The Health Care Debate

October 8, 2009

I’m not going to bore anyone with my views on the need for competition, the likelihood of a “government option” being positive or negative, or even whether there should be ‘mandates’.  Rather the focus of this piece is on the need for reform.

We have the lowest life expectancy of any industrialized nation and yet we spend almost twice as much per capita on health care as any of those nations.  Our infant mortality rate is the highest, higher than Slovenia, Poland, UAE and a host of other nations.  Oh we can blame other factors like crime and affluence, obesity and culture.  I’ve even seen one commentator blame our genetic make up (hard not to think of that as code for what is really racism).  But the reality is that we are the only system in any industrialized nation that continue to act like “fee for service” works in the area of health care.

As a mature democracy, we would never suggest that education should be based on fee for service.  While I do not  suggest we have the best schools, no one will argue that all are entitled to at least a basic education provided by the state.  And we know that, to the extent we tried to make education a “fee for service” system, large portions of the population would go uneducated.  Is health care any different. Does anyone really believe that people should not be ‘entitled’ to basic health care services as part of a just and humane society?  And yet fully 1/3 of our population under age 65 are either uninsured or underinsured and have no access or only very limited access to even rudimentary services.

As a practical matter none of the other industrial societies have ‘fee for service’ health care systems comparable to ours.  In every one of them, all have access to basic health care services, whether rich or poor, employed or not.  Oh there may be some long waits for some services, slightly fewer people may survive stage 2 cancers for quite as long as they do in the U.S., and the array of pharmcological choices may be slightly more limited than here (and is that bad?).  But the bottom line is that in single payor countries like Canada and Australia, it costs almost 50% less to provide longer life expectancies and lower death rates for all age categories, than in our private insurer/fee for service system.

A quick story is instructive.  I have a co-worker, an educated lady whose husband is retired military.  She is of the view that Obama’s plan is socialized medicine which she will fight to the death.  She is scared to death that such a pland will deprive her of her current coverage and force her to accept the government as her medical care provider, a recipe for disaster in her view.  The irony is that, as a spouse of a military retiree, the current system she so adores is in effect “socialized medicine” i.e. her medical providers are, in essence government employees who are paid a salary, not fee for service providers who are self employed or employed by private businesses.

But as has been said in this space on prior occasions, the problem is not identifying a solution.  The problem is in the process.  Our laws are made by politicians who spend millions of dollars of contributors’ money to get elected and then, lo and behold, tend to vote in ways that line the pockets of the industries that contribute.  Those same contributors also fund ‘think tanks’ which spew rationales for the status quo that only defy logic to those those that have a pulse and an eighth grade reading ability (and chose to use it).  The result is an irrational fear of socialized medicine and belief that the mythogical god “competition” is the only possible solution. 

“Don’t confuse me with facts, I’ve made up my mind.”

No the problem with the health care debate is not “what should we do?”  The answer to that is clear.  The problem is that we have a political infrastructure which prohibits us from acknowledging the obvious and implementing it.

Unless one is very active in looking for and absorbing a variety of news sources which treat matters with some depth, one might miss a critical event thats about to occur.  The U.S Supreme Court is probably going to gut McCain Feingold and give corporations unfettered power to make campaign contributions. 

As background, the Court held a number of years ago, in ruling that the federal government had only limited right to regulate campaign contributions, that, effectively money is speech and the first amendment bars limits on the freedom of speech.  Recently, several corporations made contributions to the cost of producing an anti-Hillary film that was to be aired right before an election and the lower courts (upheld by the Court) determined the film to be a campaign film.  The Court will now determine whether that film can be shown as a campaign presentation having been funded with corporate contributions outside the limits of McCain Feingold.  The premise of the ruling requested by the film’s producers is that those corporations are “persons” and therefore are entitled to first amendment protection in the form of the right to use its wealth to influence elections.  The ultimate ruling is now likely to be in favor of the producers based on the alignment of the Court, with Kennedy, the regular “swing” vote siding on the ‘right’.

Is this the right decision and why should we care?  As to the first question, there are liberals and conservatives on both sides of this issue.  Politically speaking, there are liberals who see this as an opening for political contributions by “Big Labor” in addition to big business and there are conservatives who’d rather not see unions have an expanded role in campaigns.  In fact the producers are represented by a well know first amendment attorney who has worked for many ACLU causes.  And they say “politics makes strange bedfellows”. 

But lets look at the two legal issues, is money a form of speech and are corporations “persons” entitled to first amendment protection.  As to money equating to speech, an example might help.  Last year I made $500 in political contributions in an effort to make my voice heard in a local election not governed by McCain Feingold.  That was all I could afford.  This enabled my candidate to purchase roughly 3 seconds of local TV airtime.  Concurrently a local gaming company privately held by a local family backed the opposing candidate and contributed orders of magnitude more to that candidate, giving enough money to purchase hours of local TV air time.  In effect, that corporation’s contribution enabled it to drown out my voice by the sheer weight of its contribution.   In effect, that family is permitted by virtue of its wealth to have a greater and very direct impact on the outcome of the election. 

And if money is speech does a corporation really have a first amendment right?  Did the framers of the Constitution really mean for Congress to be hamstrung in its rights to control corporations?  Did they even think about corporate entities?  While corporations did exist at the time, they were nothing at all like the corporations of today.  They were not the megaliths that exist today.  And they had little if any political role.  And if they are “persons” for purposes of the first amendment, is that because of the constitution or because of the State laws that creates them and treat them as a “person”.  And what of the concept of “strict construction”?  Why is it that the 5 Justices who decry judicial activism the loudest when the fourth amendment is stretched to bar limits on abortion because abortion is not an express right, are not saying that corporations are not mentioned in the constitution and so have no rights? 

The whole concept of free speech is that the free flow of information in the marketplace of ideas assures that the electorate will have the opportunity to make its decision on the basis of all available concepts.  Freedom of speech does not require that wealthy be given a higher podium in that marketplace or more time at the podium so as to tilt the playing field in their favor.  But when we allow corporations to use their wealth to monopolize that marketplace, to overwhelm it with their ideas and values, the values and ideas of the less wealthy, of which there are far more, are drowned out to the point of irrelevancy.  When one looks at the data of the last generation of elections, the one fact that jumps off the page is that the candidate with the most money to spend wins a greater percentage of the time than any other single determinant, i.e. the vast majority of the time.   And the margin of victory is generally directly proportional to the difference in funding.  Therefore,  one can conclude with some certainty that, if corporations are allowed to pour significantly more dollars into elections, they will have a significantly greater impact on the results.  One can reasonably argue that this will move us from a Democracy towards a “Corporatacracy” where the greatest share of political power is wielded directly and clearly by the wealthy, corporate interests and not by individuals.   Does the first amendment really require this?