Unsurprisingly, after all of their holding firm, in the end, the Republicans in the House of Representatives caved in to the Democrats and President Obama. Rachel Maddow tells us just what the Republicans got for their fight:
Really impressive, huh? No wonder the Democrats are gloating; they threw one tiny bone to the GOP, concerning income verification for Obaminablecare subsidies — something which already existed! — but their victory was solid and complete. In theory, the Republicans could have this fight again in January and February, but having had their asses thoroughly kicked this time, almost certainly won’t try again in four months.
I have said it before, very explicitly and very bluntly: if we are opposed to the idea of guaranteed health care coverage, as I am, then we have to be willing to let those people who do not have health insurance suffer the consequences of not having health insurance, those consequences being to not receive health care for which they cannot pay, even if that means that they will die from something which could be treated. If we cannot let those who cannot or will not pay for health insurance suffer the consequences of their decisions, then the argument isn’t about eliminating Obaminablecare, but simply how best and most efficiently to provide universal health care coverage.
I’ve stated previously that yes, I can allow those people who cannot or will not pay for health care coverage to die due to their choices, but I don’t know of anyone else who has expressed that explicitly.1 Even the House Republicans who stood firm against the Patient Protection & Affordable Care Act had offered their own “repeal and replace” legislation. Perhaps at least some of the Republicans had intended only a bait-and-switch, to get the PP&ACA repealed, and then not replace it at all, but we have no way of knowing that. Even when a libertarian like then-Representative Ron Paul (R-TX) spoke about repealing Obaminablecare, said that private institutions used to take care of those who couldn’t care for themselves:
We never turned anybody away from the hospital. We’ve given up on this whole concept that we might take care of ourselves or assume responsibility for ourselves. Our neighbors, our friends, our churches would do it.
Again: if we are not willing to let those who can’t pay for health care die without it, then the argument isn’t about eliminating Obaminablecare, but simply how best and most efficiently to provide universal health care coverage.
And I have, very regrettably, come to the conclusion that we must have a government-run single payer system, covering every citizen, an expansion of Medicare. Our level of care will suffer, and we’ll wind up like the Canadians, who in places have to wait more than half a year, on average, for an appointment, or like the British, where the National Health Service has actually directed regional organizations to put off care, in a sort of rationing-by-time scheme, and where patients are 45% more likely to die in the hospital than in the United States. Perhaps we’d wind up like single-payer Japan, where people of any means at all buy supplemental insurance, and still have to resort to croneyism and bribery to get decent treatment.
Or perhaps we’ll wind up like the Swedes, where some malingerers get to take years off of work, at 80% pay, for “mental burnout.“
I would now propose and support a system in which our Medicare taxes2 were raised to a number which would pay for the expansion of Medicare to cover all American citizens and legal residents3 who pay the Medicare tax. The US spends roughly $2.7 trillion on health care, and total US wages in 2012 were $13,401,868,693. A total Medicare tax of 20.1%, applied to all wages, would cover total health care expenditures. That would be a huge tax increase, but it would be counterbalanced by no longer paying for health insurance.
Those are just gross numbers, of course. A universal Medicare system should only pay for necessary treatments: cosmetic surgery, LASIK, abortion, liposuction, fertility treatments, and a whole host of other medical procedures are optional, are personal choices, and should not be covered by universal Medicare. Those things should be paid for out-of-pocket by those who want them, and such would decrease the costs which a universal Medicare system would bear. Excluding coverage for people her illegally — they’d have to be treated for emergency cases, but could then be deported and their home governments billed4 — and that’s a point on which conservatives could insist for the passage of a single-payer program.
Additionally, concomitant tort reform, such as banning malpractice suits against procedures paid for by Medicare, could dramatically decrease our health care costs.5 There should be a significant administrative cost savings, as hospitals and medical care providers wouldn’t have to employ so man people to check insurance eligibility and bill any of hundreds of different insurers.
Now, do I believe that a single-payer system would lead to better health care for Americans? No, I certainly do not. Rather, I see a system in which care is rationed by stretching out time, such as one which would have had a patient wait four months, in pain, for “free” treatment, thus “encouraging” him to pay for the treatment out of pocket to get it done in a week. I see a system in which people of some means would purchase private supplemental insurance, to insure that they have good care, rather than things like the Japanese get, where the families have to launder the hospital linens.
But I also see a system in which, if it is done through Medicare taxes on everybody, forces everybody — or, at least, everybody who works — to pay at least something for their medical care. Right now, we have Medicaid, free Medicaid, for the poor, even the working poor, and, under the P&ACA, government subsidies for the poor to purchase insurance, both of which cost the taxpayers a lot of money, in treatment costs as well as administrative overhead. Under single-payer, Medicaid is eliminated.
I have little doubt that the Medicare taxes would exceed what most of the top producers in this county pay for health insurance, and I guarantee it would be a greater tax on me, personally, than we pay for health insurance. But when I consider that I am paying a lot in taxes to support idiocies like Medicaid and SCHIP, perhaps, in the long run, my family and I would be better off.
American businesses which currently provide health insurance as an employee benefit should like that idea, a lot. According to a survey by the Henry J Kaiser Foundation, annual premiums for employer-sponsored family health coverage reached $16,351 this year, up 4 percent from last year, with workers on average paying $4,565 towards the cost of their coverage; the employers’ share averaged $11,786. Assuming a 20.1% Medicare tax, split 50/50 between the employer and employee as is currently done, the employer would face a 8.60% increase in employee compensation costs.6 For the current employers’ average medical insurance cost to be matched by the Medicare tax increase in my proposal, the employee’s wages would have to be $137,046.51 per year. For employees, the average cost of $4,565 would be matched by the proposed tax increase at a wage of $53,081.40, slightly above the 2012 median family income of $51,017. In effect, slightly over half of taxpayers would see a slight increase in their take-home pay, while a hair under half would see a net decrease.7
But not every business would benefit. We have already seen attempts by businesses to restrict part-time employee hours to below 30 per week,8 to keep those employees below the threshold at which the businesses would have to provide health insurance coverage under the PP&ACA, and the small business threshold of 49 or fewer employees means that a huge number of businesses in this county were exempt under the PP&ACA. My proposal means an absolute 8.6% increase in the cost of an employee, because Medicare taxes begin with the very first penny earned. I certainly care about that, because it would, at the margins, negatively impact job creation, but this is still a change which has to be made; it isn’t a question of if this change will be made, but when.9
And I have not, by any means, covered all of the economic changes a change to single-payer will create.
Do I like my proposal? No, I absolutely do not; I hate it with a passion. But if we are not going to impose the discipline of the marketplace, in which people who do not pay for things do not get them, when it comes to health care, I don’t see an realistic way around it. I have said, many times, that the PP&ACA was never actually intended to work, but was simply intended to pass, to establish the principle that the government is ultimately responsible for everybody’s health care. We had exactly one chance to undo the PP&ACA, and that was to win the 2012 election, and the Republicans failed in that attempt. The attempt to defund Obaminablecare at the end of FY2013 would have hampered it but not killed it, even if it had been successful, and it still failed. The next expiration of government funding is unlikely to bring such a strong Republican effort to defund, because of the political beating that the GOP took this time. By the time the next President is inaugurated, in January of 2017, the PP&ACA will have been in full effect for three years, and while its obvious failures will have created some economic turmoil,10 the principle that the government will be ultimately responsible for your health care will have been firmly established.
And, quite frankly, such has been established for a long time anyway. If someone is found in life-threatening distress, the ambulance service does not just leave him there if he has no insurance; if a person shows up at a hospital with a life-threatening condition, he has to be treated, insured or not. Over 30% of Americans are already covered by Medicare or Medicaid, and the PP&ACA expands Medicaid to cover everyone at 133% or less of the federal poverty level in income. People with private insurance wind up paying more, because hospitals have to charge higher prices for private care patients to make up for the unpaid care that they have to give because it is simply illegal to let a seriously ill or injured person go untreated if he get to the hospital.11
Our system has been slowly rigged against the responsible people, those who have been paying for their own health insurance all along, by forcing them to carry the irresponsible, the indigent and even the government. My proposal does not end that completely, as the more productive people will still have to pay more to carry the lower earners, but at least enables some cost savings and puts everyone under the same rules. My proposal is an absolutely rotten one, but it is, in the end, the only sensible option in a society that will not suffer the irresponsible and the indigent to go without health care. I absolutely hate what I have written, but sometimes there is simply no other choice; this is one of those times.
- At a Republican presidential candidate debate in September of 2011, Wolf Blitzer followed up an answer by Rep. Ron Paul (R-TX) with the question, “Congressman, are you saying that society should just let him die?” to which a small number of audience members shouted “Yeah!” ↩
- Currently 2.90% of wages, split evenly between the employer and employee. ↩
- The United Kingdom is looking into ways to charge non-residents for access to the National Health Service. ↩
- Not that I am naïve enough to think that such governments would actually pay up. ↩
- The Democrats won’t like that provision, but without checking the huge malpractice insurance costs which drive up our total medical care expenditures, single-payer really cannot work. The Democrats, as much as they love the ambulance chasers trial lawyers (even having nominated an ambulance-and-videographer chaser as their 2004 vice presidential candidate), would realize that the government simply could not continue to pay those costs in a single-payer system. ↩
- 20.10% ÷ 2 = 10.05% – 1.45% (the current employer Medicare share) = 8.60% ↩
- This assumes that their health insurance costs would drop to zero. However, there are some differences between wage income and adjusted gross income, on which this calculation is based. ↩
- In 2013, from January through July, of 953,000 jobs created, 731,000 of them were part-time, or 76.7%. ↩
- There would also be significant job losses at health insurance companies, when most health insurance plans would simply disappear from the marketplace, and for medical care providers, as the number of people needed to verify insurance coverage would sharply decline. ↩
- The economic turmoil that the PP&ACA has created and will continue to create is one reason I am less worried about the economic turmoil a switch to single-payer would create; we will have turmoil in either case. ↩
- Private pay patients also have to cover the gap between Medicare and Medicaid, which do not pay the full costs of treatment. ↩