Well, since my last writing on the subject, the health care (insurance) reform effort has gone full circle again.  The Democrats with a “super-majority” were unable to craft a plan that even this group of interventionist politicians could stomach.  Now that the party has only a majority, it has deigned to at least offer to discuss the matter with the minority party.  I anticipate that the talks will go nowhere because the Democrats want only to consider offering crumbs to the Republicans in the hope that they will take these and support the Democratic concept largely as is.  The Republicans are unlikely to stomach that any more than have the few thoughtful Democrats who have tried to read and make sense of the bills.  I guess I am one of these Democrats. 

Still, the effort has provoked thought.  Solving the problems of the health care system seemed impossible.  Now, however, I believe, thoughtful leaders are beginning to grasp the problem, and may begin to offer solutions.  The problem is that a decent attempt to address health care affordability must address the whole issue of welfare in this country.  That will be a large job, but if successful, a solution would improve the health care system, the economy, and the status of the American population. 

The main problem with health care, government provided welfare, and government spending in general is one of wanting more than we can afford and yet somehow expecting to get it.  At its worse, the assumption is that we will get it and someone else will pay for it.  The difficulty in breaking away from the “government support” is that as bad as it is, it can in the short-run make us think we are richer than we really are.

We spend too much on health care because most of us do not pay for it directly.  The first step in health care reform should be to eliminate the middleman and enable us to directly purchase our own health care services and health care insurance.  Congress can easily make this possible by giving those who buy insurance directly the same tax benefits as those who receive insurance through their employer.  Congress can also make it possible for insurance companies to sell policies in each of the fifty states.  These changes more than anything else would reduce its cost of insurance and increase coverage.

Congress can also require insurance companies to provide insurance to anyone, but should allow the providers to charge more to those who do not maintain insurance and seek it only when they become ill.  This would make insurance readily available to those who want it.  Congress does not have to obscenely mandate that each of us has to purchase this product.  It might spend a few dollars to provide education to the public on the risks of not buying insurance.

Direct purchase and opening up the insurance market would not make insurance affordable for all.  The government must encourage lower cost health care.  If, as I determined in my last dissertation, the cost per person is about $8,000 a year, it must be reduced so that most of our population can afford it.  There is no national, moral, or God-given right to equal health care for all.  Some of us can afford better health care than others.  The view that there should be equal health care for all is preposterous.  Efforts to mandate equal care make it impossible for many to buy even basic health care.  Congress can abolish this requirement and largely put the malpractice business out of business.

Congress should allow lower levels of care to be provided.  There used to be so-called charity hospitals.  Today there should be different tiered hospitals.  Some may pay to be treated in classy hospitals with fancy beds, a bathroom in every room, and the highest tech gear available.  Others will settle for a ward and accept a lower survival rate if they have a heart attack and can’t go to an intensive care unit.  They will know that they can at least afford to go to a hospital and be treated with honor when they get sick.

Even with tiered care and the availability of reasonably priced insurance, some will not be able to make the payments.  Congress may increase welfare payments to provide health care resources for the poor, but this is where the resolution of health care management problems runs head on into the issue of welfare. 

Welfare has become an enormously diffuse, confusing, and unfair business.  The universal system makes all of us welfare beneficiaries and inclined to “play the system.”  There should be one welfare program.  The monthly check should support all aspects of life.  Why should there be public housing, food stamps, school lunches, Medicaid, and educational financial aid?  Each adult who cannot support himself or herself should receive a welfare payment and decide how to use the money.  Exceptions may be made for incompetents, but most people are not that.  Some may choose to spend all of the money on gambling or alcohol, but that is what freedom is about.  If such a person ends up in the hospital without insurance, the hospital should then be able to garnish the welfare payments.  The person may pay dearly for the luxury of not buying insurance, but medical care will be provided and the hospitals will be paid.

A problem with this scheme is how to address the matter of children.  Traditionally, children have been considered the property of parents.  This view has receded somewhat in modern time because, frankly, some people are incapable parents.  There is no good solution to this problem.  In the past parents who could not afford or care for their children gave them up for adoption or indenture.  In the age of welfare, efforts were made to remove children from parents who could not provide for them.  This forced separation was seen as at times harmful to parents and children.  Philosophically, most see parents as providing better support than government even if they are poor or disorderly.  So, currently the government makes child welfare payment to parents or even a single parent in support of the children.  Sadly, this can make motherhood a profession that unfairly taxes responsible parents to support someone who willingly has children without a viable means of supporting them. 

The need for child welfare is used to justify a multitude of special programs to assure that children don’t suffer the consequences of parental incompetence even where family welfare programs in place.  Subsidized meals in schools are an example of this.  Lunches came first.  One good meal will provide for survival even if there is no food at home.  Then came breakfast because students couldn’t concentrate in the morning if they were hungry.  I wouldn’t be surprised if some schools now provide an afternoon meal to assure that students don’t go home hungry. 

We don’t want to see children suffer the parents, but we should either trust the parents or not.  If parents will not or cannot support their children, they must give them up.  Children should not provide income for them.  Society should be neutral with regard to children, but of course it never will be.  Currently, however, society is much too supportive not of the children but of their parents. All the aid provides immediate help, but fails to encourage the development of responsibility by parents or their children.   All learn that if you screw up, the government will take care of you.  This lesson may be more harmful than chronic hunger.

Welfare should not go to children and should not be based on children.  Therefore, the parent on welfare will find himself or, more likely, herself pinched by having children.  This is as it should be.  Having children pinches all of us.  The welfare parent will have to make choices.  Health care should be an important choice, but some might fail to buy it even if receiving welfare.  In this case a sick child would be treated, but the parent assessed the cost if there is no insurance.   Deciding on how to set amounts for welfare and rules for child support may be difficult, but Congress could put in some effort and create a plan.

I should mention that college education has been corrupted almost as much as health care.  Once there were scholarships for the best and the brightest.  Today there is financial aid for everyone.  Colleges have found that education is a business where you ask how much the customer can pay and bill them accordingly. Colleges also discovered that they could get the government to subsidize education and charge the parents even more.  Students naively believe that the government support “makes their education possible.”

Our welfare system has made it too easy to be poor.  One can be poor and receive housing and medical care.  One can have children and the government will pay for their food, health care and education.  Since we don’t see how much it costs to live, we don’t work as hard and skillfully as we should.  As a result our economy suffers enormously. 

Labor is outrageously overpriced.  There is a bottom end of the pay scale because welfare will pay more than employment, so only the rich can even dream of having a servant.  Employers find that in addition to salary they must pay some 15% more in payroll taxes and benefits.  Employers must also complete complicated paperwork to assure that the taxes are paid.  All this makes the employment of the poor impractical.  Large employers must even pay a “minimum wage” that effectively bars employment of the mentally retarded, unskilled, or “difficult” employees who cannot achieve an arbitrary level of productivity.  Instead of working, these people collect welfare. 

We often view the welfare payment as the total cost of this lack of productivity, but it is really only a part of the cost.  A larger cost is that the recipients are not producing. Their lack of work degrades them.  Whose life is enriched by inactivity or a lack of opportunity?

A decent welfare system should make it very uncomfortable to have children and not work.  Welfare payments should be inversely proportional to income and vanish when a certain level of income is reached.  At no point would added earned income reduce total income, so no one would be better off not working.  Those truly incapable of working would not starve in the cold but they might not be able to afford keeping children.  They might also take a spouse to help support them. This is not a harsh view of live, but a view that life is harsh.  Parents should not be fools, but if they are society does not have to support their foolishness.

With welfare fixed, productivity should skyrocket, and, I believe, people would behave more responsibly.  Those who do not will suffer, as they do now, but in some ways things will be easier for all.  Certainly health care would be cheaper.  Low cost health care would exist for those who want it.  Lawyers will be banned from suing practitioners who do not use the most expensive diagnostic tools and procedures.  Instead consumers will save several thousand dollars a year.  We might die a bit sooner for our savings, but we don’t live just to live.    Face it; life does not get better in the 80’s.  The human body is not designed to last that long.  Besides, we can do more than the doctors to increase our probability of long life by simple habits of exercise, diet, and not smoking.  These cost nothing, yet many of us disregard them.  

So, let’s see how much this Congress can do.  I doubt that the Congressional Democrats will have any of it.  I am a Democrat but have to admit that the Republicans have proposed some of these ideas.  They have not, however, reached beyond to the welfare issues.  Now is the time.  Health care will drive us to poverty if we don’t change the system.

I am a great believer in and hope for change.  Still, I am suspicious that whatever Congress will do will only cost me more money.  I should play the game, I suppose, and hope that Congress creates another Ponzi scheme for the taxpayer and that I will die before it collapses.  The problem is that I may live to see the collapse of social security. Still, perhaps the Chinese will be foolish enough to keep loaning us money.  Perhaps we can follow the example of Argentina.  It seems that no matter how many times this country defaults on its loans, people keep loaning it money.  Responsibility is oh so crass.   Let the government pay for our health care.  It can make money.  What’s the problem?

Charles Strehl