America's healthcare problem stripped of all the rhetoric

http://www.NewsAndOpinion.com | Forty million people uninsured. Or is it fifty? Both numbers have the virtues of being both memorable and round. However, when lying with statistics, precision also matters. The currently fashionable number of people without medical insurance, beloved of politicians, talking heads, social critics, whining journalists, state medicine advocates, and everybody else with an agenda, is currently 45 million in 2003, a rise of 1.4 million over 2002, and precisely 15.6 percent of the population. And, so they tell us, this number can only increase as escalating premiums (now rising faster than at any time since 1991) drive more employers out of the market entirely.

And everybody's wondering, "Why can't a country that presumes to take care of the world, take care of itself?"

The answer is, "We can." But understanding the answer requires a basic understanding of the obvious. And that, neither the chattering classes nor the government nor the insurance companies wants you to do.

To get at the problem, it's necessary first to "disaggregate" the pool of the uninsured, figure out who and what they really are and whether or not they're really quite so uninsured.

First of all, everybody is "insured" in the sense that you cannot be legally turned away from an emergency room (assuming you can find one) in life-threatening situations. Also, Medicaid insures 13.3 million poor Americans; various state programs provide some sort of coverage for millions more. So, by and large, if people aren't insured, there must be other factors at work.

There are. Some, a small minority, are simply too rich to bother with insurance. Others, estimated by the Census Bureau at over 30 percent of the pool, roughly 14 million people, are too healthy: young adults who voluntarily forego insurance on the theory that they probably don't need it. Others are millions(reported by some sources at 20 million) of illegal aliens. So that leaves two other categories.

One, obviously, is the unemployed. Here the numbers often fail to differentiate between the long-term unemployed and those who are passing through the pool between jobs. The Congressional Budget Office holds that, if you count only those without insurance for an entire year or more, the number drops to between 21 and 31 million — hardly a model of precision, but the point is made. The real number may well be half of what the state medicine mavens proclaim.

Which leaves the problem of the working poor, and of employers, especially small employers, who cannot afford to offer decent coverage. This represents millions of real and potential tragedies, and does indeed constitute a national disgrace.

It's a double disgrace because he present system is, in truth, an expedient left over from World War II. Back then, wages were frozen. Benefits weren't. So employers started offering coverage as an inducement in a tight labor market. When the IRS ruled that health coverage could be deducted as a business expense, the system became permanent. The result is that, today, the health care market is not for health care, or between doctors and patients, at all. It's between large employers and large insurers, negotiating large blocks of employee policies.

But even this wouldn't be so bad, were the system not a bizarre caricature of capitalism, hard-wired to keep costing more. Today's health insurance isn't really insurance by definition, the pooling of risk against unlikely but predictable events at all. It's the payment of a flat fee for potentially limitless services. Obviously, beyond a certain point, the only way insurance companies and HMOs can make money is to raise premiums, reduce care, or both. That point was crossed long ago.

So what to do?

First, recognize that the problem of the uninsured is much smaller and more manageable than the inflated numbers suggest. You don't wreck the health care system for tens of millions in order to help a small minority. You bring them into the system.

This you do by breaking the link between health care and employment(and government!), permitting groups to form for the sole purpose of buying insurance. And you regain the distinction between insurance, in this case "major medical," and purchase of service.

So what we have — de facto — is less of a crisis and more a problem that can be solved. The first step is to admit that the widely advocated 50 million uninsured is a medical myth.

Editor's Note: This week's provocative column was penned by Michael Arnold Glueck, MD.

Michael Arnold Glueck, M.D., is a multiple award winning writer who comments on medical-legal issues. Robert J. Cihak, M.D., is a Discovery Institute Senior Fellow and a past president of the Association of American Physicians and Surgeons. Both JWR contributors are Harvard trained diagnostic radiologists. Comment by clicking here.

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