It's one thing to criticize. What's needed is a low-risk way to
help people who can't afford insurance. The U.S. Census Bureau shows that of
the 47 million people identified as "uninsured," 14 million are
already eligible for government programs such as Medicaid and SCHIP (for
children) and simply need to sign up. Another 10 million have household incomes
over $75,000. That leaves 23.7 million people who need help affording
insurance, not 47 million.
Food debit cards help 27 million people buy food, similar to the
number who need help buying health coverage. In all fifty states, debit card
technology has transformed the federal food stamp program, which used to be
notorious for fraud and abuse. (Only 2 percent of card users are found to be
ineligible, according to the General Accounting Office.) Cards are loaded with
a specific dollar amount monthly, depending on family size and income, and
allow cardholders to shop anywhere. The same strategy could be adapted to
provide purchasing power to families who need help buying high-deductible
health coverage. It's what all Americans used to buy (see chart 5), and it's
all that's needed for families with moderate incomes, who can afford a routine
doctor visit.
Debit cards are better than refundable tax credits for three
reasons. Many people are uninsured only temporarily (about 22 percent) and not
at tax time. Also, some people don't file an income tax return. Finally, a
refundable tax credit would remove even more people from an obligation to pay
federal income tax at a time when half of Americans don't pay it.
Providing sliding scale assistance, based on household income, to
families to purchase this type of coverage would cost $20 to $25 billion a
year. The cost estimate could vary for two reasons. First, only a fraction of
people who are eligible for government programs actually apply (50 percent of
those eligible for food debit cards). Second, U.S. Census data show that many
of the uninsured are newcomers to the U.S. (some here illegally).
The largest influx of immigrants in any seven years in American history
occurred in the present decade. In this same decade, the lion's share of the
increase in the number of uninsured took place in the five Border States. In San Francisco, 61 percent of the uninsured are not U.S. citizens, according to
public health officials there. The public has not yet decided whether newcomers
should be covered.
Whatever the costs of debit cards, it will be less in both dollar
terms and risk than a healthcare overhaul that forces individuals and
businesses to buy coverage and puts European-style limits on healthcare
consumption.
Fixing Medicare
On May 12, Medicare officials announced that the trust fund that
pays for hospital care for seniors would run out of money by 2017. In unison,
the administration's key figures rushed to blame "skyrocketing healthcare
costs" for the crisis.
"The only way to slow Medicare spending is to slow overall
health system spending through comprehensive and carefully crafted
legislation," declared Secretary Sebelius. If rising health costs were to
blame, Medicare would have been thrown into crisis in 1980, when annual health
care spending increases topped 13 percent, instead of now, when the annual
increase is less than half that. Demographics are to blame, and Congress has
been warned every six months for decades that Medicare needs to be adjusted.
Telling all Americans they have to cut back on healthcare because
Medicare is fiscally unsound is like ordering all Americans to go on diets and
buy fewer groceries because the food stamp program is in trouble. Medicare can
be fixed without subjecting the nation to a regimen of healthcare scarcity. The
safer alternative is to reduce the government's share of the healthcare bill
rather than depressing the nation's largest industry and lowering medical
standards for all of us.
The Congressional Budget Office, the nonpartisan research arm of
Congress, has suggested alternatives, including inching the eligibility age
upward, two months per year, until it reaches age 70 in 2043.
No Time to Spare
Members of Congress who oppose an overhaul of American healthcare
don't have much time to woo public support for low-risk alternatives. The
president's advisors have urged him to hurry his health agenda through.
"Speed is essential," Dr. Blumenthal wrote. "Bill Clinton waited
nine months to introduce his Health Security Act in 1993, which allowed
opposition to mobilize and defeat him" (New England Journal of Medicine,
November 2008).
The president's team is also playing hardball. On May 11, the
American Medical Association, pharmaceutical industry, insurance lobbyists, and
other interest groups jointly announced that they would support the
Administration's efforts to rein in health spending. Why would these groups go
along? One answer is political arm-twisting, Chicago style. In a November
16, 2008Health Care Watch column, Dr. Emanuel
explained how business would be conducted to guarantee support for the
President's health agenda: "every favor to a constituency should be linked
to support for the health care reform agenda. If the automakers want a bail
out, then they and their suppliers have to agree to support and lobby for the
administration's health reform effort."