The Health Care Monster Returns

Like the creature from the Black Lagoon, the health insurance monster has returned, creeping back onto the public stage. After President Clinton’s jury-rigged pen to contain the monster collapsed in 1994, it never really went away. Political leaders tried to ignore the beast or deal piecemeal with its ravages, but it pushed more unsuspecting civilians into the uninsured pit, devoured more family budgets, squeezed even giant corporations’ ability to compete globally, and raised fear and insecurity among the populace.

Now its depredations have become too loathsome to ignore for even cautious politicians and business executives – who still are inclined to see the monster as one of their own. After a rebuff in the fall elections, when voters ranked health care as one of their top concerns, President Bush offered a plan that almost certainly would not deliver his promise of “quality, affordable health care for all Americans.”

Recently, chief executives like Lee Scott of Wal-Mart – under attack for its skimpy health insurance coverage of employees – and Steve Burd of Safeway – which endured a long strike by southern California grocery workers to cut their health insurance – joined progressive leaders like Service Employees Industrial Union (SEIU) President Andy Stern, head of the nation’s largest health workers union, to call for major changes in the health care system. Under fire from both other labor unions and many citizen health care groups for joining with strange bedfellows on behalf of very broad principles, Stern argues that “the most essential change is to get everyone in a system where they have health care,” then work to improve it.

Although the war in Iraq is likely to dominate the already energetic Democratic presidential primary race, health care is emerging as the leading domestic issue in both parties. Shortly after announcing his candidacy, John Edwards laid out a comprehensive health care plan. Barack Obama said that the nation should provide universal insurance coverage by the end of the next president’s term, though so far he has mostly advocated for minor and politically easy reforms, like computerizing health records. Republican candidate Mitt Romney signed a flawed plan for universal health care when he was governor of Massachusetts, and California Gov. Arnold Schwarzenegger, after vetoing statewide single-payer legislation passed last year, has his own health insurance plan.

There’s reason for hope when leaders across the political spectrum recognize the problem. But there’s no guarantee that such agreement will lead to a good solution. For more than a decade, conventional wisdom has dictated that only incremental steps should be taken. Now more politicians are willing to consider bolder steps – but the right is still determined to push its agenda. And many progressive reformers are cautious about pursuing their ideals, as they continue to nurse scars from the fight business interests waged against the Clinton plan.

“Overwhelmingly, people are trying to find incremental responses instead of a national response,” says Marilyn Clement, national coordinator of Healthcare-NOW, a coalition advocating a public insurance program as the single payer of health care bills. “They are still putting forward the same proposals as last summer, such as ‘The first step is to get national health care for children.’ Well, that’s good, but we won the election. It’s time to escalate our hopes.”

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The first crucial step is to define the problem. For many people, it’s the rising number of Americans without health insurance, now nearly 47 million. But equally problematic is the decline in quality and scope of coverage for those who have insurance. And much of the public ranks the cost of health care as their top medical and economic concern. Focusing primarily on insuring everyone won’t necessarily solve those problems. Indeed, the skyrocketing cost of health care is the main reason that the ranks of the uninsured continue to grow. Faced with rising insurance premiums, businesses have been trying to cut costs by evading responsibility for providing health insurance, leading Stern to declare that “the employer-based health care system is dead.”

But the more fundamental problem is our reliance on private, for-profit corporations to provide health insurance – the real monster in this saga. They’re the main reason for rising costs (making health insurance in the United States about twice as expensive as in most industrial countries), for the growing number of uninsured, and for the inferior health results for the average American. In 2004, the United States spent $6,100 per capita on health care, compared to $2,250 per capita on average by the countries in the Organization for Economic Cooperation and Development, which have national health insurance programs. Because public expenditures cover 60 percent of American health care costs, U.S. taxpayers are paying more than the cost of national health insurance, but not receiving it.

“How much can a new system depend on private insurance companies to provide affordable, good health care for everyone?” asks Roger Hickey, co-director of Campaign for America’s Future, a Washington, D.C.-based progressive advocacy group. “That should be the debate.”

Now the country is faced with two radically different proposals for reform. The first, pushed by conservatives and embraced by Bush in his new plans, would make individuals more responsible for buying their own health insurance. While giving them tax breaks to help pay the premiums, it would push them in the direction of lower-cost, less comprehensive plans (partly by taxing employer-provided insurance as income). As part of this strategy, conservatives have also undermined Medicare, first, by subsidizing private insurance companies to provide Medicare insurance and, second, by establishing a prescription program only available through private insurers.

The Bush strategy would be a boon for wealthy and healthy individuals, as well as employers and insurance companies, but it would ultimately leave most Americans paying more for less health security. The harsh edges of the plan could be softened – by regulating the insurance companies’ attempts to charge more or deny coverage to people seeking insurance, or by offering tax credits or direct subsidies to the poor instead of tax deductions. But these changes still embody what economist Jared Bernstein, of the progressive think tank the Economic Policy Institute, calls YOYO (“You’re On Your Own”) economics.

The diametrically opposite alternative is to recognize that “we’re in this together” (WITT, in Bernstein’s schema) and move towards social insurance, or a plan like Medicare. In this case, the federal government – through a public agency – would provide comprehensive insurance. It would be financed directly by progressive taxes on individuals and business, unlike the current system, which provides $200 billion a year in economically regressive and largely unrecognized tax deductions to subsidize employer-based health insurance. The public insurance agency would then bargain with health care providers, drug companies and others to control prices and improve quality of care.