Tuesday, December 17, 2024

Toward a Just Healthcare System in the United States: The Problem of Cost

 How Has Capitalism Run Amuck in Healthcare?

The shooting of Brian Thompson has focused our country’s attention yet again on the injustices of our healthcare system.  We are seeing a revival of proposals for Medicare for All as a way to provide a more just healthcare system, but if we are going to do that, we are going to have to find a way to control the high cost of healthcare in the United States. Otherwise, Medicare for All will break us financially.

The high cost of healthcare in our country is an example of what last week’s post called “capitalism run amuck,” but that statement is too general to be useful as a guide for action. In order to fix our healthcare system, we will need something much more specific. How has capitalism run amuck in healthcare, and what can we do about it? Several years ago, I wrote a blog post on this topic, and rather than repeat what I wrote then, I refer you to “Why Does Healthcare Cost So Much in the United States?” Here is another view.

These sources deal with systemic problems, not with instances - like that reported in today's New York Times - where greed induces companies to act in ways that are obviously immoral. Greed and immoral behavior have existed throughout human history. They are not unique to capitalism, and we should not focus on them as the causes of our healthcare system's problems. Instead, we should focus on structural features of our system that cause it to be expensive and unjust even when everyone acts in good faith. My blog post referred to above lists a number of such features in our healthcare system.

Thinking About Solutions

How can we solve the problem of the ever-increasing cost of healthcare? How can we create a system that provides care for all of us at a cost we can afford to pay?  I will not attempt to offer a detailed prescription for a solution, although a modified and improved Medicare for All could provide one answer to the question. However, I can suggest some principles that can form the basis of a solution.

First, we must accept the need for non-market methods to control costs. That is, we cannot rely on market competition to control costs in our healthcare system. We will not be able to provide care for all citizens without using non-market methods to control costs. Every country with a successful system of universal healthcare has had to use non-market methods for controlling costs, and there is no reason to believe that we can be an exception. 

Medicare's cost control mechanism is very imperfect. Medicare can set the price it will pay for any specific service, but its fee-for-service model offers no protection against the proliferation of unnecessary services or against the continual invention of new "services." 

Second, our system must encourage hospitals and doctors to strive for high quality care rather than for maximum revenue and market share.  Some incentives of this kind are already included in the Affordable Care Act. For example, a hospital may be penalized if it has too high a readmission rate. However, much more will need to be done.

Third, we need a system that encourages people to make good use of primary care. Good primary care reduces the need for emergency care and for hospitalization, which are the most expensive parts of our healthcare system.  Some encouragement for people to use primary care is already included in the Affordable Care Act. For example, the act requires that certain kinds of screening tests – like colonoscopies - be offered free to patients.  We might also reduce costs by requiring primary care physicians to act as gatekeepers to the rest of the healthcare system as is done today in the United Kingdom.

Fourth, we need a system that encourages people to live in ways that promote health.  Much of the cost of healthcare in the United States is due to the cost of caring for people with chronic conditions like diabetes or obesity, and the frequency of such conditions can be reduced by encouraging people to adopt healthy lifestyles.  Ways to do this are not hard to find. For example, Medicare could pay for membership at a gym on the theory that regular exercise will make people less likely to need expensive medical care.

Finally, the system must provide patients and doctors with accurate information about prices in order to enable them to make decisions based on costs. Often, a medical condition may be treated effectively in various ways that have widely differing costs. 

If we can find ways to control the cost of healthcare, we will be able to provide healthcare for all of our people. As we work toward that goal, we must not forget that our resources are not infinite. Other countries have found ways to control costs, and we can do it, too.

Wednesday, December 11, 2024

What is the Issue?

Two Recent Events 

A month ago, Donald Trump was elected to be the next president of the United States, and a few days ago, Brian Thompson, the CEO of United Healthcare was shot to death. The two events do not appear to be related, but they are symptoms of the parlous state of American Democracy. Mr. Thompson’s killer has been seen on social media as a kind of folk hero, and the shooting as a legitimate protest against the inhumanity of health insurance companies. Mr. Trump ran for president successfully as a kind of voice of the common people against an oppressive elite. Thus, both events are symptoms of a political and economic system that millions of Americans feel is rigged against them, and they are not wrong.

A Rigged System

We live in a system in which an outlandish share of the wealth and the income is held by a tiny minority of wealthy people. In one of the world’s richest countries, millions of hardworking people struggle to pay their rent or feed their children. We live in a country with some of the most advanced medical care in the world but where unexpected illness is the number one cause of personal bankruptcy. The injustice of our system is plainly visible to everyone, and deaths of despair have become ever more frequent in recent years.

Capitalism and Democracy

In his book, The Crisis of Democratic Capitalism, Martin Wolf argues that liberal, representative democracy and market capitalism depend on each other but that their mutually supportive relationship is fragile. It depends in each country on a tacit bargain that capitalism will deliver an acceptable level of living to all of the country’s citizens. Otherwise, they will see that the system is rigged against them, and they may turn to authoritarian, anti-democratic leaders who promise to remedy their distress. Thus, a capitalist system that fails to live up to the tacit bargain that makes it compatible with democracy will inevitably render that democracy unstable. That is the situation in which we find ourselves today.

Wolf suggests that the elements of an acceptable level of living include:

  • Prosperity
  • Opportunity
  • Security
  • Dignity

Our system produces a high level of national prosperity, but it falls short on the other three elements for millions of our people, and so, unsurprisingly, the system has become unstable.

The Propaganda of the Deed

This is not to say that either the election of Trump or the shooting of Thompson is a rational, response to the injustices of our society. It has always been clear that Trump’s “populism” is fake, and his recent cabinet appointments have made the fakery even clearer. Similarly, the shooting of Thompson will probably not have much affect on our health insurance system. The shooting of Thompson looks very much like “the propaganda of the deed” of the anarchists of the late 19th and early 20th century. It is an act of political desperation by a person who believes that all of the usual approaches to political change are blocked.

The election of Trump is the fruit of a political culture in which lying by our politicians and our government have eroded our sense of truth and morality. Today, many people believe that no politicians or institutions of government are trustworthy. Trump does not lie more than the rest, but at least his lies seem sympathetic to millions of voters. We need change - they believe - and that is what he promises. So, why not take a chance? If our system is rigged against people like us, maybe we should tear it down and try something else.

That is exactly the situation that Wolf describes in his book. Capitalism run amuck has broken the bargain that says that it must produce a decent standard of living for all of the people, and so, it has become incompatible with representative democracy. If we want to preserve our democracy, we will have to rein in our capitalism. 

We Must Frame the Issues in Economic and Sociological Terms

If we want to rein in our capitalism, we will have to think about the issues involved in economic and social-structural terms rather than psychological ones. We cannot deal with issues of this scale in terms of the psychologies of specific persons. The question to be answered is not why particular individuals voted for Trump or what specifically drove Luigi Mangione to shoot Brian Thompson. The question is what is it about our society and our economy that causes millions of people to vote for a man like Trump and that drives a young man to risk his life in an act of propaganda of the deed?

Tuesday, December 3, 2024

The Fight to Maintain the Constitutional Power of the Senate

A New Issue to Split the Republican Party 

Not long ago, I published a post in which I argued that theissue of the deportation of undocumented immigrants would cause a split in the Republican Party. Sunday’s NY Times included an article that described yet another issue that may split the party. The issue is the power and independence of the Senate. Trump wants the Senate to rubber-stamp his cabinet appointments without exercising the body’s constitutional power to “advise and consent.” This is one of the Senate’s most important powers, and senators who care about the Senate as an institution will work to preserve its power. They will work to make sure that the Senate does a thorough job of vetting Trump’s cabinet appointments.  Those senators have considerable power as we saw when Matt Gaetz withdrew his name from consideration when it became clear that the Senate would not approve him without a fight.

Support the Institutional Power of the Senate

The fight to maintain the power of the Senate is not unrelated to the fight against mass deportations because Trump has chosen people who are committed to his policy of mass deportations, and he wants the Senate to rubber-stamp them. In this situation, we can resist mass deportations by encouraging our senators to support the institutional independence of the Senate, and we can also resist deportations by working locally to build support for the senators who want to preserve the power of the Senate to advise and consent. We can begin by contacting our senators to encourage them to support and fight for the independence of the Senate, and we can work locally to encourage others to do the same.

Oppose Mass Deportation Directly

We can also work locally to encourage local leaders and others to contact their congressional representatives to express opposition to mass deportation. The opposition may be based on humanitarian concerns, but it may also be based on a purely economic argument. Mass deportation will cause many local businesses to lose their work forces or their customers, and that will damage the communities where the businesses are located. The cost of the deportations will be paid using taxes paid by the residents of the communities that are damaged. Why should we allow our government to use our tax money to damage our communities?

So, if you believe in preserving the constitutionally mandated power of the Senate to review a president’s appointments, you should contact your Senators to let them know that you support them in their fight. You should also encourage your friends and neighbors to do the same thing. In the meantime, we can all work to spread understanding of the harm that mass deportations will do to our communities.