Harry Truman lived for many years in Independence, Mo., a few miles from where I grew up in Kansas City, Mo.
He’s famous for saying, “Give me a one-handed economist! All my economists say, ‘On the one hand, on the other.’”
It would be great if I could be a patriotic Missourian and get by with thinking about health insurance with just one hand, but I also have a bachelor’s degree in economics from Washington University in St. Louis, and the basic theme there was, if you want to look at all of this properly, you’d better be an octopus. Or a millipede. The more hands, the better.
In some ways, health care is like any other product. The less it costs, the more people get. The more it costs, the less they get. The unsettling truth is that the market “rations” routine care – limits use of it — every day.
Sometimes, the system limits use of care the usual way, by using high fees, co-payments, coinsurance percentages or other out-of-pocket costs to scare off people who visit doctors for the joy of having someone listen to them rambling on about their foot fungus.
More often, of course, the system limits use of care by imposing other types of barriers, such as problems with getting an appointment at a convenient time in a convenient location, to using any routine care that is not desperately wanted.
But, of course, health care is unlike most other products because it has to do with life and death, sick people, babies and elderly people.
Governments have used tax money (or slave labor, or both) to help fund health care since the days when Greek temples provided care based on a combination of surgery and prophecy.
In our hearts, most of us want society to spare no expense when it comes to providing necessary care for a cute baby or that sweet old lady who lives down the street. Our hearts pour out for the ailing child on the cover of the magazine.
But, for people who aren’t related to us, our unlimited compassion tends to max out at about $20. Maybe $100, in extreme cases.
And, no matter how compassionate and generous we are, it seems shockingly obvious that the United States, in particular, has to spend less on health care.
Health spending swallowed 38% of federal revenue in 2009 – and that’s down from 54% in 2008.
People can and (obviously) do argue about how to reach a compromise between compassion and fiscal discipline, but, clearly, we must.
If we make promises we can’t keep regarding Medicaid, Medicare, private acute care insurance and private long term care insurance, but somehow go through the motions of meeting those promises – spending money that doesn’t quite exist on care that, after a time, will be hollowed out and not really quite exist – that wouldn’t be a compassionate solution. That would just be sad.
Insurance companies have become the bad guys in these debates because they employ the claims people, actuaries and accountants who understand the math behind the glossy brochures. The numbers people come up with the courage to say, “No, that would be a great claim to pay, but your policy doesn’t cover it,” or, “No, we can’t cover that expensive new treatment, because we can’t afford it without skimping on covering other types of treatment.”
In discussions about health care today, the most important word anyone can say may well be, “No.”
But, on the other hand: What if it were your baby who needed that expensive new experimental treatment?
But, on the third hand: What if paying for that experimental, not necessarily helpful treatment for that one baby takes away some of the resources needed to educate all of the other babies and help turn them into the productive adults who will keep payroll taxes flowing into Social Security?