Tethered Swimming

There is a mental disconnect anytime anyone in this country tries to discuss what we euphemistically refer to as “Healthcare Policy”.  On the practical side, just about everyone has been to a doctor’s office or a hospital at some point in their life, it’s close to a universal experience.  The white coats, the needles and stethoscopes, the out of date magazines, it’s all familiar.  On the less tangible side is the riotous expense and incomprehensible complexity of what goes on behind the scenes.  How can a few hours in an emergency room or a few days in a hospital cost tens of thousands of dollars?  In what twisted bureaucratic nightmare of a world does one need to file reams of paper for something as mundane as receiving a few stitches or having a broken bone set?  Trying to reconcile the two in one’s mind is damn near impossible.

That disconnect has been used repeatedly over the years to stymie any serious attempts to change the way we deliver and pay for medical care here in the United States.  The most famous example of this are the “Harry and Louise” ads, but the basic pitch is always the same: reform could make your life worse.  If someone tinkers with the back end, which you don’t see and don’t understand, they might screw up the front end, which you do see and which you and your family need.  It’s an appeal based on fear and, in the 1990s at least, it was very effective.

The reason it was so effective is fairly simple but frequently left unstated: the vast majority of Americans have some kind of health insurance.  They may not be happy with it and they may think it’s much too expensive, but they have it, damn it, and anything that threatens to make it worse or more expensive is a real threat.

The difference between then and now is that the problems that weren’t dealt with then have now festered for so long that they’re beginning to squeeze more and more Americans.  This is an actual line from one of those infamous ads, “My health insurance went from twelve-hundred to thirty-two-hundred dollars a year.”  Adjusted for inflation, that guy’s higher rate, the one he found so intolerable, is now $4,423.  Average healthcare costs for a family of four today (if Obama’s numbers are to be believed): $13,000 or not quite triple.  To be completely fair, it’s not clear if the commercial is talking about a family of four, but it’s a fairly standard yardstick, then and now.  The end point is the same; the system has gotten much, much worse since the early nineties, when it was already a hideous crisis.

Since the election Barack Obama has repeatedly pledged that reforming the way we pay for medical care is at or near the top of his list.  Of course, every time Obama announces an intention to do something he is immediately asked how he can afford to do it in the face of our economic woes.  His stock response, and it’s a good one, is that the economic crisis makes whatever it is he wants to do all the more urgent.  This happened again at the Tom Daschle press conference this week.  As quoted by TPM:

“Some may ask how, at this moment of economic challenge, we can afford to invest in reforming our health care system. Well, I ask a different question — I ask how we can afford not to….If we want to overcome our economic challenges, we must also finally address our health care challenge. “

He is correct.  The inefficiencies in our medical system cost us enormously and straightening them out would save staggering amounts of money.  Paul Krugman, who, with a fresh Nobel under his belt and a sympathetic Democrat in the White House, is set to become America’s leading economist, has made that point repeatedly over the years.  From his 16 February 2007 New York Times column:

McKinsey & Company, the consulting firm, recently released an important report dissecting the reasons America spends so much more on health care than other wealthy nations. One major factor is that we spend $98 billion a year in excess administrative costs, with more than half of the total accounted for by marketing and underwriting - costs that don’t exist in single-payer systems.

Tossing around imaginary rhetorical billions has become something of a fad lately, but $98 billion per year (and that was two years ago, it’s certainly more by now) is a catastrophic number.  That’s nearly the $10 billion per month we’re supposedly spending in Iraq.

Obama has not, so far as I know, come out in favor of a single payer system, though John Conyers recently introduced a bill calling for just that.  Obama’s stated plan works through insurance companies instead of eliminating them altogether, but for political purposes either approach will have long lasting benefits for those responsible.

The details of how any new system will work are complex beyond understanding and my sneaking suspicion is that even people well versed in the ins and outs of our medical system have only the faintest idea of the practical day to day realities of either guaranteed universal coverage or a single payer system.  None of that changes the fact that the current system is severely broken and deeply unpopular, that is the salient political point.  The existing setup now displeases far more people than it pleases and that means it’s going to get changed.  If that change turns out to be largely beneficial, the political ramifications are incalculable and will be with us for decades.

The key term there is “largely beneficial”.  The new system needs to do two things in practical “go to the doctor’s office” terms.  The first is to reduce the cost of care, in terms of money and bureaucracy, for people who already have some type of medical insurance.  The new way of doing things cannot be seen as a step back by a significant population or it’s going to be perceived as a failure.  The second is to eliminate the existing medical underclass by covering everyone.  Allowing millions of people affordable access to medical care will have two big implications, the first is that their lives will improve.  The second is that they will fight tooth and nail to keep it once they have it.

The party that made it possible for someone to take their kid to the asthma doctor or not see their parents struggle with medical expenses has won itself a reliable voter for life.  Successfully reforming the medical system will add millions of votes to the Democratic pile for a long, long time.  That is the political reality of successful and effective medical reform; it would be the final nail in the coffin of the Republican Party of Ronald Reagan and Bush the Younger.  That Party is already reeling from two straight overwhelming rebukes at the ballot box and it probably cannot withstand another body blow of this magnitude.

The goal for the remaining Reds in Congress is therefore clear: stop health care reform at all costs.  If they can’t, if the five out of six Americans who have insurance see their medical bills reduced and simplified and the one out of six Americans who don’t have insurance get it, then it’s all over.  The next time the Republican Party takes Congress or the White House will be a very long time from now and the people who win the elections will be as different from George W. Bush as he is from Dwight Eisenhower.