The Coming Health Care Apartheid

Paul Krugman tackles the weighty question of how much health care society can afford and who should pay for it in this morning's New York Times. His critique of the Bush administration proposal to use individual health savings accounts to drive those decisions -- it's called "consumer driven health care" -- points out the obvious: no individual savings account, no matter how well it is designed, can afford to pick up the really big health care bills that hit people with serious, often terminal chronic conditions like cancer, heart disease and diabetes.

The bills from these diseases can bankrupt even the upper middle class in our society. Add to that the fact that the incidence of serious illness is closely associated with poverty, stress and low social status and it's easy to see that health savings accounts are nothing more than free market ideology masquerading as social policy. How likely are the poor and near poor to save for those unhealthy rainy days when they can't even save for their own retirement?

Eventually, the government will get stuck with the tab. As Krugman rightly points out, health care -- like food and housing -- ultimately is a social responsibility. Society, i.e., the government, will have to face up to its responsibility to provide for those who can't provide for themselves.

But what will society provide? The coming debate over health care reform will be ugly. It's not being driven by concern for the nation's 45 million uninsured or the savage inequities in the current system or what new drugs, devices and expensive imaging technologies meet a reasonable test of cost effectiveness.

Rather, health care reform is being put back on the political agenda by a corporate sector that is just a few bankruptcies away (can anyone say General Motors?) from pulling its support from the employer-based system that has undergirded American health care policy since the 1940s.

Where will corporate America go? Will it opt for a government-run system -- Medicare for all? -- that tries to make rational decisions about what health care the system should provide for everyone, which is the subject of the new Brookings Institution study Can We Say No?, that Krugman touts today. Or will it embrace a form of health care apartheid that is growing up in the belly of the current failing system.

In this emerging system, most of the very sick, once they've exhausted all their health care savings accounts and other assets, will get thrown into a public sector-financed health care system that provides minimal care. The quality of care will be determined by the costs of the technologies deployed, the salaries paid to its personnel and the maintenance of its facilities, all of which will be seriously underfinanced because the system has to compete for the scarce resources of an impoverished public sector to which the very rich refuse to pay taxes.

Meanwhile, the very well-to-do will either finance their own health care or buy expensive catastrophic insurance financed by a self-selecting pool of upper middle class people who have on average far fewer debilitating illnesses and can afford the high premiums.

Health care providers will be more than happy to cater to this two-tier health care system. As we've seen in virtually every other walk of American life, there's a lot of money to be made in catering exclusively to the rich. The coming debate is not about what technologies "we" should buy. It's about whether there is any "we" at all.

Posted by gooznews at December 26, 2005 10:20 AM