HEALTH CARE/Joan Retsinas

I Miss You, Bernie Sanders

I miss you, Bernie Sanders, with your pie-in-the-sky promise of universal healthcare. So unpragmatic. nnActually, I miss a slew of unpragmatic legislation, including the New Deal (with Social Security now considered routine), the Hill-Burton Act, the interstate highways, Medicare et al (including the Voting Rights Act and Environmental Protections), Food Stamps (the reign of Richard Nixon), the extension of Medicaid for children and mothers in the State Children’s Health Insurance Program (SCHIP), Medicare Part D (whatever its flaws, an improvement over the original Medicare in providing prescription drugs), workplace safety protections, and the maligned Obamacare (which may become as accepted as Medicare). At times Uncle Sam has benevolently bolstered the lot of the unhealthy, unwealthy among us.

Sadly, this president bolsters the fortunate among us, the ones who cheer the rising Dow.

Who will help the bulk of us? The challenge falls to Congress.

For health insurance, let’s discard the tried-and-failed ideas touted under the banner of either pragmatism or ideology. Let’s return to the past.

Community Rating

Once upon a not-so-long-ago time, when employers enrolled their employees in nascent Blue Cross plans, the rate depended on the geographic region – the “community pool.” Bank clerks paid the same premium as circus acrobats. Furthermore, the health of any one enrollee did not spike the premium: the person with arthritis paid the same as the marathoner. Public insurance – Medicare – operates by the same principle: whatever the enrollee’s medical history, everybody pays the same.

“Experience” rating killed that idea. Insurers rated the experience of different workforces, segmenting the one pool into smaller pools. Bankers, who needed fewer services than acrobats, paid less. Of course, dumping the sickest into their own pools raises the costs into the stratosphere: the “high risk pools” that some legislators tout have proven too expensive for states to subsidize.

“Community rating” (one pool) raises premiums for healthy enrollees, but lowers them for the sickest. One reason to do this harks back to the principle of distributive justice: a just society should distribute access to health care equitably. If income inequality threatens the fabric of our world, so does health-inequality. More practically, the young enrollees reaping low premiums will probably eventually develop the diseases that land them in the costly pool.

So let’s return to community rating – one nation, one pool.

Comprehensive Coverage

A strange notion persists that you should choose insurance as you choose food in the supermarket: what do you need? What do you predict you will need? The health-fates might know our futures; we don’t. Cancer, arthritis, glaucoma, vehicular accidents, multiple sclerosis, Alzheimer’s — all happen without warning. And while we can reduce our risk for some diseases (slim down, exercise, stay out of the sun, wear seat belts – trite-but-true advice), we can’t eliminate risk. As statisticians point out, humans have 100% mortality risk. Most of us will need “comprehensive” coverage. Without it, “insurance” turns into a cruel scam leading us into debt, if not to Chapter 10.

“Model T” policies sound alluring – you pick a basic car over a Mercedes, depending on your income. You buy a mansion over a cottage. But you don’t die from your choice; indeed, thousands of Americans live without owning cars, live without owning homes. You do need health care, however; and insurance is your one conduit. “Cheap” insurance translates into minimal care: you can die from minimal care.

Government Subsidies

We can’t avoid them. No developed country leaves its citizens to “pay their own way,” watching a huge swath of its population forego insurance. If we have community rating for insurance, we need the “community” (a.k.a. taxpayers) to pick up part of the global tab. We do it for Medicare. Nobody has proposed dropping Uncle Sam’s subsidies of Medicare. In fact, the administrative costs for Medicare are far lower than for private for-profit insurers (3% vs. 12+%).

We pay the highest costs for healthcare of the developed countries, with not-so-great results. But the hodgepodge of private insurers, the maze of regulations, the administrative nightmare of the policies – all contribute to the costs, as do insurers’ double-digit returns, their seven-figure administrative salaries.

Other countries practice their versions of community rating, provide comprehensive coverage, and partially subsidize the whole shebang – giving their citizens better care. Surely we can do the same. Let the legacy of this Congress be universal health insurance – the kind we have provided elderly and disabled citizens for more than 50 years.

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

From The Progressive Populist, September 15, 2017

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