The Private Option

Despite Trump’s speech Monday, ridiculous, mendacious, inappropriate and embarrassing, as expected, he said something right: the ACA is not a good system of medical care delivery.

It is the worst healthcare system among economically advanced countries. 

There are two worse systems, though. The private insurance hustle without the ACA that the US had before, and all of the vicious tax cut and insurance company subsidy plans that Ryan and McConnell have put forward since Trump told them to make “repeal and replace” not just a battle cry, but actual legislation. 

 After two more defeats last week, McConnell and his deplorable allies are still plotting to Make America Sick Again.

If he succeeds, more of your money will be pumped into propping up the cash flow of the worst system of medical service delivery in the developed world, so they can backwash some of it to McConnell and his political hustle. If that does not really sound like a serious medical service, it’s because it isn’t.

McConnell’s disdain for public opinion is stunning. He is apparently immune to the tested fact that the vast majority of the population detests his nightmarish “healthcare” bills. And he doesn’t care. The donor-sphere fulfills his every political need.

The Public Option

Remember the Public Option? It was going to be a federally owned health insurance company or agency. It was not publicly funded healthcare. The mechanism was to be something like Medicare that you could pay for. It would have competed with private insurance companies. It might have driven premium reduction and less benefit challenging through market operations. Might have – by the time your legislators, following lobbyists’ instructions, got done embedding it in limitations and prohibitions, it might have looked more like something McConnell could be proud of.

At best, it would have been a clumsy compromise, mitigating some of the worst effects of the private insurance cartel while propping up an illogical and inappropriate presence at a healthcare provision system.

It was not Medicare-for-all or “single payer.” One proposed model was Medicare that you could buy. It could have at least had the government’s negotiating power, but under pressure of private hospitals, the AMA and the insurance cartel, congress would probably have blocked that.  It might even have set precedents that would have corrupted Medicare, opening breaches for Republicans to undermine even that part of the country’s weak safety net.

The private health insurance gang went ballistic, of course. They don’t want to have to sell services that you buy on their merits. They want control.

The public option was finally shot down by the chronically repellent fake Democrat and now klepto-family supporter, Joe Lieberman. (Fake Democrat then; now he is a fake Independent.)

Private Corporate Medical Insurance

Connecting right wing objectives to real medical services is a tricky mental exercise, requiring insertion of fictional constants and false assumptions.

The private insurance model is simply an irrational, ineffective way to pretend to achieve the goal.

The pernicious effects of the system are to some extent masked by the the high quality of the US’s medical capacity. It is commonplace that it is marred by overprescription of opioid painkillers and too may tests, probably more as defense against malpractice suits than real necessity, but the quality of the product is real. The problem is not what it can do. The problem is sho it excludes.

One of the results of the tangle of unreason combined with Republicans’ divide and rule instincts is the mad misunderstanding occasionally announced by Paul Ryan, who suggests further subdividing the premium pools of a system already rendered too weak and expensive by being partial. Ryan pronounces these gems of ignorance with one of his brow-wrinkled expressions. He calls that look intelligence.

Some history

During WWII, the US had full employment and high demand for workers. Wage controls were imposed to counter inflationary pressure. Corporations were challenged to attract enough workers to meet demand. The courts decided that fringe benefits were not wages, so corporations designed benefits to attract and retain employees. One innovation was to convert disability insurance that had started in the 19th century to medical insurance. Disability paid the wages of a worker temporarily unable to work. It was capped at a percentage of his wages. Insurance based on medical cost changed the equation, but between the major employers and insurers, they worked it out. Healthcare became a corporate tool.

At this point, it should already be clear that the basic design of American medical service provision was to keep some people in and others out. Employment based healthcare was designed to exclude people. As a loyal house man of the corporate state, Mitch McConnell does not care that his insane healthcare bills push twenty or thirty million people out. In his world, it was always thus, and so shall remain while his masters so order.

“Conservative” fictions imply that European healthcare systems like the UK’s NHS nationalized or socialized traditional insurance models, and that the US never has enough money to support real national medicare. Bogus. European countries got their tax funded medical systems going more or less when the US corporate system was taking shape, when they were destitute after WWII and the US was by comparison fabulously wealthy.

It seemed to work for a while, providing good, even excellent coverage for employees in secure jobs with major employers while cementing workplace and corporate loyalty.

It was partial and exclusionary, but papered over a lot of cracks under conditions of near full employment, high demand for labor and general prosperity. But things changed. Automation and offshoring changed the playing labor/capital equation. A locked in, dependent work force became a liability. General Motors went insolvent on health insurance. Reaganite regressive policies freed corporations from social responsibility. Business schools started teaching “shareholder value” to further detach directors and executives from their workforces and communities.

European and other advanced countries had already sorted out better healthcare delivery, but American conservatives and the successive red scares had so distorted Americans’ understanding of social services that should be the minimum price of politicians’ strut and power that the US often has to be dragged reluctantly into the emerging world. And now that some formerly intelligent countries are dragging themselves backwards, some available models are not performing at their best. When Trump says that one option is to let the ACA – he calls it “Obamacare” – fail, he is following a UK model, in which the Conservative Party progressively starves and weakens the NHS, claiming fiscal responsibility as justification, then points to the failings that they themselves caused to justify progressive privatization.

What makes America backward in these areas? It might be deeply cultural, perhaps rooted in America’s anti-intellectual, anti-logical, media-linked religiosity; but might simply be that other countries do not have to overcome an oligarchic corporatist culture working through a sadistic insurgency like the Republican Party.

The Private Option

What do you think about giving the insurance companies a job to do without giving them license to kill people?

Change their market space and some of them may shrink, go broke or succeed at selling a good idea.

You can have a serious national healthcare delivery system, and still have a commercial insurance market, without a Rube Goldberg idea like the Public Option.

Here’s how to do it.

Set up a proper national health system. Forget the American insurance model. It is a waste of money. Obama and the Democrats took that near to maximum benefit with the ACA, and it is still not good. All other systems proposed for a private insurance based system are worse.

Follow Bernie Sanders idea as a starting point: Medicare for All. Medicare is closer to a clean system with low administration costs. It needs work, to leach out the co-pays, reduce or eliminate charges “at the point of delivery,” as they say in the UK; get rid of the strange “doughnut” that can bankrupt a long-term patient if they don’t or can’t play the system right. For All means there are no pre-existing conditions to fuss about because everybody is in the plan from before birth.

Of course, to do this you are going to have to retire the Republicans. They are too delusional (some call it ideological; I think my word is more accurate) to handle it. I don’t only mean vote them out. Quite a few of them seem to have strange mental disorders of types usually associated with old age. They really need to go fishing, forever. As a warning to the next authoritarian insurgency, Trump and his crime family should be indicted and tried for at least some of their criminal activity. Money laundering would be a good start. A sound prosecutor should find some actionable corruption in McConnell’s game.

But you don’t have to shut down the for-profit insurers. You just take the power of life and death away from them. They should never have had it anyway.

After a satisfactory, complete national healthcare service is in place, the insurers can sell elective products. They would provide access to a limited private system that provides luxury and elective timing for a price.

The deluxe level of hospitals and insurance top-up plans can be paid for by people to whom the service is worth it, or by corporations or employers offering the insurance top-up as a perk.

Private insurance should not be an opt-out, though. Never an opt-out. If you offer tax reductions for the private insurance, it will change from an elective top-up to a replacement, and policy holders will want relief from the tax that supports the national system. No tax relief for the private policies!

You have to ensure that none of this happens at the expense of people who prefer to be in the national system, and that it does nothing to diminish the quality of care in the national system. The insurers must be debarred by law from undermining the basic system in any way. It should be a criminal offense for them to try to initiate or support any action or legislation to weaken the system.

There must be no means-test for the national healthcare system. It must not be a poverty or charity system. In the UK, as an example, for obvious ideological reasons, no Labour politician can be seen ducking out of the NHS. It has to be good enough for members of Parliament and Jeremy Corbyn.

Many doctors will work in both channels. They may have a national hospital contract, a government-funded private practice and some privately remunerated work.

If that sounds like a fanciful idea that could never really work, let me break it to you: I didn’t think it up. I lived in it for a few decades. In the UK’s NHS, pre-existing conditions are not a concept. For the private insurers, they are, but if they won’t give you a policy, you are still covered at no additional cost. In fact, at no cost at all, except your tax bill.

I have seen it work, so it can be done. Insurance propagandists will point out that the NHS is not perfect. No, and neither are the national systems of France, Holland, Spain and Scandinavia. Perfect hasn’t happened yet. But they are all better than here.

So Public or National Medicare: necessary. Not an option.

Private insurance: optional. Make sure it is really optional. Don’t let the industry use medical care as a murder weapon.

Why do Trump and Republicans want to privatize and restrict medical care?

A speculation: economic despair makes a good recruiting ground for the growing American fascism, as it was in Germany in the 1920s and 1930s. The evangelical fundamentalists could extend control over social services and ethics while expanding their net of magical thinking and superstitious oppression.

Either way it goes, whether the ACA lives through today or dies, the United States will not have modern best-practice access to medical service until the people overthrow the Trump kleptocracy and the Republican and Evangelical superstitions.

© Bob Freilich July 2017

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