America's healthcare is broken. President Bush's recent remarks on the availability of healthcare for all Americans ("You just go to the emergency room,") notwithstanding, most agree that the current system is a good stretch shy of ideal.
A staggering 47 million people do not have health insurance. More than 30 million of the uninsured are women or children. Those who are lucky enough to have insurance have to bushwhack through thickets of paperwork from doctors' offices, hospital administrations, medical billing companies and insurance providers, and then battle coverage denials and sky-high deductibles and co-pays to get the coverage they deserve. Nearly twice as many women as men are "underinsured," unable to afford adequate coverage.
Considering all that, it's a minor miracle we get healthcare at all, but even when we do, it is sub-par. For a country that has the largest and most technologically powerful economy in the world, we're nowhere near the best when it comes to health. In fact, we barely make the cut. Of 222 countries, we rank forty-second in life expectancy. We're thirty-seventh of 191 countries in overall health systems. And of 38 industrialized countries, we're bottom-of the barrel: second to the worst in infant mortality, just ahead of Latvia.
Part of the problem is that the U.S. healthcare system is a patchwork system of private insurance and public programs. Private insurance is prohibitively expensive for most, and public programs like Medicaid and Medicare are only available to the neediest cases. So people who have coverage tend to be employed and healthy or poor, sick and/or elderly. And for the unlucky uninsured the only choice is to wait until health issues become medical emergencies, then go to the great democratic healthcare solution for all: the emergency room.
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These are some of the many reasons that there is one area in healthcare where the U.S. outpaces everyone else: spending. We spend more per capita on medical services than any other country-upwards of $5600 per year per person, about 15 percent of our gross domestic product. It's like being strapped with a $600 car payment for an old beater held together with primer paint and duct tape.
But the good news is that nearly every presidential candidate has – or claims to have – a way of fixing the deep issues in the current system. Naturally, the Republicans and Democrats approach the issue from very different points of view.
Access for All vs. Free Market Medicine
Democrats begin with the belief that too few people are insured. The sick are denied coverage from private insurers, the poor and middle class can't afford it, employers are cutting back on it, and everyone who does manage to secure private coverage pays exorbitant premiums. The problem, Democrats say, can be solved by increasing access and lowering costs and exclusions: expanding employer-based coverage, adding more options for coverage both private and public, implementing regulations and mandates, setting price caps and offering subsidies. All cite the expiration of Bush tax cuts as a major source of revenue for their plans.
Hillary Clinton and John Edwards both would require insurance companies to guarantee eligibility for all individuals, which would be counter-balanced with a federal mandate that all individuals actually carry insurance. The dual requirement would dilute risk to insurers by compelling even young and healthy people to insure themselves, thereby lowering premiums for all.
Barack Obama's plan is similar in that it would guarantee eligibility, but shies from implementing an individual mandate except for children, enabling him to occupy a political middle ground – while leaving at least 15 million uninsured, says to Jonathan Cohn, author of Sick: The untold story of America's health care crisis–and the people who pay the price, and senior editor at The New Republic.
In contrast, Republican plans believe that the problem isn't that people don't have access to healthcare, but that they abuse the current system by choosing not to insure themselves, living unhealthy lifestyles, and relying on expensive life-saving care on the government's dime. Republican plans, in addition to exhorting people to take better care of themselves, revolve around the twin sine quibus non of conservative thought: capitalism knows best, and that the federal government should exert itself only as much as necessary to prevent people from taking advantage of the system. They call these promoting the "free market" and encouraging "personal responsibility" respectively.
Not surprisingly, Mitt Romney, who recently implemented a plan for universal health coverage in his home state of Massachusetts, has the most detailed proposal. But the governor of the famously liberal state is assiduously remaking himself as the conservative's conservative in the presidential race, and seeking to duck charges by fellow republicans like Mike Tanner of the Cato Institute that he endorses "HillaryCare."
Romney contends that by implementing federal tax deductions, deregulating insurance companies, punting reform to the states, and ending "free care" (ER care subsidized by the states and federal government), insurance companies will enjoy greater revenues, enabling them to drop their premiums so more people can afford it. Call it trickle-down health-onomics.
The other leading Republicans' strategies for remodeling healthcare abnegate as much federal responsibility as possible to the states and the free market, trusting the wise winds of capitalism to distribute health care equitably. John McCain's recently unveiled proposal focuses on tax credits and health savings accounts over coverage expansion. Fred Thompson's plan reads more like a statement of goals, without any concrete strategy for attaining them. And Giuliani offers a plan featuring tax deductions of up to $15,000, introducing medical liability caps and "streamlining the FDA process" (presumably because if the FDA would approve more medications like Vioxx, there would be fewer people in general to insure).
In essence, the two approaches-Democrat vs. Republican-boil down to the schism that divides the parties on almost every other issue: Protecting people vs. defending the market.
Republicans are quick to brand the Democratic plans as socialized medicine, conjuring the specter of a Kafka-esque dystopia, government bureaucrats mindlessly rubber-stamping towering piles of medical charts as the ailing masses queue in listless lines to await care from surly government physicians, DMV agents with stethoscopes and speculums.
But of the Democrats, only Dennis Kucinich proposed what could fairly be called socialized medicine-a single-payer plan that overhauls the entire system, replacing the mishmash of public and private, federal, and for-profit institutions with one government-run system accessible to all. Pinko fear-mongering aside, in an ideal world, Kucinich's "Medicare for All" could actually solve the problems that face the un- and under-insured.
But there is a big catch: while we can be reasonably assured that we will have a new president in 2009 (barring further abuses of executive power from the current White House), most of our representatives and senators, accustomed to energetic advances from health care lobbyists, will remain. Federal healthcare lobbying expenditures since 1988 total about $2.2 billon, and have surpassed all other sector's spending from 1999 to 2006, according to the Institute of Health and Socio-Economic Policy, likely making the sort of sweeping fundamental reforms like a single-payer system impossible.
Meanwhile, the Republican plan of letting capitalism work its magic freed from the shackles of federal interference may seem like a fabulous idea. (Imagine, a $15,000 tax credit to spend on your own medical care, no one to tell you who or how to do it!) But tax deductions and tax credits assume you make enough money to have a significant tax liability, and to spend the money to begin with. But the sad truth is, women still make less money than men and are more likely to be the sole caregiver in the family. For most women- and anyone who doesn't have $15,000 of disposable income every year, the credits and deductions are worthless. Tax breaks don't work for the broke.
Letting Go of Cultural Fantasies
With resurgence of public and political interest in healthcare this year, the phrase "socialized medicine" is sure to become the "flip-flopper" of this election, the new rotten tomato of the right to be lobbed at any healthcare plan that puts protecting people before market promotion. But while the charge might be a stinging one, it's also spurious.
Americans all grow up with the belief that we, as individuals, have the birthright to boot-strap our way to the top; that if we are good enough, if we work hard enough, we not only deserve to get the very best, we will demand it. The flipside of this cultural fantasy is evident in the favored phrase used against healthcare reform. "Personal responsibility" assumes a moral tone. It implies that if people do not rise to the top, they must be irresponsible, less deserving, immoral.
Embracing a system where everyone is entitled to healthcare means sacrificing the fantasy that inequities in the system work to your benefit. That belief has gotten us to where we are today: spending twice as much money for half-as-good healthcare than countries with "socialized medicine."
It is time to put aside these cultural fantasies and fears- the same way we do when we rely on fire and police departments to keep us safe, when we educate our children in public schools, and when we drive our cars on public roads. There is nothing pink about approaching healthcare as if it is a right, not a privilege. There is nothing more American than expecting the best.