HEALTH CARE/Joan Retsinas

Insurance and The S Word

For decades, the S word has derailed substantive health reform. To any proposal that would expand the federal role, critics yelled “Socialism.” Our free market system of private insurers, competing for our business, does very well, thank you. That is the American way. None of this big government insurance. Europeans do that. Not us. We’re not them.

In the last few weeks, though, we look very much like them. Already Uncle Sam has played his visible hand in orchestrating the rescue of more than a few financial megaliths. More recently our Republican president, our secretary of the Treasury, and both presidential candidates (including the Republican one, who had always blocked any governmental regulations that would hinder the omnipotent markets) have proposed a multi-billion dollar “investment” (aka “bailout”) in our financial underpinnings. We are living in an “S” world.

Now that Uncle Sam has marched into the financial market, let’s welcome him to the health insurance market.

We don’t know what this new world financial order, crafted by Henry Paulson et al, will look like. But we can predict how Uncle Sam’s Insurance would work.

Universal coverage: Every citizen would have basic coverage. (Probably, for the sake of the public’s health, Uncle Sam will eventually opt to cover everybody living in America, whether or not they are citizens.) Old and young, rich and poor, sick and hale, employed and unemployed—Uncle Sam’s Insurance would embrace them all.

Today the maze of policies reflects a mishmash of rules. If you are a child (the maximum age will depend on the state) in a family whose income is low enough (the threshold will again depend on the state), a Medicaid plan might cover you, but it probably won’t cover your parents. If you are severely disabled, the federal government might cover you. If you are partially disabled, you can get coverage via your employer—unless your care is so costly that your employer drops workplace insurance. If you work full-time, your employer might, or might not, offer insurance; and you might, or might not, be able to pay the premiums. It depends.

If you work half-time, are self-employed, or work intermittently, you can search the “individual market” for a health insurer who is licensed in your state and charges a premium you can afford—a pre-election quest we should require of all our elected officials, just to prove their mettle at navigating the system they extol.

Funding that depends primarily on tax revenues: Premiums, co-pays, and deductibles will persist. Uncle Sam can charge them—just as employers now do. Indeed, American workers generally pay only a percentage of the costs of their insurance. Uncle Sam’s Insurance, though, will protect people with low incomes. A graduated income scale will correspond to a graduated scale for enrollee-payments. At the lowest end, people will pay no premiums, no co-pays, no deductibles; farther up the scale, people will pay no premiums; at the highest end, people will pay them all. Workplace employers will no longer pay for health insurance: those companies can redeploy their “benefits” personnel to R&D.

Comprehensive coverage: The term “pre-existing condition” will be archaic, as will “underinsured.” Uncle Sam will cover the maladies that beset people. Right now self-insured employers craft their own benefit packages: even if states mandate coverage for specific services (like cardiac rehabilitation), a bare-bones policy can streamline those out. Preventive care will be covered.

The newest “innovation” in private market health insurance is the high-deductible policy, aligned with tax-deductible “health savings accounts.” Presumably people wealthy enough to afford these policies put aside money for the lower-cost services, like vaccinations, annual check-ups, mammograms, cholesterol screenings. Not surprisingly, a lot of enrollees put off those basic preventive visits. Uncle Sam’s Insurance will cover—even encourage—people to take care of themselves.

Uncle Sam will still institute guidelines for tests, surgeries, medications; but the experts who draft those guidelines will be seeking the best care for patients, not the cheapest care. Since the taxpayers are both the investors and the patients, the goal of quality will not disappear in a flurry of spreadsheets.

Choice of plans: If you love a group plan with a limited network of providers, you could stay with that. If you want a physician not allied with a group, you could pick that. Uncle Sam’s Insurance would not restrict providers or networks.

Streamlined administrative costs: Uncle Sam won’t need to market this plan with glitzy advertisements. Nor will Uncle Sam honchos reap multi-million dollar salaries, with bigger bonuses. These honchos would make what top-level government bureaucrats make. Nobody would earn more than $400,000, the salary of the President.

Uncle Sam’s Insurance should sound familiar. If you are over age 65, disabled, or on renal dialysis, you have it: Medicare. In 1965, Congress overcame opponents yelling “S,” and gave a swathe of Americans national insurance. Maybe in 2008, we’ve stared down the “S” word enough for Uncle Sam to insure the rest of us.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, November 1, 2008

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