Things to Like About the Senate Health Reform Bill (3): A Small Step Toward Solidarity
A few short years ago, those who wanted Americans to treat medicine as just another commodity were the thought leaders in health reform. Some could afford better care, some worse; concepts like a “unitary standard of care” were becoming increasingly quaint. We were about to resign ourselves to ever more tiering of the health care system. For just a taste of this movement, turn to David Goldhill’s attempted revival of “consumer directed health care” in the Atlantic last summer.
“How [should] we pay for most of our health care?”, Goldhill asks. “The same way we pay for everything else—out of our income and savings [including Health Savings Accounts, or HSA's]:”
What about care that falls through the cracks—major expenses (an appendectomy, sports injury, or birth) that might exceed the current balance of someone’s HSA but are not catastrophic [i.e., are less than $50,000]? These should be funded the same way we pay for most expensive purchases that confer long-term benefits: with credit. Americans should be able to borrow against their future contributions to their HSA to cover major health needs; the government could lend directly, or provide guidelines for private lending.
Never mind that, as Donald Cohodes noted 15 years ago, “The need for medical care is often immediate, allowing little time for shopping around and seeking advice or alternatives.” Goldhill’s proposal is one more engine of inequality in an already lopsided society. For the frequently sick (or those with chronically ill dependents), being “out” up to $50,000 a year for care would be devastating. Meanwhile, the healthier would reap windfalls.
Visions of consumers with more “skin in the game” of health care finance entranced the Bush administration (and yes, that “skin in the game” metaphor was being used even as wealthy people in search of cosmetic enhancements were bidding away the attention of dermatologists from lower and middle class patients who worried about skin cancer). But leading legislators behind this reform effort understand the dynamic of inequality unleashed by individualist health care financing. Perhaps that’s why virtually none of them reached out to Goldhill (as of 9/09) for his advice on how to structure the bill.
By passing this reform bill, Democrats help turn the page on the consumer-directed movement’s efforts to more thoroughly “marketize” health care. Washington will commence an endless argument (read: notice and comment rulemaking and subsequent administrative adjudications) over what constitutes an adequate baseline of coverage, what is the fair share of revenue for middlemen like insurers, and what regulatory infrastructure can best vindicate the entitlements (and impose the burdens) specified by the bill. Interest group politics will no doubt distort many of these debates. But the fundamental victory of reform is a national commitment to the idea that no one should have to choose between bankruptcy or disability, suffering, and possible death when confronted with a serious illness that medical attention can treat.
Photo Credit: SEIU.