Fix or “repeal and replace” is a political issue.
“So you've got this crazy system where all of a sudden 25 million more people have health care and then the people who are out there busting it, sometimes 60 hours a week, wind up with their premiums doubled and their coverage cut in half. It's the craziest thing in the world."
Sounds like something President Trump might’ve tweeted except it’s more than 140 characters. However, this is a quote from President Bill Clinton about the Affordable Care Act (aka ACA aka Obamacare). He walked it back some the next day but he knew what he was talking about.
If Hillary Clinton had been elected President, she’d be dealing with the same real health care cost problems Republicans are struggling with. The main difference would be political: she’d have to be sure that her left wing accepted that changes were only routine maintenance while Republicans have to mollify their right wing by claiming that whatever they come up with is not Obamacare.
There are two separate issues: how do we stop the relentless climb in the cost of health care and who pays the remaining cost. As we’ve seen with ACA, moving the costs from one population, in this case the uninsured and the hospitals who are required to treat them, to another population, “the people who are out there busting it”, doesn’t make the costs go away. This post is about the hard choices we have to make to reduce overall cost. Because all of these choices are politically unpalatable, they are mainly missing from the current healthcare debate. Nor do I have answers for them, but they must be discussed,
The drug epidemic. An increasing share of hospital budgets goes to treating the same population over and over for drug abuse and its health consequences. Tragically, more and more children of drug abusers need treatment for addiction from the moment of birth and suffer poor health and many other evils from having incompetent parents. Is there a way and is there the will to withdraw treatment from serial abusers who will not (or cannot) be cured of their habit? Is there a way to stop drug abusers form having babies? These are very tough questions.
The obesity epidemic. Obesity is known to cause heart disease and diabetes and multiple other ills, all of which require treatment. We do know that much obesity is caused by bad diet abetted by sedentary ways. We know that children on food stamps are more likely to be obese than those who are not and that childhood obesity is particularly dangerous. We can and should defy the candy and soda lobbies and make these products ineligible for food stamp purchase just as liquor and cigarettes already are. How much of a nanny state should we be after that? If we’re offering healthcare to everyone, do we have to be a nanny state to keep the cost down?
Geezer care. I benefit from this. But how much treatment should my Medicare pay for? A huge part of the country’s medical budget is spent caring for people in the last year of their lives. Any discussion of this gets shut off politically with talk of “death squads”. But you can’t have free care without rationing it somehow. A dollar spent on me is not available to treat a child with a lifetime ahead of her or him.
If we can bring down the overall budget for healthcare by addressing these issues, then the problem of who pays for it gets simpler to solve. But we can’t bring the cost down while ignoring the elephants in the room.