A red/blue dialogue on health care

Don Dodson and I went to high school together. And like all high schoolers, we pretty much resembled each other during the years we shared wandering the halls at our alma mater, the Greenhill School in Dallas, Texas. Much like the rest of the world, thanks to facebook we've recently reconnected. Interestingly enough we've chosen different paths for our lives in the intervening 20 (!) years. I am a secular humanist Democrat, living in the Bay area, working at an internet company resolving disputes -- and Don describes himself (on his blog) as "a follower of Christ first, a husband and dad second, a software engineer who designs algorithms for the new F-35 fighter, and of course a proud Reagan conservative."

As some of you may know, last week many thousands of people chose to make the following statement their Facebook status: "No one should die because they can't afford health care, or go broke because they get sick. If you agree, post this as your status today." I saw the statuses going up on many of my friends' accounts and decided to put it up as my status as well. Don saw my status and responded, pushing for further clarification.

Don: "I guess I just don't understand your original statement: "no one should go broke because they get sick". Let's say someone only has $500, and he gets sick and needs $500 for medical bills. According to your statement, someone else should be compelled to pay those bills to prevent him from going broke. Who should be compelled to pay those bills, and why is the sick person entitled to take the $500 from the person who earned it? The other part of the statement is a red herring. Hospitals must treat people regardless of their ability to pay, and we have Medicaid and all sorts of other programs which provide medical care for people who can't afford it. People in America are not dying because they can't afford health care."

I responded:"Don, you're missing the point of insurance. We all pool our risk so everyone is taken care of. The sick person doesn't take money from the healthy person. Everyone pays to be protected. Every industrialized country in the world does it this way except for the US. http://onlinejournal.com/artman/publish/article_2111.shtml ... Getting access to emergency care isn't health care. The 47 million uninsured in this country are cutting back on meds, not getting treatments, even ignoring symptoms because they can't afford it. That's leading to ~22k deaths every year, and untold misery. http://www.truthout.org/082309Z ; http://www.pnhp.org/news/2008/january/make_that_22000_uni.php"

Don replied: "I understand exactly what insurance is. Anyone who decides to buy insurance at the market cost should be allowed to buy it, and anyone who decides not to buy it should be allowed not to buy it, with the understanding that if they get sick, they are not entitled to demand that the rest of us pay for their treatment. But Obama's proposed plan is not a voluntary system. Everyone does not pay to be protected. Some pay and others do not. The fact that the IRS is handling the transaction doesn't change the fact that it amounts to one person compelling another to pay their medical bills. I voluntarily give to charity, but I would not gang up with my friends and force someone else to do the same. What makes it ok to hire Congress to do that on my behalf?"

It was clear to me that the short comment length on facebook was hindering our ability to engage in this conversation in a thoughtful way, so I suggested we move it off of facebook and onto our respective blogs. So I'll be able to post and respond to Don's points here, and Don will be able to post and respond on his blog as well.

As to the narrow point about insurance, I still believe people pay into insurance programs to protect themselves against risk. If you're protected, you got what you paid for. You shouldn't view the person who gets a payout from the program as the "winner" -- we all need to be protected, and if it turns out you need that protection, then that's very unfortunate. Fortunate people never need to call on the protection. And it's perfectly appropriate for government to require that we all participate -- much like auto insurance. We're all required to purchase auto insurance to protect against the risk of an accident. The winner is the person who never has the accident, not the person who has the accident and has to file a claim to cover the damage. How is health fundamentally different? Let's pool the risk as a society and we all get protection.

Now the way that this health care plan is being designed, all the different options for health insurance will still be private companies -- so each individual will be able to pick the plan they prefer. The so called "public option" would also create a public insurance program that individuals can elect to join if they like. This will also probably be the preferred option for the many people out there that insurance companies don't want to cover, for whatever reason. This will enable every person in the United States to get some sort of health protection, as opposed to the 46 million who go uninsured today and have no protection.

Before we get to the moral controversy, I hasten to point out that there's a clear economic rationale for all of this. The US is spending more of its GDP on health care than any other industrialized nation, and that percentage is certain to increase in the absence of reform. There's no question that the current system is deeply flawed, and it is generating huge social costs and delivering inferior quality care. There's no need to re-hash that debate here. Pretty much everyone agrees the system has to be changed, the only disagreement is around what kind of change is most appropriate.

So going back to Don's point, I think his question asks a deeper, and more fundamental, question. Why should anyone be _compelled_ to participate in a health care scheme like this? Why can't we have a voluntary system where everyone picks the quality of care they want and pays the appropriate premium? That was Hillary's point during the debates, and I think it's a valid one. I also think this cuts to the more fundamental question about how we see ourselves as a nation, and how much connection and interdependence we are willing to have on one another as a society. So maybe at base this debate gets to a question of social trust. And it's clear from the intensity of the backlash that much of the country does not feel the same level of social trust that Obama is calling for.

We are a nation that values individualism and self-determination, and I absolutely see how this proposal can be viewed as a threat to that. I am sympathetic to the libertarian perspective of leave-me-alone, let-me-decide. But as with everything, cross-cutting values have to be weighed against each other -- we want self-determination, but we are also interdependent. We all have to jointly pay for our national security, we have to jointly pay for our food safety, we have to jointly pay to combat H1N1, we all have to jointly pay to protect the environment -- individuals cannot solve these issues alone, so we as a society have to work together to address them. The question is whether health care is one of these things. I believe that it is.

The system is broken, and we have to fix it. There's no question about that. The question is how. I think all serious people acknowledge the stats quo is untenable.

So Don, if Congress was to drop the public option, and the plan was to migrate to something closer to the Swiss model -- where all insurance is provided by private insurers, but the government regulates the plans to ensure they can't disqualify people unfairly, and every citizen is guaranteed coverage through some private insurer -- would that address your concerns?