Editor’s note: this commentary is by Paul Manganiello, MD, emeritus professor of the Geisel School of Medicine at Dartmouth and the medical director of Good Neighbor Health Clinic in White River Junction. He is a member of GunsenseVT.
[W]ell, it has finally happened, they are going to repeal Obamacare. Just tear it up! I never did like it, way too complicated!
How did we get to where we are today? Our current employer-based insurance system was encouraged to expand by President Roosevelt during World War II when wage controls prevented companies from increasing their workers’ wages, but allowed companies to expand health benefits in order to attract workers. Employers have been able to claim premium payments as a tax-deductible business expense, while employees’ health benefits were exempt from taxes, so the government for all these years has been subsidizing employers and employees. This subsidy is enormous, hundreds of billions of dollars per year. In 1965 Congress established the publicly funded Medicare program for the elderly, and the Medicaid program for the poor and disabled.
Let’s fast forward to 2009. World War II is long over and wage controls are no longer in effect. The Affordable Care Act (ACA, aka Obamacare) is about to be debated. Republican Sen. Bob Bennett of Utah and Democratic Sen. Ron Wyden of Oregon introduce the Healthy American Act S.334. Their plan called for the elimination of the current employer tax exclusion for their employees’ sponsored health care insurance, and in place of the tax exclusion, an income tax deduction, adjusted annually for inflation, would be available to the employee. It also mandated that employers, no longer being required to provide coverage, would be required to increase wages over a two-year period to equal the amount of money the employers previously paid to cover their employees’ insurance premiums.
So now that Obamacare is going to be repealed, where do we go from here? As Americans, do we really believe in “Life, Liberty and the Pursuit of Happiness” for all of our citizens? Isn’t it appropriate to expect everyone to contribute in the support of a health care financing system? Have I ever, in fit of passion, forgot to use a condom; have I ever taken a ride on the back of a motorcycle without a helmet; have I ever gotten behind the driving wheel of a car after drinking too much? Unfortunately yes, I have done a lot of other stupid things in my life, which could have impacted not only my health but also the health of others; fortunately there were no long-term adverse consequences. I try to live a healthy lifestyle (eat properly, exercise, don’t smoke, etc.) but I have also needed treatment for conditions that I was not responsible for: medications to treat my asthma; contact lens to treat my eye condition called keratoconus; surgery to treat my low-grade cancer. The question is not if we will need health care, but when will we need health care?
Seeing patients in our free clinic, I find myself wondering why I, a second-generation Italian-American, should have access to affordable health care, while other citizens whose ancestors go way back, do not. As an example, one of our local farmers, who couldn’t afford to have a colonoscopy, was seen because of rectal bleeding, he was found to have an incurable colon cancer, he presented too late for effective treatment. The custodian at one of our local schools, who couldn’t afford his antihypertensive medications, subsequently suffered a stroke. What makes me special? Should health care be determined by who your parents are, by what part of town you live in, or by whether or not your chosen profession is reimbursed adequately? Is it really acceptable in the United States today to designate some of our citizens as being in a lower caste?
Should health care be determined by who your parents are, by what part of town you live in, or by whether or not your chosen profession is reimbursed adequately?
Where can we go from here? For starters, make Medicare available for everyone. That’s what I have. When I was working, I paid a payroll tax into Medicare, now I pay premiums based on my income. Am I happy with it? You bet, and by the way don’t ever touch my Medicare! I have not seen a survey of Medicare recipients who overall are not happy with the program. One can choose between the traditional Medicare plan, which I chose, or a privately insured managed health care plan, Medicare Advantage, which can substitute for Parts A and B of traditional Medicare. With the traditional Medicare, I can see whomever I want to see and go to the hospital of my choice.
But I can hear the wail “How will we ever be able to pay for it?” The answer is we already are, and we are not getting great “value” (great outcomes / what we are paying in) for how we are spending our trillions of dollars ($3.2). If you were to enroll those in Medicaid, our veterans, and our workers and their dependents into Medicare, you would see enormous, “HUUUGE” administrative savings. From such a large patient database, you would be able perform outcome research on which treatments are more effective and reduce costs even further. A progressive federal income tax would capture not only those who are receiving a paycheck but also those who make money through investments. With every worker eligible for Medicare, Congress could get rid of the employers’ deduction that they receive for supplying their employees with insurance. Also Congress could decide that all those paying for their insurance could be eligible to receive a tax deduction towards the cost of their Medicare premiums.
What the Republicans are proposing will not bring about a healthy health care system but a continuation of our present dysfunctional health care system. We will regress to having more uninsured, again have “job lock,” hospitals will cost shift, businesses becoming less competitive because of increasing cost of offering insurance to their employees, etc. We all need to be in the same boat, and pulling in the same direction; the time has come for publicly funded, universal health care.
