Health Costs (and how to deal with them in our Constitutional System)

The US does not get a good value for the money we spend for health care in this country. Of the countries in the OECD (Organization for Economic Co-operation and Development, or the developed countries of the world), the US spends 2.5 times the average per capita expenditure on health care. The US spends over 20% more than the next highest expenditures in the group (Luxembourg). Yet for all of this spending, our health outcomes are nowhere near the top of the group. And we still have a significant percentage of our population that does not have insurance coverage, while our insurance system has caused sticker shock for many with the increases in deductibles and co-pays.

Why is our system so inefficient? Part of the reason is because so much of the payment in the US is done via the private market. The government pays 46% of the total health care bill in the US, while most countries in Europe and Asia that are leaders in health care outcomes pay between 75% and 86% of the total bill. Since most countries other than the US rely upon a single-payer system,  we pay more for private companies to administer the billing. One of the benefits of the ACA was that, in order to comply with the regulations as an insurer, at least 80% of the premiums had to go out as benefits. That still leaves a 20% administrative burden on the money being paid to insurers.

What really happens though, is that with this administrative burden, we end up with an accountants arms race between the insurers and the providers. Providers send bills out reflecting the desire to recover not only the direct costs from services, but the extra costs from unreimbursed and under-reimbursed care. The insurers fight back through negotiated settlements, allowing only a fraction of the charges to be reimbursed. Thus come the horror stories of being charged for $100 for an acetaminophen tablet if you are uninsured and have no accountants to fight for you.

For many of us, the single biggest expense we will incur in our lifetime is an extended hospital stay. Yet nowhere in this expense is there any semblance of transparency in the billing or payment process. Still, administrative charges pile up and grow exponentially throughout the system.

This does not even consider the diagnostic device arms race that goes on between health care providers. And empire building as well. Each institution feels that they are justified in building that new wing, or stand-alone facility aimed at treating one specialty disease. The group wards I can remember being in when I had my tonsils out in the early 1960’s have all been converted into suites of individual rooms, resulting in a huge expansion of support personnel to manage the increased space.

Then, there’s pharmaceuticals. Once upon a time, the TV network news shows were supported by advertisements for aspirin brands, for antacids, for tonics (remember Geritol?), and sleep-aids. “Take Sominex tonight and sleep. Safe and restful sleep, sleep, sleep”. Then, only 20 years ago, the first prescription medicine advertisements appeared on TV, and the pharmaceutical world has never been the same. Now there are advertisements for pharmaceuticals to counteract the laxative effects caused by other pharmaceuticals. Of course, with the last large effort by Republicans to improve benefits to older Americans, they put in a requirement that Medicare could not negotiate prices from pharmaceutical companies. They protected the drug companies profits, disregarding how much of the cost of these new drugs were being spent on promotional activities. Added to these expenses is the practice by pharmaceutical companies of pricing their products in the US so as to recover their research expenses, and the perfect storm of exponential pharma price increases marches on.

None of this is a surprise. What is a surprise is that the current Republican plan to revamp the health care coverage crisis does nothing to attack the underlying causes of the bloated expenditures. Instead, what we are seeing is an attempt to shame Medicaid recipients into believing that they are living sinful, slothful lives if they are sucking at the Medicaid teat. The Republican’s had their Marie Antoinette moment of “Let them eat cake” when Jason Chaffetz said poor people should spend money on health care instead of buying the next generation I-phone. There seems to be a total lack of awareness in the souls of Republican legislators that it is not possible, given the low income levels of many full time workers, to afford health care insurance payments. It is even less feasible for these workers to afford to fund health savings accounts to deal with the deductibles and co-pays.  The solutions that the Republicans offer presume an upper-middle class standard of living at a minimum. If you are below that, you should be working to better yourself. Don’t look to the government to provide a hand-up.

Of course, those who are Darjeeling patriots begrudge even the low levels of tax credits doled out in the version of health care now being discussed. These are the folks who say that if it is not explicitly in the constitution, then we’re agin’ it. At least these folks are attempting to base their argument on principle rather than hypocrisy. So let’s look at the founding documents, the Declaration of Independence and the Constitution, to see how it is possible to support a more inclusive method of paying for health care and stay within the constructs of our nation.

Let’s start with the Declaration. Even though this document is not the guidance to the laws of this nation, it does describe the guiding principles upon which all other documents are created. Right at the beginning, it states that among the inalienable rights given to mankind are Life, Liberty, and the Pursuit of Happiness. To me that is a clear statement that it is a given right to have life, and within modern society, that means having health care to protect and preserve this life.  It further states that “to secure these rights, governments are instituted among men.”  In the first document agreed to by our founding fathers, it explicitly says that government has the responsibility to secure the right to life and the means to protect and preserve this life.

Let’s move on to the Constitution. Entire legal careers have been spent parsing the original intent of this document and my reading may be lacking nuance, but hopefully I can determine what the constitution means in today’s world. Again, in the preamble, it states that one of the goals of this document is to promote the general welfare. In today’s world, promoting the general welfare means providing health care to the citizens of the nation. In Article 1, Section 8, it states “Congress shall have the power to ….. provide for the common Defence and general Welfare of the United States”. It is my belief that the general welfare of the United States includes the health of its citizens. Further down in Section 8 it states that Congress shall have the power to regulate commerce among the several states. This is the infamous commerce clause that has been under discussion since the adoption of the Constitution, Indeed, Amendment 10 states: “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people”.

This amendment is held to be the reason why the US government is not allowed to administer health care as an inalienable right, since it is not explicitly listed in the Constitution and therefore must be delegated to the states.

But I argue that the right of the Federal government to provide for the general welfare means has been delegated to the United States by the Constitution. It is explicit in the preamble and in Article 1. The right to Life has been proclaimed as an inalienable right in the Declaration of Independence. To this observer of the political parade, this settles the argument about the right and responsibility for assumption of health care administration. What remains is for someone to come up with a complete redesign of the US health care system that provides the same level of care at a much lower overall cost. That must be the challenge that we accept as citizens. This current version of nibbling around the edges of a dysfunctional system must stop, and we must draw up a new social contract that includes the right to health care as a means of promoting the general welfare.



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