As Congress returns from its August recess, the political debate on health care reform revolves around four basic issues. First, how should the government provide health care for uninsured Americans? Second, how can reform reduce overall medical costs and improve health care? Third, who should pay for reform? Fourth, should there be a single payer government health care option?
The analysis by politicians and pundits will continue to focus on the costs and benefits of the present health care system versus various reform proposals. Unfortunately, this cost-benefit analysis obfuscates the underlying philosophical debate on health care between conservative Republicans and liberal Democrat. The real debate is whether the individual and his or her doctor should be responsible for health care or whether the government should be responsible.
Republican supporters of the current private health care system (which includes a heavy dose of government involvement) have good evidence that it does a good job providing health care services to most Americans. Approximately 85 percent of Americans are covered by the system and 80 percent of Americans are satisfied with their health care coverage. Many of the individuals who are not covered by a health care program are either illegal aliens or individuals who decide for their own rational reasons not to purchase insurance.
Republicans recognize that the current system is expensive compared to Western European socialized medical systems. Much of the additional cost is due to aggressive judicial interference by tort lawyers, government regulation, unhealthy lifestyles, research and development of new medical technology and consumer choice (i.e. the lack of rationing by the government). Republicans may support the need for improvement of the current health care system but not wholesale dismantling.
Democratic proponents of reform see the current private health care system as one which fails to provide adequate health care to many American residents. Approximately 15 percent of Americans are not covered and 20 percent of Americans are not happy with their current medical coverage. Liberal Democrats think that private insurance companies and pharmaceutical companies are a major cause of America’s high cost medical system because they provide health care products and services at a profit. It is irrelevant that profits drive advances in medical technology.
Liberal Democrats also think that the government has a responsibility to provide universal health care for all Americans. Universal health care should be paid for through higher taxes and health care mandates on employers and medical service providers. In their view, medical care is not a commodity to be allocated by market forces like other essential commodities such as food, shelter, clothing and energy. Hence, for liberal Democrats, health care nirvana would be a single payer government run health care system.
These seemingly irreconcilable positions are a result of the underlying conflicting political philosophies held by conservatives and liberals. Conservatives think that the individual is generally responsible for his or her own situation in life. They have faith in the individual to make rational decisions regarding important issues. They also think that the individual in the private market is better able to allocate economic resources than government bureaucrats. In addition, conservatives do not like radical change for a system that is not dysfunctional. On the other hand, liberals believe in communal responsibility for the individual because the individual is constrained by his or her circumstances. They believe that the free market often provides an “unfair” result for certain critical commodities and services; (in this case health care for people of limited means or who make improvident decisions in life).Liberals distrust of the judgment of the individual responding to the economic forces of the market; but they have faith in the judgment of enlightened government bureaucrats and liberal politicians. This makes liberal Democrats receptive to radical change in a system that is not dysfunctional. Since they have limited faith in free market economies, they do not view the migration toward socialized medicine and eventually socialism as a negative.
Blue Dog Democrats, moderate Republicans and many political independents think that health care reform must be bi-partisan if it is to be effective. Approximately 40 percent of Americans identify themselves as “conservative”; 20 percent identify themselves as “liberal” and the remaining 40 percent as “moderate.”
If Congressional Democrats are united, they have the unencumbered ability to pass any legislation they want. However, if liberal Democrats ram public option health care down the throats of conservative and moderate Americans, they run the risk of creating a schism in American society similar to that created by the Vietnam War and maybe even the Civil War. In order to create bi-partisan health care reform, it is instructive to examine the issues that are difficult or impossible to reach a consensus on and areas where there may be common ground between the two views.
Certain reforms will be difficult to agree on because there is no philosophical common ground between the liberal Democrats and the conservative Republicans.
However there are some reforms that both Republicans and Democrats may be able to agree upon. These areas are primarily marginal fixes to the current health care system and do not entail a major restructuring. Reforms where there may be common ground include: subsidizing low income American citizens and legal residents; requiring all Americans to have health care insurance; reform of medical malpractice tort system; permitting inter-state competition among health insurers; portability of insurance; and promoting healthy lifestyles. Obviously, the devil will be in the details of crafting these reforms.
If the real issue of reform was to reduce the overall cost of medical care in America, the health care reform debate would center on medical malpractice tort law, promoting healthy lifestyles and dealing with the high end of life costs. Medical malpractice insurance and defensive medicine account for approximately 18 percent of health care costs. Obesity accounts for approximately 9 percent. Alcoholism and smoking account for another large percent. Approximately 40 percent of medical costs are incurred in the last six months of life.
If the real issue was how to insure those American residents without insurance, the discussion would center on subsidies for the poor and the incentives required for other uninsured Americans to get insurance. However, the cost of medical care in America and covering the uninsured are not the real issue. The real issue is whether the individual or the government should control medical care.