Thursday, June 30, 2011

Let's Have the Real Conversation

The health reform debate has been brutal, focusing on everything from "death panels" (no, they do not exist) to the constitutionality of a requirement that everybody purchase insurance (with subsidies if they need them) or pay a (small) penalty. Accusations of a government take-over and rationing of health care are repeated over and over, no matter how false they are. In the end, it seems to me that we're not having the conversation that underlies all of this: What's the proper role of the federal government?

Some people are in favor of small government. They would go so far as to privatize Social Security and Medicare. They think the market can fix pretty much any problem that arises, with perhaps a little help from state governments. The funniest Tea Party sign I've seen is "Take Your Government Hands Off My Medicare." This is funny because Medicare is a federal program completely created and run by the federal government, and the vast majority of people -- even most small-government advocates -- do not go as far as Paul Ryan would, by ending Medicare as we know it and, instead, providing people with a voucher that they could use to buy private insurance. But there are many within the GOP who believe that providing incentives, like high costs, for people to use less health care would be a good thing because it would bring the costs of health care down.

A couple of reality checks. First, Connecticut tried to shift responsibility for running its Medicaid program to private HMOs. It cost far more that way because government has lower administrative costs. Second, there are, by now, several studies that show that when people don't get the health care they need, their illness spirals out of control and they end up costing far, far more than early and adequate health care would. So making medical care more expensive will cost more in the long run. People who don't take their medication because they can't afford copays are likely to get sicker, and that just costs more.

But setting reality aside for the moment, others (like me) believe that the federal government has a role in ensuring that people get the health care they need. First, we believe that health care is a basic right, like food and shelter. Second, we look back at the civil rights struggle, the women's rights movement, and we know that, while some states will protect individual rights -- like New York, where you can buy health insurance even if you have a pre-existing condition -- others will not -- like Mississippi, where the state refuses to even allow consumers to file external appeals seeking review of insurance company denials of coverage. In those instances, the federal government has been the agent of change.

For me, health care is a civil rights issue. For conservatives, it's not. For me, we gave states and the private sector plenty of time to try to fix health care, get affordable insurance for all, get control of costs. For conservatives, any solution should be found in the private sector. I listen to the voices of people who can't get care every day. Conservatives listen to industry (both health care and insurance), which feels that they are being squeezed by health reform. Indeed, conservatives might look at Advocacy for Patients with Chronic Illness and say that we are a private sector nonprofit performing a function for people who otherwise cannot afford this type of help, and that we show that the private sector will respond to people's needs. I think the government should be funding lots of organizations that help people access health care and health insurance.

The whole health care debate comes down to whether you like big government or small government, whether you believe private markets will correct problems or you believe it sometimes takes government intervention. So why isn't that what we're talking about?

And that's my point. We should be having a deep and meaningful debate over the proper role of government. The debt ceiling debate isn't so much about whether we need to increase taxes or whether spending cuts are enough on their own; it's about whether you believe that the federal government needs more income so that it can do more, or whether it's okay to simply shrink the size of government and assume the private sector will pick up the slack. Small government types think the federal government should exist for defense, mostly, not for social programs. I could not disagree more.

I think the American people are smart enough so we could be having the right conversation, the conversation about what's really underlying the whole controversy. Rather than scaring people into believing in fictional death panels, or arguing to courts that the individual mandate in unconstitutional because it regulates inaction instead of action, we should be talking to each other about our philosophy of government. Because until we have that discussion, we're really just talking past each other, so deadlocks like the one over the debt ceiling will continue to occur.

People are angry and afraid based on lies they've been told, knowingly, deliberately. Nobody really believes there are death panels in the health reform law -- at least, nobody who's read it. They keep saying it when what they mean is that they don't like health reform because it's an expansion of the federal government. That's a fair point -- one with which I completely disagree, but at least it's honest. And until we have the honest and straightforward debate we need to have in this country, we can expect to keep banging our heads together over non-issues. We can expect to get nowhere.

I believe how one feels about the size of government depends a lot on your experience. I am sick. I spend a crazy amount of money on health insurance and health care. I talk to people with chronic illnesses all day long. I hear tragic stories. I like to believe that at least some of the people who are against health reform would change their minds if we would all stop screaming so loudly that we drown out any serious discussion. Since we're not getting very far with the present level of discourse in America, how about we try having the real conversation we need to have about the role of the federal government. I don't know how that conversation would end, but I know that, by avoiding it, we are getting nowhere. Jennifer

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