Op/ed piece on health care from 1994

[The below is an op/ed piece I got published in The Birmingham Post-Herald on August 25, 1994]

ANSWER QUESTIONS ABOUT HEALTH CARE BEFORE VOTING

It is coming down to lick log time on health care.  After a year and a half, the cacophony of debate is rising to a fever pitch, and the special interests are weighing in to the utmost with their agenda.  You are going to cast a vote on 14% of the national economy that will affect every American man, woman and child for the rest of their lives.  In reaching your voting decision, do you have it right, are you thinking clearly, and will you cast a vote that will be best for the American people?

While health care is enormously complex, there are some relatively simple things that you can think about and consider and that may help you immensely in deciding how to vote.  Indeed, if you do not address these points satisfactorily to yourself, you may be called to account on them this November or in 1996, or if and whenever any mistaken action taken at this moment becomes clear to the American people and they decide to retaliate.  In the mind numbing welter of multiple health care proposals, lightning fast modifications, drafts and redrafts of legislation, inscrutable budgetary costing estimates, frenzied lobbying and an unprecedented media advertising barrage for and against, this John Q. Public citizen suggests you pose interrogatories to yourself along the lines of the following to assist you in what you need to decide.

 1.  The "spending someone else's money" problem.  Acknowledging that the causes of the health care cost problem in the Unites States cannot be quantified precisely, in relative order of magnitude terms, to what extent do you believe the cost problem has resulted from a system in which consumers do not impose any limits on their own health care spending the way they do when they are spending their own money, because any particular health care expenditure, for all practical purposes, is coming out of someone else's pocket?  If you think the "spending someone else's money" syndrome is a major cause of the cost problem, what do you think should be done about it?  Should we change to a system where consumers will be more clearly spending their own money and limit their spending accordingly?  If that is not feasible, are not third party limits on health care spending needed if the "spending someone else's money" dimension of the cost problem is going to be addressed?  If third party spending limits are needed, should the limits be imposed by the government or by employers and insurance companies?  In trying to answer these questions, have the American people been ill served by public debate that has not adequately explained the "spending someone else's money" problem and the need for third party spending limits to address the cost problem, and by debate that has instead been filled with, on the one hand, false denials to the effect that there will be no rationing (the dreaded R word, which is another name for third party limits) and, on the other hand, terrorizing of the public about rationing without explaining the need for third party limits?  If public debate has been deficient in this regard, does it warrant putting off legislative action until the people get the benefit of better debate?  

2.  Freedom of choice.  Is not the freedom of choice question inextricably linked up with how one answers the questions under the "spending someone else's money" topic above?  Is it not the case, if people are spending their own money, they can be given all the choice in the world they want, but, if they are "spending someone else's money", either you have to limit their freedom of choice or else you cannot address the health care cost problem to the extent it is caused by the "spending someone else's money" syndrome?  Has this been adequately explained in the public debate for the benefit of the American people?

3.  Scientific and technological advances.  Has proper account been taken of the avalanche of amazing scientific and technological advances in medicine that have occurred and that will undoubtedly continue to occur and that offer the opportunity to spend untold tens of billions, if not hundreds of billions, of more dollars on health care?  Has the public debate addressed the extent to which the nation's total economic resources are limited and that there may be need for a conscious national choice between health care and all the other ways the nation's resources are spent, with the consequence that the more fully we pursue and avail ourselves of all the medical advances that have been and can be made, the greater the extent to which economic resources may need to be diverted away from other purposes, so that ultimately there are less houses and/or less cars and/or less education and/or less entertainment and recreation for the American people?

 4.  Demographics.  Has adequate consideration been given to the demographic factors at work and to the increased medical needs of an aging population and how to avoid fifteen or twenty years from now a bankruptcy crisis like the one that is looming ahead for social security.  Has not the social security problem been caused by Congress being less than laudably responsible, by time after time increasing social security benefits beyond the county's ability to pay for them in the future, which has been particularly exacerbated by demographic trends, and do not we run the same risk as regards gold plated universal coverage health care benefits packages?

 5.  Administrative savings.  How much can really be saved in terms of administrative costs, be they costs related to the making of decisions about the purchase of particular health care services, or related to the effectuation of payments for purchased services?  Is not the administrative savings question as regards decisions to purchase medical services linked up with the "spending someone else's money" topic in the sense that, when people are spending their own money, they shop around, decide how much they want to spend, and try to be sure they get what they want for the price they are willing to pay, but if they are not spending their own money and therefore are not inclined to do the foregoing, someone else needs to do those things in one form or another (i.e., the third party limits referred to above), and this is going to show up as administrative costs in the system which simply are not subject to elimination?  As regards effectuating payments for health care services, would a single payer such as the government result in significant savings over a multi-payer system, taking into account computer technology and the possibility of hooking up multiple payers and providers electronically?  If administrative savings can be realized, can the government realize them better or can the private sector realize them better?  

6.  Progress and experimentation.  Has adequate consideration been given to what profit seeking employers are motivated to do to bring down health care costs since they pay most of the bill, and what employers have done and will do apart from a national health care reform project?  Has adequate consideration been given to the benefits of experimentation on the state level or other smaller scale and the extent to which these will be squelched by a single federal solution?

7. Universal coverage.  When the President has asked whether the public favors universal coverage and a substantial majority says yes, has he ever asked the follow up question of what level of universal coverage do you favor?  If he never asked that follow up question, has there been a deficiency in the public debate as to whether the minimum benefit package under universal coverage should be a Cadillac (which seems to be the President's answer to the unasked question), or should it be a Ford?

8.  Price controls.  To what extent do you think price controls can help solve the health care cost problem and what particular form of price controls do you favor, or are price controls a bad idea in the health care area in any form and should we therefore rely on third party spending limits other than price controls?  

9.  American character and expectations.  In terms of looking to the health care systems of other countries, has adequate consideration been given to whether Americans have higher expectations about their health care and that they would not be willing to accept what citizens of other countries are willing to accept?  If this is so, how are we concretely prepared to deal with Americans having higher expectations about their health care than citizens of other countries?

 It is submitted that each member of Congress would do well to answer for him or herself each of the above series of questions, and that the answers that are given will go a long way in guiding the Congressional member in how to cast the vote that he or she will soon be asked to cast.  It is further submitted that, in evaluating in November how members of Congress have done on health care, American citizens should want all these questions answered by a Congressional member as helps explains to the citizens why the member shall have cast his or her health care vote this fall the way he or she did.