The Health Care Debate We Should Be Having-Part One

By Mike Appleton, Weekend Contributor

“We’re going to have insurance for everybody. There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us. . . . It will be in a much simplified form. Much less expensive and much better.”

-President-elect Donald Trump, Washington Post (January 15, 2017)

Even if one supports the Affordable Care Act, there was nothing satisfying about watching the legislative circus over repeal and replacement unfold in the Senate over the past few weeks. To an outsider the entire process appeared disjointed and at times almost incoherent. It became increasingly impossible to fathom what Senate Republicans were trying to accomplish. So when the final effort, an eight-page bill apparently drafted over lunch, was rejected in a 51-49 vote, the most appropriate emotional response was neither elation nor disappointment, merely exhaustion.

Efforts to lay blame for the debacle have already begun, of course. Reince Preibus has been summarily booted from the White House and the three Republicans who defied Mitch McConnell by voting against the so-called “skinny” repeal bill have been castigated by the right. But it would be wrong to think that there isn’t a way forward. That first requires that we dispel several misconceptions.The first attempt to fully repeal the ACA was the “Repealing The Job-Killing Health Care Law Act,” introduced by then House Majority Leader Eric Cantor and passed by the House on January 19, 2011. According to a recent report by the Congressional Research Service, while there were several additional pure repeal bills over the following years, the vast majority of the proposed bills concerned modifications to the ACA, either by eliminating or postponing the effective date of certain provisions, withholding funding approval or otherwise hindering implementation of portions of the Act. Several proposed revisions to the ACA actually passed both houses of Congress and were signed into law by President Obama. Therefore, the Democratic charge that Republicans have had eight years to draft a replacement for the ACA, while technically accurate, is somewhat misleading. A true replacement bill has never been drafted because replacement of the ACA following repeal was not a Republican goal. The “repeal and replace” slogan only came into prominence when Donald Trump was nominated with his promise to give the nation better and cheaper health insurance coverage as soon as he took office. His surprise election victory left Republicans scrambling to come up with something in a hurry. The fact that they were unable to do so does not mean that a good faith effort to develop a comprehensive bipartisan solution to the acknowledged deficiencies in the ACA is impossible.

A second misconception is that Congress can expect meaningful leadership from the White House on healthcare reform. In the same interview with the Washington Post quoted above, Mr. Trump said that his proposed plan was “very formulated down to the final strokes. We haven’t put it in quite yet, but we’re going to be doing it soon.” Either his plan was not submitted to Congress in the ensuing six months or I missed it. But if I missed it, so did Congress, because neither the measure passed in the House nor any of the Senate’s failed efforts bore any resemblance to what the President has repeatedly described: lower premiums, lower deductibles, more coverage and cheaper prescription drug costs. He celebrated the passage of the House version in May, only to criticize it in June as “mean, mean, mean.” Since the most recent Senate vote, the President has almost simultaneously vowed to let the ACA die on its own and encouraged the Senate not to give up on passage of “Repeal & Replace.” One is left with the impression that were Congress to pass a statute simply stating, “We love healthcare,” Mr. Trump would sign it with a flourish before a battery of cameras and send out multiple tweets proclaiming his great legislative victory for the American people. If any bill it adopted under guidance from the White House, it ought to at least mandate whiplash coverage.

Perhaps the biggest misconception, however, is the assumption by the President and congressional Republicans that their views on healthcare policy represent prevailing public attitudes. The unpopularity of the House and Senate bills has been widely reported. Moreover, recent polling suggests that a slight majority now prefers that the ACA be retained and improved upon. Most importantly, a January report by Pew Research reveals that fully 60% of the public believes that “government should be responsible for ensuring health care coverage for all Americans . . .  .” That number includes 52% of Republicans with annual incomes below $30,000.00. What this means is that it is time for political leaders to abandon partisan rhetoric and seriously engage voters in debating questions which are routinely relegated to academics. What kind of animal is healthcare? Is it a public good or a commodity like any other? Where do personal and collective responsibility intersect? What is the role of the free market in the provision of healthcare? What are the proper limits of government involvement? Is universal healthcare a moral imperative or merely a desirable goal? How should the burdens of the cost of healthcare be allocated? These are issues that go to the heart of how we view ourselves, our relations with others and the limits of constitutional government. Until we eschew the slogans and the convenient labels we use to categorize political views and thoroughly review first principles, no consensus is possible. Part Two will address some of these questions.

Sources: “Trump Urges Republican Senators Not To Give Up On Healthcare,” Huffington Post (July 30, 2017); David A. Graham, ” ‘As I Have Always Said’: Trump’s Ever-Changing Position on Health Care,” The Atlantic (July 28, 2017); Kaiser Health Tracking Poll: The Public’s Views on the ACA (July 15, 2017); Astead W. Herndon, “What’s more popular than the Senate health care bill?,” Boston Globe (June 29, 2017); Jessica Estepa, “Poll: Majority of Americans want to keep Obamacare,” USA Today (March 7, 2017); C. Stephen Redhead and Janet Kinzer, “Legislative Actions in the 112th, 113th and 114th Congresses to Repeal, Defund or Delay the Affordable Care Act,” Congressional Research Service (February 7, 2017); Robert Costa and Amy Goldstein, “Trump vows ‘insurance for everybody’ in Obamacare replacement plan,” Washington Post (January 15, 2017); Kristen Bialik, “More Americans say government should ensure health care coverage,” Pew Research Center (January 13, 2017); Byron York, “No, House Republicans haven’t voted 50 times to repeal Obamacare,” Washington Examiner (March 25, 2014); Ed O’Keefe, “The House has voted 54 times in four years to repeal Obamacare. Here’s the full list,” Washington Post (March 21, 2014).

The views expressed in this posting are the author’s alone and not those of the blog, the host or other weekend contributors. As an open forum weekend contributors post independently without pre-approval or review. Content and displays of art are solely their decision and responsibility.







183 thoughts on “The Health Care Debate We Should Be Having-Part One”

  1. The disturbingly high percentage of Americans who favor gov’t-run health care underscores the age-old fatal attraction of bread-and-circuses. We really have permitted ourselves to be transformed into the People’s Democratic Socialist Republic of America. And, of course, history teaches us how that ALWAYS turns out. This so-called constitutional republic is oh so D-E-A-D, and we have only ourselves to blame. Most Americans today do not deserve a republic. They’re too damned dumb and unvirtuous for such a blessing.

  2. Well for part duce here’s the gist….is it true only half the working age population even works? And in that one half that does 25 percent are government workers? So really we are asking “workers” to pay for everyone elses healthcare first….I.e. medicare, medicaid, chip. Etc. And they over use because it’s “free” ….and the reimbersement is so low on govt plans…even champus and tricare…the workers are really getting double slapped.

  3. “What kind of animal is healthcare? Is it a public good or a commodity like any other? Where do personal and collective responsibility intersect? What is the role of the free market in the provision of healthcare? What are the proper limits of government involvement? Is universal healthcare a moral imperative or merely a desirable goal? How should the burdens of the cost of healthcare be allocated?”

    These are good questions. There should be one that gets to the heart of the matter, the reasons for the high cost of healthcare. The costs will continue to rise, even if single payer was implemented. The costs continue to rise because chronic illness is affecting more people, and, at younger ages.

    Why is that?

    That is the question mainstream medicine does not ask really, nor effectively addresses when it attempts to.

    It is the one that must be changed before costs will go down.

    Food choices, sleep, stress of all kinds, chemical and hormonal disturbances from chemicals, plastics, pills–they all contribute to the development of chronic diseases and doctors primarily prescribe bandaids for symptoms.

    The government will not improve this; they are part of the problem. A grassroots development called Functional Medicine addresses the underlying causes of chronic disease. It would be better for patients if it was more readily available.

    If the government is going to be involved, then keeping the government involvement limited would keep costs down (e.g., no new bureucracy) and give doctors and patients more freedom.

    HSAs would keep the government involvement limited and allow people to choose how to treat and be treated.

    The food stamps program has to be changed, too. Processed food needs to be heavily limited. If a person must have everyone else pay for their food, then we should get a say in what food that person eats. Since food choices heavily affect a person’s health, then the choices must lean toward real food, otherwise we pay again for that person’s chronic health conditions. Fifty percent of kids below the poverty line are overweight: what does their future probably hold? Type II diabetes, high blood pressure, NASH? As a society we will pay, one way or another.

    Even if a young person is not below the poverty line, there is still much concern about their future health. Children today may not outlive their parents, dying instead at younger ages due to the burden of chronic disease acquired at younger ages.

  4. So, my bro in law last week was diagnosed lung cancer and aside from the diagnosis he’s freaking out because he knows his wife who has MS will be on the hook for the bills as they have some lousy Obamacare. Dude didn’t make enough to purchase life insurance. Thing is this an ordinary working class guy who was unfortunate enough to grow up Parkerburg, WV which both Dupont and Marvon heavily polluted with chemicals involved in producing Teflon.

    EVERY person in that family (ALL non smokers/drinkers) have had some form of cancer including my husband. Sad thing is this is his second event – first time testicular two decades ago and he never was able to reproduce.

    Why in the richest damn country in the universe should he, a worker and fully engaged in the community even have to worry in advance about the bills and how his wife might be affected?

    Answer: he’d not in the club and disposable

    1. The crude rate of lung cancer deaths is about 1/3 higher in West Virginia than it is in the rest of the country. As we speak, cigarette smoking is more prevalent in West Virginia (encompassing 25% of the adult population) than it is nationally (wherein 18% of the adult population smoke cigarettes); I’ll wager you will find that was true 30 years ago, and therein is your explanation for West Virginia’s elevated rates of lung cancer.

      Lung cancer not attributable to smoking is generally attributable to exposure to radon, asbestos, or 2d hand tobacco smoke. There’s a residual which is random strike. DuPont isn’t killing your brother unless it had him working on asbestos manufacture 40 years ago. (And the signature ailment for asbestos workers is mesothelioma).

    2. Sad but true, Autumn. All societies are caste systems whether they admit it or not. We’ve done the best to eliminate that very human proclivity but it’s in our basic DNA to seek out “us” and elevate our tribe over “them.” Survival of the fittest is a team as well as a contact sport.

    1. Mike posed the question, amongst others, whether health care is a public or private good. All that has been adduced thus far is that because private enterprise cannot meet the health care needs of all of the public, but can exclude non-paying customers from the beneficiary pool for health-care services, therefore health care is supposedly a private good that private industry cannot ever fully provide to the public. This should mean that health care is a public good–by definition–and despite the ability of private enterprise to exclude non-paying customers from the beneficiary pool for health care services.

      Oh! But the tax burden is too onerous. Yes! And the annual defense budget for our country is a bargain.

      1. This should mean that health care is a public good–by definition–

        Diane, I can explain something to you. I cannot comprehend it for you.

      2. I think it’s quasi-public given its necessity and the inability of the private market to meet demand. A lot like national defense

        1. Thank you Mespo. I will gladly accept the quasi- qualifier. Incidentally, do we really need to spend eleven times as much on military defense as our next closest peer-rival–which, unless memory fails as it so often does, is currently The People’s Republic of China? Most of our NATO allies have some form of government intervention in the health-care industry as well as significantly lower military spending. OMG! Did I just agree with Trump? How is that possible?

          1. We spend on the military for lots of reasons in addition to deterrence and defense. For example, one of the ways to spur short term economic growth is government spending. Buying guns and blankets from the private sector does that. We also spend that much because today’s allies are tomorrow ‘s rivals are the day after that’s enemies. See Iran — with Turkey in hot pursuit.

            1. Mespo says, “. . . today’s allies are tomorrow’s rivals and the next day’s enemies.”

              I cannot yet see my way clear to disagreeing with Mespo’s maxim. And that is truly alarming. For we currently have more treaty-based allies than any other nation in the history of treaty-based alliances. Hoo-Rah! One wonders for how much longer we can stave off having more enemies than any other nation in the history of treaty-based alliances. Would single-payer, universal health care with however many out-of-pocket costs to the patients it would take to achieve sustainability become the day before the whole wide world turns on us?

              1. Don’t fret, Diane. The world is ever like Hobbes’ jungle but we’re the alpha predator. It’s not about love, but respect — to mix a political metaphor and two wonderful philosophers.

                1. I’m afraid I must fret, Mespo. The Hayo Makamak earns respect best from providing care for his own people rather than subsidizing the care that his lesser predators provide their own people–and no matter how much that latter ploy might earn the lessers’ love by intimidating their most aggressive neighbor.

              2. The problem with having too many alliances is that one “wrong turn” and all hell breaks loose. Or so was the case with the Archduke’s chauffeur.

                1. Excellent point, Darren. Poor Gavrillo Princeps. He killed the Hohenzollern most sympathetic to his cause.

                  BTW, given Trump’s demand that our NATO allies pay their fair share for that mutual defense pact while so many of them have one form or another of universal health care, if we cut military spending to fund our own form of universal health care, and if our NATO allies thereby had to spend more of their own tax revenue for their own military defense, and if they thereby had to spend less on their own forms of universal health care, would we be excluding free-riders from the beneficiary pool for the armed forces of The United States of America? Or would they all hop into the sack with the beta predator currently stalking them?

        2. No it is not. Diane has some a priori conception of ‘needs’ that she fancies would not be met by voluntary exchange. We commonly want things we cannot afford. That does not render those things a ‘public good’.

          1. Admittedly the desire to live a longer life rather than a shorter one might as well go ahead on and become an a priori conception of ‘want,’ or wont, for that matter. But then the desire to be and to remain a member of a social group at least on occasion to be referred to as the public might also become just such an a priori conception of want or wont. That. in turn, would seem to be consistent with Mespo’s position on social dominance hierarchies as the alleged font of human political instincts.

            Whence the simple notion that most humans want longer lives, whilst some humans can’t afford longer lives, supposedly renders the treatment of treatable illness a strictly private rather than a public good–by definition, no less, which in turn is further presupposed to be something, almost anything else, other than an a priori judgment.

            Surely that cannot be.

            1. Oh no! I’ve lit a fire under the seat of my own pants. I hereby retract my prior use of the term, ‘by definition.’ All the same, the notion that some desires, such as the desire for a longer life, are felt with sufficient intensity as to be called by the name of ‘needs’ could easily be applied to the utmost public good known as military services. We do need to defend ourselves from time to time; and it does lead to longer lives for at least some of us who stand and wait.

          2. You’re right about “need” versus “affordable.” “Need” is an objective assessment (a horse needs water) while “affordable” is a subjective decision (I’d like a new Tesla). But Diane is not wrong to suggest health care with all its ramifications on production and costs, isn’t at least a national need. BTW, I disagree with Nick’s pithy comment that you’re a “box of hammers” with a thesaurus. I find your comments a good read even when I vehemently disagree.

            1. I thank you, again, Mespo. But I made a horrible statistical error on the thread about Trump’s comment to police about not being too nice and taking the hand away from the head of a criminal suspect. I think I can actually feel the reptilian portion of my brain slowly constricting the thin human layer up top. I do get confused from time to time–especially whilst salivating over rabbits in the garden. IMO, experimentally induced psychosis was Pavlov’s greatest achievement.

            2. “Need” is always paired with a purpose. Markets can be described without reference to purposes (other than the purpose to consume and produce the good or service in question).

              Again, the production and consumption of medical services incorporates some distributional challenges because of the common opinion, intermediated through the political process that the distribution of services according to market dictates would be unjust. This is orthogonal to the question of whether or not something is a ‘public’ good. Public goods are those things that private providers do not produce because of features incorporated into the service in question.

        3. The private market could easily meet demand. The AMA just chooses not to. The data at the link are old, but Wikipedia states there are only 141 accredited MD-granting institutions in the US, with ~30 DO-granting schools.

          I do not want the federal government dictating acceptance criteria for medical schools, were it to negotiate/mandate for more schools to be established.
          The SJWs have made it virtually impossible for white males to get accepted as it is.

          1. The SJWs have made it virtually impossible for white males to get accepted as it is.

            About 35% of the M.D. and D.O degrees awarded in 2014 were so to white male domestic residents. White males are not treated fairly in the admissions screening, but they are not debarred.

            About 28% of such degrees were awarded to white female domestic residents; 5.7% were conferred on domestic blacks, 5.7% on domestic hispanics, 21.6% on those of the domestic population of Orientals and East Indians, 2.6% on a jumble of others in the domestic population, and 1.2% on non-resident aliens.

            1. Average matriculation rates don’t provide any information WRT regional/state differences in acceptance/matriculation rates, and of course say nothing about school quality/desirability, despite accreditation status. Not all schools are equal. But your stats will be cold comfort to all my relatives and sons of friends who were at the top of their graduating classes, had the requisite MCAT scores and clinical hours, but who cannot get into their top 5-7 choice schools unless they want to reapply for 2-3 years.


              1. Those are not matriculation stats. Those statistics are on degree awards.

                But your stats will be cold comfort to all my relatives and sons of friends who were at the top of their graduating classes, had the requisite MCAT scores and clinical hours, but who cannot get into their top 5-7 choice schools unless they want to reapply for 2-3 years.

                Disappointments people will have. Nothing you can do about that per se. My complaint was that you said something that’s demonstrably untrue.

                1. Your stats may have been on degrees awarded. My stats were on applications and matriculations per med school in each state.

                  “My complaint was that you said something that’s demonstrably untrue.” And yet your initial reply was this:
                  “White males are not treated fairly in the admissions screening”. Which is my point, although you apparently serve as this blog’s self-appointed Exaggeration Police. Duly noted.

                  “Disappointments people will have.” No sh$t, Sherlock. Hope your Economics textbooks (and your complete inability to see anything from a personal perspective) keep you warm at night.

                  1. You’re initial complaint was “The SJWs have made it virtually impossible for white males to get accepted as it is.” . If 35% of the medical degrees are awarded to white males not imported from abroad, no they haven’t made it ‘virtually impossible’. About 63% of the population is white and so is the pool of medical school graduates. I think there’s some bias in the admissions process, but I doubt it’s reducing the number of white people admitted by more than about 10%.

                    Now, it’s difficult to get into medical school. If medical school was ever less than vigorously selective, it was over a century ago before the reform of medical school curricula at the beginning of the 20th century.

                    1. “If medical school was ever less than vigorously selective, it was over a century ago before the reform of medical school curricula at the beginning of the 20th century.”

                      Not the point; the point was that there were inadequate numbers of medical schools to meet demand, which was aptly discussed in the Forbes piece. Perfectly qualified candidates are being turned away and forced to reapply after sitting out 1-2 years. The US has seen an increase in applicants to PA schools as more and more students are opting to go that route, rather than sacrifice more than a decade of their adulthood to the med school/internship/specialization grind, and due to the increasing reliance on PAs as the primary medical contact for most Americans. This is particularly true if college grads who really want to go to med school can’t afford to do unpaid volunteering/internships to try to beef up their resume when they reapply. And top PA schools are now demanding over 2500 patient contact hours as hoops for applicants to jump through as applications increase, and, not surprisingly, PA schools are limited. Since this blog freaks out with multiple html links, I’ll just post this one:


                      To iterate: the private sector is doing a crappy job meeting the demand for health care in this country. That was obvious before ACA, and it’s even more obvious now that so many doctors are retiring early or selling their practices and working for hospitals who handle the onerous EHR responsibilities.

                    2. CCS, Medical schools are private goods to be provided for by private industry with some distributional inefficiencies that could be subsidized by government, as in the case of land-grant universities, if you’d like; so long as you know that’s what you’re doing. BTW, what ever in the world is an SJW, anyhow?

                    3. You’re welcome, CCS. But I still don’t know what an SJW is? Nor do I understand how an NGO like the AMA can prevent a “private” market from meeting “public” demand without holding said market “captive.” Has the AMA not yet rejected the philosophy of Ann Rand the way DSS has?

                    4. Diane, SJW = social justice warrior, which to me encompasses anyone who advocates diversity for diversity’s sake. As to your post, I thought you were just injecting some humor by reiterating your longstanding disagreement with DDS, but I am in agreement with you about the AMA and captive markets. Although apparently, some people believe there are adequate doctors for the US population, despite the expert opinions of others in the medical field, and the fact that it is standard for people (including myself) to have to wait 6-9 months to get an initial healthy patient exam with an internal medicine doctor on the Cape (that is if you can find one who is taking new patients).

                    5. the point was that there were inadequate numbers of medical schools to meet demand,

                      That was not your point. You’ve shifted ground here.

                      The number of M.D. and D.O degrees awarded increased by 29% between 1986 and 2014. The population increased by 33%.

                      The Bureau of Labor Statistics reports that the mean compensation for physicians is currently $210,000 plus fringes; in the economy at large, fringes on average amount to $5,700 per employee for a medical plan and contributions to pensions and social insurance amounting to about 11% of cash compensation. That would suggest total compensation for physicians is as we speak on the order of $240,000 per year, on average.

                      The Bureau of Labor Statistics does not have comparable figures for 1985 posted online. An article in Health Affairs in 1992 on the evolution of physicians’ incomes reported that in 1985, mean compensation was $130,000 a year in 1989 dollars, which translates into $114,000 in 1985 dollars. The Bureau of Economic Analysis reports that nominal employee compensation per year has increased 4 fold since 1985 while the working population has increased by about 1/3, so nominal compensation per worker has increased by 3 fold or thereabouts. Physicians’ gross incomes (nominal) have increased by 2.1 fold over that period of time, if the figures from Health Affairs and the BLS are true.

                      Unless the data from the three sources is incompatible, it would appear that the number of medical degrees awarded has increased almost pari passu with population and that physicians’ incomes have been growing more slowly than other employee incomes. That does not sound like a ‘shortage’ to me. The wait times in doctor’s offices are certainly shorter than they were 40 or 50 years ago.

                    6. DDS, No. Go back and read my original response to mespo at 9:38 am. You latched onto a snarky throwaway comment I made at the end of the post and turned that into your ‘nitpick du jour’ for the last 24 hours. Again, you may think your interpretation of BLS stats support your thesis that there are adequate doctors. The AAMC disagrees.


                      A PBS article states the shortfall may be as high as 130,000. And the anticipated shortage in surgeons, noted in the article above, is particularly interesting, given that most surgeons are male, and that is unlikely to change significantly in the time-frame given, due to human nature.

                      Medical schools stopped growing over 30 years ago in response to a poor prediction by the AMA/AAMC that there would be a MD glut. As a result, according to a 2011 article by Brian Palmer for Slate, half of all residents in family practice, pediatrics, and internal medicine positions came from abroad. Medical schools have started to remedy this, but the increases in US med school graduates will simply displace the imported doctors.

                      And wait times in doctor’s offices are shorter now compared to 40-50 years ago? You crack me up.

                    7. I have no clue how employees at PBS came to the conclusion that there’s a shortage. T

                      he number of practitioners per capita is not declining. Compensation is on a lower trajectory than the mean for the labor market as a whole, which is to say that other lines of work are more lucrative vis a vis medicine than was the case in 1985. Typical working hours for physicians are also not increasing. (see
             None of these three factors is consistent with the thesis that there is a ‘shortage’.

                    8. You crack me up.

                      Evidently, you were not around in 1970 or 1980.

                    9. Oh, I was, but I’ve read enough neuroscience and psychology research to know that memories are error-filled.

                    10. half of all residents in family practice, pediatrics, and internal medicine positions came from abroad.

                      About 14% of those who were placed in 1st year residencies this year are foreigners who attended medical school abroad. There’s also a bloc of Americans who landed residencies having studies abroad (about 8% of total placements, I believe).


                    11. CCS, The humor was intentional. Oily crepe! I’m an SJW. I had no idea. When did this happen? And why was I not informed? Wait a second . . . Diversity for diversity’s sake is not quite exactly what I mean by social justice. And being a warrior is really asking too much of anyone. I wouldn’t expect it of my worst enemy. Can I be an SJP [Social Justice Peacenik] instead? It’d be easier on my poseys.

                    12. Thanks CCS. The link confirms my prior suspicion of being hopelessly out-of-date–video games and all.

                      So the SJW’s are now to be dismissed out of hand as so many grandstanding showboats of sanctimony. I loathe sanctimony. I’ve always loathed sanctimony. But the great wheel has turned again; and the loathing of sanctimony is, itself, sanctimony, in keeping with the old schoolyard playground principle known as I’m rubber; you’re glue; everything you say bounces off of me and sticks to you. Nana nana nana. Pfffffffffffft!

                      But what about the social justice? That, too, is sanctimony. Huh? Because some video-game-making Simon-Sayser says so??? What have you whippersnappers done to my children’s world? Do you really think your Mothers are proud of you? Well, do you?

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