By now, we’ve been told repeatedly that there’s not a dime’s worth of difference between the policies of Hillary Clinton and Barack Obama. There’s really only one exception, and because it stands alone, the interviewers and the pundits keep coming back to it.
That is, of course, the healthcare proposals that the two have put forward. Clinton proposes a universal system, mandating participation for everyone. Obama believes that by driving costs down, almost everyone will voluntarily participate in the system, so there’s no need for a mandate (except for children, all of whom would be covered).
Which is the better choice? Simple: Obama falls short on universality, Clinton on sustainability.
Rather than pick apart the two proposals, let’s consider the problem that both address: the more than 45 million Americans who are today uninsured. These are a huge drain on the system; if and as they do need medical care, they end up (often too late) in the emergency room, and costs there, which all of us are paying for, are frightfully — and unnecessarily — high. Hence the emphasis on “universal health care.”
But even if, whether by magic wand or by detailed legislation, all the currently uninsured were suddenly covered, the crises in our health system would not be solved. For, indeed, there are two crises — and the one the candidates are addressing cannot be solved unless the other is adequately addressed.
That is the crisis of ever-increasing healthcare costs — not the number of people outside the system, but the costs within it. Healthcare costs continue to rise much faster than the growth in our Gross Domestic Product and the rate of inflation; the price of private and employer-based insurance becomes confiscatory, the cost of government-mandated programs — principally Medicare, SCHIP and Medicaid — threatens to displace other critical social expenditures, from education to infrastructure to basic scientific research.
Currently, healthcare takes 16% of our GDP — $7,000 for every man, woman and child in the United States — and it is projected to reach 20% of GDP in another seven years. It is fair to say that any proposal that does not focus centrally on cost-containment is missing a central ingredient of a long-run solution to both health care crises.
In the current issue of the New England Journal of Medicine, Robert Kuttner argues persuasively that the “usual suspects” that account for the cost problem — “The aging population, the proliferation of new technologies, poor diet and lack of exercise, the tendency of supply (physicians, hospitals, tests, pharmaceuticals, medical devices, and novel treatments), excessive litigation and defensive medicine, and tax-favored insurance coverage” — have been misidentified. They are all real enough, but the underlying issue is that the American system stands alone in its complete commercialization. Healthcare in the United States is a for-profit system, and that’s the heart of the problem.
The result? As Kuttner points out, “Researchers calculate that between one-fifth and one-third of medical outlays do nothing to improve health.” That “extra” expense pays for billing, marketing, administration, executive compensation — and, of course, profit. Covering everyone while leaving the for-profit system intact, or tinkering with cost-containment efficiencies while the incentives in the system remain profit-oriented, leaves the mess intact.
Imagine: Mark the halfway point in the estimate of current medical outlays that “do nothing to improve health,” and calculate what it would mean were the cost of healthcare to be reduced by that amount. We’d save, at current prices, more than $500 billion a year. (The Clinton and Obama plans both seek greater efficiencies in the system, both depend on rescinding the tax cuts on the very wealthy, and both require new federal dollars as well.)
More: The notion that all of us who are currently insured are “safe” is just that — a notion. Between deductibles, co-payments and exclusions, the actual coverage of those who are ostensibly protected is spotty, uncertain. And very expensive, to boot.
Furthermore, it is simply not true that because our system costs so much more than the systems of other industrialized nations, we get better care. Last May, The Commonwealth Fund reported on health outcomes in Australia, Canada, Germany, New Zealand, the United Kingdom and the United States. Ours is by a wide margin the most expensive of the systems studied (on average, about twice as much per capita as the other five nations), yet ranks last on dimensions of access, patient safety, efficiency and equity.
Or try this: We rank 21st among industrialized nations on infant mortality — behind Greece and Portugal, behind the Czech Republic and Italy — and 16th in life expectancy, tied with Cyprus and a few months ahead of Albania.
The nature of the American health care crisis and the international data demonstrate the superiority of a single-payer healthcare system. Why not, then, let employers and individuals choose between a government Medicare system and a private one and see which costs less and which serves them better?
But a single-payer system is plainly not in view in the United States today. Both Clinton and Obama know that; it is not an obscure piece of esoteric knowledge. Alas, they know as well they’d be pilloried were they to propose it.
Yet we can do better then what they do propose. Why not insure everyone up to the age of 25 — that is, essentially, Medicare for the young as it is today for the aging — and then, perhaps in five-year stages, creep upward from 25 and downward from 65 until everyone is covered in a rational and efficient system?
It won’t happen during this campaign. Instead, we will devote much energy to debating the relative merits of two fundamentally flawed plans. A pity.
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Yes, Kuttner had a good article in the NEJM, but he was even better in his interview on Amy Goodman's program, Democracy Now, which is on the Pacifica Radio Network and on the Internet. Amy Goodman pointed out that, during the debate, when Hillary Clinton mentioned single payer, the audience cheered -- and she brushed them aside and said it was politically impossible. Kuttner said that if she and Obama had come out for single payer, it wouldn't be politically impossible. Here's the excerpts: Democracy Now Amy Goodman February 08, 2008 <a href="http://www.democracynow.org/2008/2/8/examining_clinton_obamas_stances_on_the">http://www.democracynow.org/2008/2/8/examining_clinton_obamas_stances_on_the</a>> Examining Clinton & Obama's Stances on the Subprime Mortgage Crisis, Universal Healthcare, Privatizing Social Security and Nuclear Energy With Senators Hillary Clinton and Barack Obama in a dead heat, we look at their stances on some of the most pressing domestic issues with Robert Kuttner of the American Prospect, Max Fraser of The Nation and Paul Gunter of Beyond Nuclear. ---snip--- AMY GOODMAN: Let's hear how Clinton and Obama discussed their plans at last week's debate in Los Angeles. SEN. HILLARY CLINTON: We cannot get to universal healthcare, which I believe is both a core Democratic value and an imperative for our country, if we don't do one of three things. Either you can have a single-payer system, or— [cheers from the audience] which I know a lot of people favor, but for many reasons is difficult to achieve—or you can mandate employers—well, that's also very controversial—or you can do what I am proposing, which is to have shared responsibility. ---snip--- ROBERT KUTTNER: Well, one of the reasons that it's difficult to achieve is the lack of leadership on the part of leaders like Hillary Clinton and, for that matter, Barack Obama. I mean, if you had Hillary Clinton and Barack Obama say, "You know, this is an intramural debate that we should not be having, this debate about mandates; we should do this right: we should have national health insurance," public opinion would turn around on a dime. And instead of it being this fringe idea, all of a sudden, just because the two of them had blessed it, it would become a mainstream idea, and we would be having a debate that we should have been having all along.
So, so true. I've seen so many explanations of how a single payer system could work for less than what our health care costs are now. There is even a network of physicians who promote a single payer system. I know that Obama originally preferred that system. I think he maybe switched because he knew it couldn't get passed. I'm hoping he will find some way in the next eight years to do so.
How about the Church Obama, attends? The Rev. Wright, iis a known bigot, who's best friend is (the black Hitler) Louis Farrakkan, toghether they went to visit, one of USA enemies, Mohmar Khadafi, of Libia. Maybe he shares their philosophi. He,Obama, should answer this question.
You folks call yourselves intellectuals? How about a little critical thinking. Have a look at reality, instead of abstractions like "moral rights to healthcare". Why is health care so unaffordable and progressively less available? Why is the quality sinking? Over 85% of health care dollars are ALREADY controlled by government policy, either by direct taxation to fund government programs (Medicare, Medicaid, SCHIP, V.A. etc,) or tax policy favoring employer-sponsored insurance. Every perverse method of price and volume control are already in place. Thats why hospitals, doctors emergency rooms are going out of business.Most doctors will not see you for what Medicare pays, certainly not for Medicaid or SCHIP, and the risks of being crushed by the regulatory burden make it impossibly risky to function in return for the diminishing benefit. By current law, Medicare payments to doctors will GO DOWN 40% over the next 5 years, 10% DOWN in June of this year. I will no longer see you without payment. I'll accept cash, credit cards, or a good check. To think any good doctor will work under conditions of serfdom is absurd. You will get what you pay for. It's ironic that the only goods or services under price controls are also the same items in great shortage, with quality sinking. Rent controlled apartments are rarely available without key money, and resemble slums. Price controlled medical care is progressively inferior, and progressively less available, with 5 minute visits to harried providers taking months to get in to see. Go to any emergency room with a heart attack and see if you can get in. Even with cash, you may end up dead. 48-72 hour waits on a gurney in a hallway are commonplace. Ambulances with sick and injured patients driving around looking for an open emergency bed. Sadly, the free market in goods and services is all but dead in health care. Congratulations. Except for Lasik eye surgery, plastic surgery, and now psychiatry and dermatology, price controls have kept prices low and quality high. Any of you weenies want a rational and efficient system can go to Cuba and North Korea, where everyone has "coverage". Canadians love their system until they get sick. Then they bolt to the U.S. for care, or die in the queue. The real flaw is the absence of intellectual honesty. None of you would want universal ANYTHING, much less a health care system both degrading and inescapable.
How is it a "for-profit system"? 85% of private hospitals are non-profit, about half of us with private insurance are covered by non-profit insurers, and government which pays half the health care tab (Medicare, Medicaid, VA, etc.) is obviously non-profit. Profit is not the problem: the problem is that in the U.S., patients only control about 14 cents of every health care dollar, while 3rd parties control the rest.
Hillay would mandate that everyone purchase unaffordable health insurance, and sanction those who don't buy. Obama is not so sure about the mandate. Really? Is that the difference? Any of you that get sick should seek care from Robert Kuttner or Amy Goodman. I'm sure they'll take very good care of you. Meanwhile anyone wanting to see a real doctor, bring me your Visa card and pay me, like you do for every other good or service.
Herbert said: 'Over 85% of health care dollars are ALREADY controlled by government policy, either by direct taxation to fund government programs (Medicare, Medicaid, SCHIP, V.A. etc,) or tax policy favoring employer-sponsored insurance. Every perverse method of price and volume control are already in place. Thats why hospitals, doctors emergency rooms are going out of business.' But the US spends much more per head on healthcare than any other nation - are you suggesting spending even more?
Please tell me what the aggregate spending of the nation on health care, some percentage of GDP, has to do with you and me? It's an abstraction, and includes dental floss and Viagra. Who can say what the correct number should be? I have no idea. The US is a different place from other countries, where Health Ministries control spending. the aggregate number has nothing to do with you and me.
Wow, Herbert Rubin, MD...looked you up, you must be in your 60's by now and you practice in Overland Park, Kansas...a die-hard, isolationist conservative no doubt. You really do need to talk to a Canadian before you stupidly repeat the ignorant propaganda regarding the Canadian system - die in a waiting room queue? that is FAR, FAR more likely to happen in the US. Turned away from a hospital emergency room for lack of coverage? that would NEVER happen in Canada, and is commonplace at Kaiser's hospitals (look it up). Additionally, Canada's system isn't perfect, but its definitely better than the U.S. System. (Look at WHO's ranking of world health systems http://www.photius.com/rankings/healthranks.html). Canada isn't the model for what a Universal Health Care system can be, France is. Are you employed under a for-profit HMO?