikes in your demand for these services. If we are being admonished to place the interests of the poor front-and-center it ought be acknowledged that the information deficits in the purchase of these sorts of services tend to be more acute the more impecunious the recipient and that trouble with time horizons is inversely correllated with income. Legal counsel and common schooling are also a facility for taking your place as a citizen and common schooling and mass transit are a facility for entering the workforce. Ergo, there is a case to be made for redistribution taking the form of common provision of a modest selection of purchasable services. What is mad about our current welfare system is that policy is generally to subsidize the purchase of frequently replenished goods of which consumption varies according to consideration of amenity. We can ‘pay’ for the collective consumption of certain services in part by erasing the unnecessary subsidies as well as certain baleful income transfer programs (TANF, for example), as well as targeting the role of public agencies in heath to public health measures and the provision of care, not to academic pork barrel. Concern about ‘cost control’ is somewhat misplaced. What should concern us is that public expenditure not be put on autopilot, which we can accomplish by adjusting a deductable upward every few years in order to maintain the committment of the state in the realm of medical and custodial care somewhere in the neighborhood of 8% of GDP.
John,
Does the preferential option for the poor entail a right to health care? What does the option entail? I don’t believe this has ever been spelled out in any specifics in terms of policies. I think it means political leaders and leaders of communities should consider the poor in all that they do.
Based on Darwin’s estimate of $4-6K for 1yr of insurance, I’d think that we could just buy ordinary insurance for those folks at a cost of $50B/yr. (And I assume that merely adding those people to medicaid would be less expensive than $5K/yr.)
According to this story,
http://www.cbsnews.com/stories/2009/08/10/business/moneywatch/main5230656.shtml
the reform plan will cost $90-100B/yr over the next ten years. According to the same story, we could make up that amount either by raising taxes for individuals making over $280,000 and families with income over $350,000 or by taxing employer provided health insurance as income. I think that either of these would be fair ways to pay the tab for the extra 10M uninsured.
QUESTION: What is the source of the 10M figure? I’ve seen George Will’s column…
http://www.washingtonpost.com/wp-dyn/content/article/2009/06/19/AR2009061902334.html
but that gives 9.7M illegals and 9.1 over $75K income, for a total of 18.8M not to include so far.
Then he says that there are AS MANY AS 14M who are already eligible (which implies that there are likely <14M) and that there are many who are uninsured for 6 months or less (but states no figure). He ends up suggesting that there may be 20M remaining, not 10M. In other words he is sure that at least 25.7M can be excluded. That would mean that the figure for the already eligible plus the 6 monthers may add up to as little as 6.9M Moreover, his starting figure was 45.7M and not 47M, which would mean adding a possible 1.3M
To me, that implies that there may be as many as 21.3M chronically uninsured, unless there is another source for the 14M which does not use it as an upper limit and another source for the 3-5M figure. (Daylightsmark gives no sources, and the 3-5M seems to come from there.)
The two sources of funding I mentioned above, when combined, would still accommodate the larger estimate of uninsured.