The NEJM has an editorial out in which it claims to tackle the three “inconvenient truths” about health care. From the editorial:
1. Over the past 30 years, U.S. health care expenditures have grown 2.8% per annum faster, on average, than the rest of the economy. If this differential continues for another 30 years, health care expenditures will absorb 30% of the gross domestic product1 — a proportion that exceeds that of current government spending for all purposes combined…
2. Advances in medicine are the main reason why health care spending has grown 2.8% per annum faster than the rest of the economy…
3. Universal coverage requires subsidies for the poor and those too sick to afford insurance at an actuarially appropriate premium; it also requires compulsion for those who don’t want to help pay for the subsidies or who want a “free ride,” expecting that they will get care if they need it.
As true and inconvenient as these might be, the NEJM still misses discussion of the core inconvenient truths that will result in impasse. Here’s how I see it:
1. Will a national plan cover elective abortion? Say yes, and you lose half the country, say no and you lose the other half. The result will be impasse.
2. Will a national plan cover illegal aliens? Some 8 million of the 47 million who are uninsured in this country have no right to be here. If a plan decides to subsidize their non emergency care, there will be a rebellion. Refuse to cover them and others will cry xenophobia. The result will be impasse.
3. Will a national plan be Cadillac or Yugo? A Cadillac plan will cover areas of expensive care beyond the basics such as mental health, dental, and etc. That will break the bank. A “Yugo” plan is bare bones requiring all of us to obtain private supplemental coverages. Try and exclude an area from coverage will enrage one segment of society, putting in all the extras will (further) bankrupt us. Result? Impasse.
4. Will a national plan include rationing? The NEJM is right about the costs going out of sight. For some, this means rationing. But advocates for those who will be discriminated against in a national rationed plan—people with disabilities, AIDS patient advocates, etc.—will ensure that their cadre are not rationed. Result, impasse or rationing only against the politically weak.
Until and unless we come to grips on these issues, the talk about dramatic health care reform will be just talk. Areas of compromise are obvious. But we are so divided, I don’t think compromise is possible. Now, the coming election may provide such massive majorities on one side of the issue that certain agendas can be imposed. But that too will just explode the country into mutual hatred, recrimination, and political agitation.
This is what happens when a culture loses a common frame of moral reference.
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