The idea that everyone should take responsibility for themselves, their lives and well-being is in many ways a good one. Self determination and individualism fosters innovation, ingenuity, a desire to better oneself, and can have a spillover effect of lifting those around you. It is a key ideal and significant part of the American fabric, and one that helps keep our democracy alive and vibrant. Like most things in life, though, it is a double edged sword, it’s opposite side just as insidious and destructive as it is constructive. As we’ve seen and experienced in the United States it’s also an idea and ideal that, promoted as the be all and end all of the “American Way” has led to a breakdown of communal responsibility and kinship. In the face of reality, modern society, and the growing urgent need for Americans to come together as a whole to combat disease, rising long-term health issues due to our increasing lifespans, income and housing inequality, and global warming, this idea that the individual is above and more than the State and community needs to be combatted, the ideal of Self Determination rethought and reworked for a world and life that requires civic involvement and communal responsibility.
Nowhere is the fight between Rugged Individualism and Collectivism more evident than in healthcare. Don’t think this is something new. It’s a fight that goes back decades to before Bill Clinton’s tenure as President. And, like so many issues that would ultimately require federal involvement, it’s a fight that the Right couches in terms such as “Socialism” (with the Big ‘S’), “Communism” (with the Big ‘C’), and “Big Brother”. Regardless of which political side you fall on there is a growing mountain of evidence showing that the American Way of dealing with healthcare is failing. For as much as we want to believe that a smart individual will come along and start a company that will somehow in someway save private healthcare and insurance from itself hasn’t happened. It’s not going to.
There’s a very simple reason as to why not. Greed and protectionism. When health insurance was first introduced it looked good. For a small amount paid in a person and their family would have their medical expenses covered and doctors would be paid accordingly. Somewhere along the way, though, the insurance companies decided to prioritize profits for profit’s sake over health outcomes and fairly compensating doctors and hospitals. Doctors, in kind, raised their rates to ensure that not only were they compensated well but they had enough money to cover their expenses, including hiring people to handle the billing and labyrinthian code system employed by the insurance companies. Health insurance in the US, as it stands today, has almost nothing to do with actually helping to keep people healthy and fit. Rather, it’s an arms and profit race between insurer and doctor where the weapon is money and the victims the patients. We, the individual and business, the ones paying both the insurance company and the doctor, have been left on the sidelines if we’re lucky. Mostly, though, we’re more often than not nothing more than cannon fodder, used for our money and thrown to the wayside to literally tend to our own wounds.
Without real government intervention I don’t see this situation getting any better. Sure, the ACA (aka Obamacare) has relieved some of the financial pressure on individuals, but premiums keep going up, co-pays continue to rise, and the burden of cost sharing is enough to bankrupt people. It’s time to face reality, Obamacare is a nice first try. But, the real solution is not in the private sector, it comes from the Federal Government. Whether that’s a Federally funded State administered Medicaid system or a fully national Medicare-for-All solution doesn’t really matter at this point. What does matter is that the answer is a national tax-payer funded public option, one that gives each person the ability to seek medical care without worrying about any out-of-pocket expenses. The freedom to not worry that their medicine will cost more than their rent or mortgage, or put them in the terrible bind of which bill not to pay, or trying to figure out how little food they can get by on so they can afford their much needed medication. While the Build Back Better Act aims to fill the gaps in the ACA with federal subsidies to cover the cost of private health insurance in the 12 States that haven’t taken expanded Medicaid this is still not the long-term answer. As we’ve seen with drug prices and with private insurance costs will continue to go up and outcomes get worse as insurers continue to maximize profits. Without real competition wherein out-of-pocket costs are either zero or negligible and outcomes improve private insurers will have no incentive to change their practices.
The big question is how do we get this passed? How do we convince our reluctant Representatives and Senators that the private health insurance industry and a public option can co-exist? Simple. There are two fundamental pieces I believe are needed in order to get the country to embrace and demand a public option. First, continue with what the States are doing with Medicaid, a public/private alliance wherein the State provides the funding and private companies handle the administration. Second, make the Public Option truly optional. A checkbox on your withholding and taxes. An option on the ACA exchanges. As long as the cost per person and family is lower than private health insurance and the care one gets is the same or better it’s a win. As long as it’s a program that covers people across State lines means a larger pool of the insured, reducing costs for each individual, while removing a barrier for people to move out of State or seek care while travelling.
What we also need to recognize is that entrenched business interests with solid profits and a captive audience rarely if ever change to be more beneficial. There’s no market pressure. It’s like evolution, if there are no environmental pressures necessitating a change then, well, we get the horseshoe crab. Unfortunately for the horseshoe crab health insurance industry the pressure’s building and a monstrous earthquake is coming. If we don’t adapt then millions will be left without health care, regardless of what the Build Back Better Act provides or requires.
The health insurance industry has spent decades lobbying and miseducating both doctors and politicians. Our profit focused society has been conditioned to believe that any service provided by any government body is “Socialism” and a free and open society can’t have “Socialism”. It’s time to disabuse ourselves of this notion. There is nothing in the Constitution that flat out disallows a national healthcare scheme. I’d even go so far as to say that it’s just the opposite. The Constitution starts off with “We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.”
We clearly see the following four words: “promote the general Welfare”. It’s clearly defined in the Constitution that one of the roles of the Federal Government is to promote the welfare of the nation. The health and well-being of the people of this country is definitely a large piece that makes up the “general Welfare” (also note that “welfare” is capitalized clearly indicating, to me at least, the Founders considered this a key tenet).
Lastly, I want to come back to this idea of “personal responsibility” as it pertains to one’s own health situation. While many health issues can be and are self-inflicted (smoking related diseases, not taking appropriate precautions when engaged in any risky behavior) just as many, if not more, are out of a person’s control. Addiction, diabetes, poor nutrition, communicable diseases that have no vaccines or prevention, accidental injuries caused by another, etc. (For the record, some of these can be absolutely self-inflicted but often times have a socioeconomic foundation that can trap people into poor choices, or at least the path of least resistance.) For example, I’ll use myself. I have a sewing needle in my heart, it’s been there since I was very young and truth is, no one really knows how it got there. The working theory is that I fell on it when I was a toddler. My parents probably thought I just fell over and any spot of blood, if there was any, most likely came from me scratching myself. Being the third child my parents had gotten used to a certain amount of transitory self injury and would have put this incident in that same category. Nothing was broken, I fell on carpet, no bruises, maybe a scrape or two, but nothing looked life threatening or internal. No one gave any thought that perhaps I fell on a needle and needed to be checked. Reasonable given the circumstances, I’m sure.
Here we have an example of an injury and medical condition that one has control over. While it’s not a congenital birth defect it’s still a condition that has been, for all intents and purposes, life long and will certainly be with me for decades to come (it’s not coming out any time soon). One that has affected my ability to engage in certain activities and limited career choices (whether or not I was ever going to become a pro athlete or fighter pilot is a whole other conversation). Now I ask, aside from keeping an eye on the needle and making sure that it doesn’t move or cause more problems, what exactly is the extent of my “personal responsibility” here? Should I be forced to pay higher premiums or large sums out-of-pocket because of something I literally have no control over? While the ACA has answered this question to one degree or another and the Build Back Better Act attempts to close the coverage gap for those living in the 12 States that never took expanded Medicaid, there are still gaps and holes and skyrocketing premiums and excruciating out-of-pocket expenses, especially for those with private insurance. Which begs the one question the ACA and the BBB have yet to answer: do we as a society keep ourselves fractured and broken so that we can point at ourselves and say “I’m free to do whatever I please and pay only for myself” or do we heal the life threatening fissures and decide that our individual freedom isn’t as much a priority as the health and well-being of our fellow humans?
While this may smell a bit of socialism I counter with the very fact that we as a nation have already answered this question in other areas, from roads to schools to our military to allowing Congress to throw subsidies, our very tax dollars, to multi-billion dollar corporations (looking at you, Big Oil). We have decided that the collective good of the interstate highway system outweighs our desire for complete control over our local way of life. We have decided that supporting farmers in Nebraska while we live in Connecticut is more important for our well-being than being left to our State’s ability to feed its citizens and no one else. So, why do we look at each other and deem those with health issues less? Why do look at our country and decide that each State should have it’s own insular healthcare system which contributes to higher individual costs?
Ultimately, the why of what we as a Nation have done to create more cohesion and connection between communities, cities and States is simple: money. The interstate highway system facilitates easy moving of products from coast to coast. Public schooling means more children are educated making them better fit for today and tomorrow’s jobs (yes, I know this isn’t wholly true, but the socioeconomic disparities here are best left for another thread). Ensuring our farmers can put food on their own table, keep a roof over their heads and continue farming means those of us not fit for such a life can also eat. And so we come back to promoting “the general welfare”.
By tying rising healthcare costs, including spiraling drug prices, to a weaker economy, a shrinking workforce, lower tax revenues we can say to our conservative friends, neighbors and colleagues “Look, if we have an ever growing population of sick people who can’t afford healthcare, fall out of the workforce, lose their homes and jobs, we can’t as a nation afford to support the causes you hold dear, like the military.” Tie our health and well-being to the Nation’s ability to defend itself, our overall prosperity and our standing in the world as the largest economy in all of history. We must show that by turning insular on the individual level we will tear the nation down and shatter its foundation. We must show that every person’s financial well-being is dependent on their neighbor’s.
Now, I’m not advocating we ditch capitalism. What I am advocating is a return to the nation’s roots as one that was driven by community, by each individual looking out for their friends, neighbors and fellow citizens. A healthy society and nation is one that recognizes and promotes the social good while keeping the gates of ingenuity, inspiration and individualism open. For the good of the nation, for the long term prosperity and health of each of us we must ensure that our desire for Freedom and our love of Capitalism are kept in context. No one is an island. No one can succeed without outside help. While it is imperative we avoid the pitfalls and cages of Communism we must recognize and embrace the positives that promoting the general welfare through a more equitable economic structure can bring. We can keep the reigns of entrepreneurship and enterprise loose with a foundation of economic reciprocity. As we have found time and time again when you raise the tide you lift all boats.