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Moral Imperative

OVER THE LAST 25 years, liberalism has lost both its good name and its sway over politics. But it is liberalism’s loss of imagination that is most disheartening. Since President Clinton’s health care plan unraveled in 1994—a debacle that this magazine, regrettably, abetted—liberals have grown chastened and confused, afraid to think big ideas. Such reticence had its proper time and place; large-scale political and substantive failures demand introspection, not to mention humility. But it is time to be ambitious again. And the place to begin is the very spot where liberalism left off a decade ago: Guaranteeing every American citizen access to affordable, high-quality medical care.  

The familiar name for this idea is “universal health care,” a term that, however accurate, drains the concept of its moral resonance. Alone among the most developed nations, the United States allows nearly 16 percent of its population—46 million people—to go without health insurance. And, while it is commonly assumed that the uninsured still get medical care, statistics and anecdotes tell a different story. Across the United States today, there are diabetics skimping on their insulin, child asthmatics struggling to breathe, and cancer victims dying from undetected tumors. Studies by the Institute of Medicine suggest that thousands of people, maybe even tens of thousands, die prematurely every year because they don’t have health insurance. And even those who don’t suffer medical consequences face financial and emotional pain, as when seniors choose between prescriptions and groceries—or when families choose between the mortgage and hospital bills.

These are not the sorts of hardships that an enlightened society tolerates, particularly when those hardships so frequently visit people who, as the politicians like to say, “work hard and play by the rules.” Yet American society has tolerated this situation for a long time. It has done so, at least in part, because the majority of working Americans still had private health insurance, generally through their jobs—the consequences of losing health coverage were, for the most part, somebody else’s concern. Universal health care promised them security they already had. Change would only be for the worse.

But how many people can really count upon such security now? Precisely because working people expect to get insurance through their jobs, they are dependent upon the enthusiasm of employers to help pay for it—an enthusiasm that is waning in the face of rising medical costs and global competition. Companies have responded by reengineering their workforces to shed full-time workers that receive benefits, by redesigning their insurance plans to offer skimpier coverage, or by simply declining to offer coverage altogether. Soon, the only employers left offering generous health coverage may be the ones forced to do so by union contracts—employers like the Big Three automakers, which, when we last checked, were barely skirting bankruptcy themselves.

When such gaps in insurance have appeared previously in U.S. history, the government has stepped in to fill them. It did so most audaciously in the 1960s, when the Great Society produced Medicare and Medicaid in order to guarantee at least some coverage to the elderly and the poor—groups the employer-based system had repeatedly failed to serve. But chronically under-funded Medicaid, a program that never reached all of the uninsured, cannot accommodate the growing demand when conservatives keep cutting taxes and gutting public services. Combined with the decline of employer-sponsored coverage, this failure means that even middle-class Americans are just one downsizing away from losing health insurance altogether.

Such widespread insecurity might be understandable (though not necessarily forgivable) if it were the unavoidable consequence of an otherwise well-functioning health care system. After all, economics teaches us that tradeoffs between efficiency and equity are inevitable. But medical care in this country is inequitable and inefficient. The United States pays more for its health care than any other nation on the planet: 16 percent of our national wealth, at last count. Money spent on health care is money not spent on other things, like corporate investment and wages. That’s an exorbitant cost that even Americans with secure health insurance pay.

“Exorbitant,“ to be sure, is a subjective word: Money spent on wellapplied medical technology might be worth it. But, perversely, our extra spending doesn’t seem to buy us better medical care. According to virtually every meaningful statistic, from simple measures like infant mortality to more carefully constructed data like “potential years of life lost,” Americans are no healthier (and are frequently unhealthier) than the citizens of countries with universal health care. Nor do Americans always get “more” medical care, as is commonly assumed. The citizens of Japan, for example, have more CT scanners and MRI machines than we do. And the French, whose system the World Health Organization recently declared the planet’s best, have more hospital beds. They get more doctor visits, too, perhaps because their access to physicians is nearly unfettered—a privilege even most middle-class Americans surrendered with the spread of managed care. In fact, aside from cost, the measure on which the United States most conspicuously stands out from other advanced nations may be public opinion: In a series of polls a few years ago, just 40 percent of us said we were “fairly or very” satisfied with our health care system, fourth worst of the 17 nations surveyed.

The last time a Republican president presided over a nation with serious health care problems, in the early ’90s, he had little of consequence to say until he was about to lose reelection. And, while this Republican president talks about health care more frequently, none of what he says is particularly encouraging. To conservatives, it is axiomatic that the private sector can deliver health insurance better than the public sector. It was precisely such thinking that led Bush and the Republicans to insist that private insurers, not the government, be put in charge of providing drug coverage to seniors. The result has been chaos, with seniors baffled as they try to figure out which plans cover which drugs and, even worse, with many of the sickest and poorest Medicare beneficiaries unable to get their prescriptions during the program’s early days. The only benefits the program delivers effectively, it seems, are enormous subsidies to insurance companies.

But the Medicare drug benefit is just a taste of things to come. The right’s real hope for health care is to radically transform health insurance altogether, so that risk is gradually transferred away from large groups (i.e., the government and large employers) and onto individuals (i.e., you). And, while Bush promises that this approach will empower consumers by offering them more choices, the effect would be just the opposite. Insurance works best when large numbers of people share risk, so that modest premiums from a large number of healthy people cover the very high medical costs incurred, at any one time, by just a few. Enacting the conservative agenda would unravel such arrangements, shifting the burden of paying for care back from the healthy to the sick. The worst-off would be those left to buy insurance on their own, directly from insurance carriers rather than through their employers or the government, since they will be at the mercy of underwriters who screen out bad medical risks. Beat cancer? Have your diabetes under control? Well, no matter. The commercial insurance industry still wants nothing to do with you—at least not at a price you can bear.

The right, in other words, has decided the problem with unaffordable health care is that it needs to be more unaffordable, at least for the people who need it most. And, into this vast, disturbing intellectual void on what is arguably the most important domestic issue of our time, the Democrats are proposing ... well, not a whole lot. In Washington, party leaders not named Ted Kennedy or Pete Stark have called only for modest, incremental changes, such as expanding Medicaid to cover more of the poor or opening up the insurance plan for federal employees to modestly wider enrollment. These ideas are all worthy enough. The number of people without health insurance today would be far higher if not for the quiet expansions of Medicaid and the creation of the State Children’s Health Insurance Program during the ’90s. But, taken together, these suggestions are still inadequate. It’s the equivalent of giving aspirin to a heart attack victim: At best, it keeps a bad situation from getting worse. And only for short time.

It’s time for the government to be much bolder, to try something even more far-reaching than what it attempted in the ’60s: making health care a right, not a privilege. And doing so for everybody, even if that means having the government provide insurance directly. Such a proposal might confound the conventional notions about what works and what doesn’t work in public policy. But providing health insurance happens to be a job the public sector has already proved it can do very well. The most popular health insurance plan in the United States is Medicare—which, except for the drug benefit and a few HMOs that contract for the business, is a government-run health care program. And Medicare isn’t only popular. It’s also efficient. Nearly all of the money that goes into the program, via taxes and the premiums seniors pay, goes back out to purchase actual medical services. Private insurance, by contrast, inevitably diverts a much greater share of its premium dollars to administration, marketing, and profits, which means less money for the beneficiaries. In theory, insurance companies should be competing to provide their subscribers with the best, most costeffective medical care. In practice, they compete over who can enroll the healthiest patients, since that is the surest way to improve profit margins.

The other reason universal health care may seem an unconventional suggestion is because it is an “old” idea. The first proposals for universal health care surfaced at the end of the Progressive era, nearly a century ago. But “old” is not the same thing as “bad,” and time has only made universal health care more relevant, not less. During the twentieth century, this country saved capitalism not only from its foes abroad but also from its deficiencies at home—chief among them its tendency to visit catastrophe on a few unlucky souls. While the foreign threat to capitalism has subsided, the domestic inadequacies are becoming severe once again, as pensions and job security vanish in the hypercompetitive global economy. The historic solution to this problem was to insulate individuals from excessive risk. And, while the private sector once did this for health care, it’s no longer up to the task. Government isn’t the best way to provide all Americans with health security. It’s the only way. And it’s time for liberalism to say so openly.

This article appeared in the March 20 & 27, 2006 issue of the magazine.