America’s healthcare future lies in a continued public/private mish-mash

Last Thursday, Democratic candidates for President debated global warming, taxes, reparations and more.  But the biggest debate was on healthcare.  Not a single candidate debated the need for governmental involvement in healthcare.  No candidate even debated the need for more governmental involvement.  But the differences were stark in how much involvement.

On the one hand you had the likes of Joe Biden and Kamala Harris, who argued for governmental programs to do more but either co-exist with private insurance companies to have them be part of the process.  Joe Biden wants to allow Americans to buy into Medicare while Kamala Harris wants to expand Medicare to all but allow insurance companies to provide the plans.  Such a system is similar to Germany’s where plans are regulated and must meet minimum requirements.

On the other side of the ledger are Senators Bernie Sanders and Elizabeth Warren.  Sanders plan calls for a complete governmental takeover of healthcare in two years and ultimately means 180 million Americans would see their private insurance yanked.  Warren has largely piggy-backed off Sanders but been able to avoid political heat by simply labeling insurance companies as heartless and greedy.

Even the Trump administration has somewhat gotten into the act despite its zeal to replace Obamacare by proposing limits on drug price increases, pricing transparency and allowing insurance companies to trade across state lines (more-so than they currently do).

Healthcare ranks as one of the most important issues for the average American and it plays politically.  Democrats largely campaigned on healthcare in 2018 after Republicans failed to repeal the ACA and it paid off magnificently.  Now, the shoe is on the other front.  This time, due to Sanders, it is Republicans crying Democrats are the party trying to take away care from the average American.  

What purists in both parties miss, and let’s be honest, Bernie is a purist, is it is unlikely the American healthcare system will be fully private, or government provided.  Contrary to the assertions of our favorite crazy uncle that our neighbor to the north provides all its care through the government, or Rand Paul, who claims the private market solves all, almost no system in the world is one or the other.

Sanders often invokes Canada as his shining example of government provided insurance and care.  Except, in 2006, in Chaouli v. Quebec, the Canadian Supreme Court affirmed a private market for insurance.  Since that time, Quebec and Ontario have allowed the expansion of their private markets.  This partly has to do with cost.  The Canadian public system is notorious for sending individuals to private specialists for care to cut costs.  Bernie’s plan would cost a whopping $32 trillion in 10 years and that is the conservative estimate.  Unlike Canada, the public system would not have ANY private providers to fall back on.

Other Democrats, like Biden and Harris, and some Republicans, have tried to straddle the middle, recognizing a government takeover of care is impossible in this country.  Cost alone, to say nothing of the increasing lack of care in rural areas, make this a certainty.  Rather, these various plans (Medicare buy-in, Medicare provided by private carriers, eligibility restrictions such as income requirements for Medicare) all follow the public/private model.

More conservative Republicans are fond of arguing we do not want our system to be like Europe’s.  But, in many respects, our system, a mix of public and private, already is.  For example, Medicare Part D is administered by the government, but care and drugs are provided by private carriers.  In Germany and France, while care is universal, private carriers administer the plans under heavy regulation.

This system has served these countries well.  Just like America’s mix of governmental mandates and private care has.  The idea one can just force everybody to have the same plan in a one size fits all format ignores wealthy Americans would not take this sitting down.  Doctors are unlikely to accumulate hundreds of thousands of debts and have their income limited.  Specialists are unlikely to remain in rural areas already lacking care.  Finally, cost considerations mean government provided care will always have to hit a bottom-line.  Elizabeth Warren can hammer away all she wants insurance companies are greedy and thus will limit benefits, but government has to watch its bottom-line too.  There is a limit to what exponentially higher taxes can pay for.

Americans rightly worry about the quality of care but should be wary of quick fixes and promises like Medicare for All and a purely private system.  Rather, the often belittled but successful mix of public/private care and give and take of private care and government mandates is where America is likely to remain.

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