As Hillary Clinton and Barack Obama race to the finish line to the Democratic nomination -- and as more superdelegates begin to line up with the latter despite his recent stumbles -- one issue that has gone underreported is that of how difficult health care reform is actually going to be. It may not be as simple as what the candidates state, or as simple as Michael Moore would want us to believe. Yes, Sicko (which I reviewed here) was a great movie but he forgot to mention -- or ignored -- another symptom of the American mess.
Like Canada which isn't a single, single payer regime but where each province and territory runs its own system (with very limited reciprocity, a fact which is itself against the law), there likewise isn't one single health care system in the United States. There are in fact fifty-one, one for each state and the District of Columbia. Each one has its own set of rules and regulations and because of that are each served by a different basket of insurance companies, and the states will not yield their authority to the federal government. Worse, reciprocity is next to impossible to obtain even within the same insurance company, which impinges on the right to travel and even work (many people live in one state but work in another).
Ever notice the small print in so many television and radio commercials, "Not available in all states"? Many companies don't bother selling insurance to those who need it not because the companies want to sell (of course they do) but because of the bureaucratic burden from regulations that prevent them from doing so.
If there was some interoperability allowed, that would drive down costs substantially. A company that can compete in all fifty-one areas instead of just a dozen or so could make insurance affordable for the masses because of the lowered overhead. Health care needs may be different in Wyoming or California, obviously, but having to make regulatory filings with fifty state agencies (and the home rule government in Washington) is patently ridiculous.
Hillary's plan of "mandates" -- forcing people to buy their own insurance -- is silly. Not just for the reasons above. Massachusetts has a mandate law but over 300,000 residents in the state still don't have insurance. They can't buy insurance if no one will sell it to them. Her plan overall would cover more Americans in the long run, but it still relies on the insurance companies -- which bought her off in the fourteen years since her last plan tanked.
Obama's plan isn't that much better. His plan does call for portability as well as "pay or play" (what they have in Hawaii) but it also relies on tax credits to help low income people buy insurance. He also does call for a ban on companies denying benefits or claims on so-called "pre-existing" health conditions. However he doesn't say how he's going to make sure premiums charged are fair -- or how premiums will be more levelled off across the United States.
As for McCain? Same old same old: Tax credits. They're useless if you can't get insurance in the first place. He also says absolutely nothing about ensuring interstate competition.
In the long run, I think America will ultimately have health care for all. It won't be a Canadian system and certainly not a Cuban system, but more of a hybrid system of public and private health care; not unlike what they really have in the UK, where there is a basic basket of services from the NHS but people can get private insurance for faster (and better) service if they can afford it. To get there however and to make even minimal reforms, Obama or Clinton will have to first confront that convenient catch phrase of "states rights" which once meant pro-segregation laws but nowadays simply means no federal mandates without just compensation for the lost of that aspect of state sovereignty.
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