The Problem

The crisis of the 40 million uninsured in America is not one of altruistic charity but of urgent national utility.

We as a nation cannot afford, financially and morally, to continue to leave such a broad swath of the nation unprotected, and the task clearly lies to the public sphere in the face of the private ‘solutions’ illustrated failure to provide feasible coverage for Americans. The lack of coverage for the uninsured puts a drain on our healthcare system, both in terms of cost and resources, through the gross inefficiency with which the uninsured are given real world care. Unable to afford routine checkups and basic preventive medicine, the uninsured typically are admitted to hospitals with more costly and resource draining needs than the insured.

This inefficient use of our health care system drives up costs for all Americans, and drains our hospitals of the ability to distribute care and resources at maximum productivity.
The uninsured are also less productive in the larger US economy than their insured counterparts.

Bluntly, to leave these 40 million Americans uninsured is to statistically insure an earlier departure from the workforce. Lack of insurance is correlated with earlier deaths in the uninsured than the insured, which cuts of years of productivity in the workplace that otherwise would have contributed to the American economy. And when the uninsured are alive and working, they are frequently suffering from chronic illness or injury that they cannot afford to bring to medical attention. These ill and/or injured workers are incapable of operating at the same levels as healthier insured workers. Again their lack of insurance manifests itself as a drain on the economy.
To have a basically healthy population is in the interest of the public good, just as it is to have a basically educated population. It is not a question of handouts, but of strengthening the security, stability and productivity of society as a whole. It is the public interests, and is thus a public concern meriting a social and accountable solution.

For years the problem of the uninsured has been left to the private sphere to solve, largely in the form of employer provided insurance.. Underlying this negligence has been the myth that the uninsured lack insurance because they do not work. Our nation is seeped in a get-a-job-get-health understanding of the problem.

The reality, however, is that the majority of the uninsured are the working poor. These Americans are not insured because their private employers have chosen not to provide insurance or they simply are not paid enough to be able to feasibly enroll it what programs their employers offer. Medicaid covers the very poor, but these working Americans, the majority of the uninsured, have been left up to dry by private ‘solutions’.As of mid 2001, 36 % of low-income workers were uninsured, and another 7% worked for small employers not covered by COBRA.

The private ‘solution’ of employer provided or individually purchase insurance has failed this large portion of the uninsured population, necessitating a public solution. ‘Wal-Mart law’ type solutions can twist the arms of private providers, but they still dodge the reality that the private sector has proven inadequate in providing healthcare for America.

The Solutions

Having arrived at the need for public coverage of the uninsured, we are faced with the immediate question of how to go about providing that coverage. The two strongest options are the extension of Medicaid to cover the uninsured nearly-poor or the replacement of our convoluted current system with a single-payer systems that would cover all Americans.
The least revolutionary option, the expansion of Medicaid has relative ease of implementation and a track record of success behind it. This solution would incorporate the uninsured into existing programs, and thus would not require dramatic systemic overhauls in the financing or delivery of care. It is also probably the more politically viable option. It’s attractiveness is in part because of the high satisfaction rates associated with Medicaid. In a 2003 survey Medicaid had a satisfaction rating of 87 percent, better than that of employer or individual insurance plans. The happiness of thus covered by Medicaid indicates the plans high merit, perhaps enough so to address the problem of the uninsured by expanding Medicaid’s proven and institutionally established coverage.
We must consider, however, that the systemic problems associated with the high levels of uninsured may be two great to be addressed with out larger change than the simple extension of an existing program. Those feeling this to be the case advocate the consolidation of the multi-webbed and convoluted system we current have into a single-payer system that would cover all Americans. Our current system carries with it much bureaucratic waste and inefficiency that would be largely eliminated with a shift to a more streamlined approach.

Additionaly, the fragmentation of the existing system makes accountability a very difficult thing, and the establishment of a single-payer systems would democratize decision making , thus bolstering accountability in addition to giving the public a larger role in influencing policy. Much of Western Europe functions under a model similar to this, as does Canado. Our northern neighbor in particular would be wise to look to as a model, as their system is more cost-efficient and transparent, and less restrictive than many of those over the Atlantic.
Determining the particular public solution to take merits much research and deliberation on the part of policy makers, but that something must be done is clear. We do not leave the education of our nation’s children to the whim of private interests, and idt is time we likewise assert the value of a healthy population by assuming public responsibility for providing insurance, just as we do for providing basic education

* When I wrote the following I was pretty darn frustrated at all the circumstances surrounding Obama’s close second in NH. I’m still uncertain about some of the assumptions embedded below, but It felt good to get it out. So here it is …

A lady ‘found her voice’ and got emotional.

But she wasn’t just any lady, she was a political candidate lady. The common - and arguably masculinist - punditry of the moment cast the event as the closing breakdown of a candidacy that had fallen from forgone to forlorn. The spectre of Iowa, tongue of Obama, and vapor of NH indie voters whirled in the centrifuge of the national press. We all felt pretty certain it would create a cocktail too toxic for Clinton.

Her tears were…I’m sorry…. Her welling-up was at the time simply Hillary reacting sincerely to her campaigns encroaching silence. Or, alternately was a desperate manipulation of the press and public in her final hour.

A week later, Hillary’s found her voice and that teary moment is now an instance of game-changing Hillary-humanity, or, alternately again, a inspired tactical play for the female vote. Discussion of her response to that question is ubiquitous still, and will live on in political science courses for decades.

Regardless of that particular episode of interest, Clinton’s win clearly had more to do with the strength of organization and argument she had marshaled over the past year in New Hampshire. The folks that act like her’s was this crazy out-of-left-field win need to take a deep breath and remember that a.) she was 15-points up two months ago, b) New Hampshire voters tend to decide late and, to do so contrarily. There is a lot neglected in focusing so on her answer to ‘how do you do it?’

What’s also neglected, however, is inquiry into the question itself. I speak not to whether it was planted, but to whether it’s a legitimate enough question to take at all seriously as more than idle chatter. To publicly ask Curt Shilling at the tail end of a playoff run ‘how he does it’ in such a way would be ridiculous. It is what he does as an ace pitcher. We, and he, expects nothing less.

To ask Janet Robinson, CEO of the New York Times, or Indra K. Nooyi, CEO of PepsiCo, ‘how they do it’ is at least just as absurd. Imagine either of them being asked such a question at earnings conference call, or even at a less formal Harvard Business School speaking gig. How about Ginsberg? I find it impossible to mistake the gendered subtext in a female presidential candidate being asked just that.

In order to take the question seriously, we have to be a little bit surprised that Hillary can ‘do it’ in the first place.