Critical: What We Can Do About the Health-Care Crisis

by Tom Daschle

Reviewed by Theresa Welsh

Former Senator Tom Daschle, once slated to be Secretary of Health and Human Services in the Obama administration, understands the health care problem. He "gets it" that millions of Americans do without the health care they need because health insurance is too expensive and, for many, unavailable at any price. He knows that Americans are driven to bankruptcy by their high medical bills, and he repeats in this book many of the horror stories I've heard before and many new ones as well. I am glad that he is listening to these stories.

DECLINE OF EMPLOYER-PROVIDED HEALTH INSURANCE

I am also glad that he recognizes that getting health insurance through an employer is a practice that no longer works for millions of Americans. He writes about the "increasing number of independent contractors, temporary employees, and part-time employees…" who do not qualify for employer-provided insurance. I have been one of those workers and I've seen the options shrink for anyone who is part of the contingent or self-employed workforce. Daschle has a good sense that an employer-based system cannot meet our needs. Nor, in my opinion, is it fair. Why should people who work for large, prosperous companies get better health care than someone who works for a neighborhood restaurant or does free-lance writing? Why should your employment situation determine whether or not you get health care? No other country on earth has such a system, and many American employers find it an increasing burden that puts them at a disadvantage in a global economy.

HEALTH CARE REFORM: A LONG TIME COMING

The book has a nice summary of historic events that shaped our current non-system, including a few I didn't know. I didn't realize that Teddy Roosevelt made National Health Insurance part of his platform in 1912 or that the labor movement tried to get government-funded health insurance way back in 1914. It was opposition to this that led some employers to consider providing insurance to their employees. During the Depression years, hospitals tried to keep their beds filled by offering prepaid plans. These later evolved into the Blue Cross plans that originally were based on a social insurance model but later adopted the same practices as commercial insurance companies.

But the modern history of attempts to bring government-funded universal coverage to Americans begins with Franklin Roosevelt. He intended to give us universal health care in the Social Security Act, but, facing serious opposition, mainly from the AMA, he pushed the legislation through without the health care provision. It wasn't until the administration of Lyndon Johnson that we got Medicare and Medicaid. These government-funded plans have helped millions, but they exist along with for-profit insurance companies whose objective is to make money, not help people who need medical care. Our legacy is an unplanned, almost accidental, health care environment that does not serve the American people and is so expensive that, if costs continue rising at the same rate, health care will consume 100% of our income by 2025. Obviously, this is not sustainable.

A "HEALTH CARE BOARD" TO SORT OUT WHAT WORKS?

While I'm satisfied Daschle understands the severity of the problem, I'm not sure he has a handle on the best solution. He does have one very good idea though, and that is that we should have a national health board that oversees health policy and determines the details of how a reformed health care system should work. He compares this to the Federal Reserve Board which oversees banking and financial institutions. Despite the current financial melt-down, which some might say shows the Federal Reserve can't guarantee financial stability, we might be in even bigger trouble if we didn't have an independent board capable of acting quickly, once the danger to our economy is obvious. Any concept of having a group of experts deal with the details of running a complex system like health care or financial markets is subject to the expertise and ethical principles of those who serve on the board. But I think our President and his advisors could find capable people who would operate in the public interest.

This is a good idea because, as Daschle points out, our Congressmen and Senators are hardly health care experts and most probably don't know or understand the complexity of delivering health care to a nation. For them to decide all the details of how health care should work seems inappropriate, and is a slow and clumsy process when changes are needed. Congress should lay out broad principles, then leave it to the board to come up with the details.

CAN INSURANCE COMPANIES DELIVER US WHAT WE NEED?

But even using broad strokes, a number of decisions must be made up front. Daschle does not suggest kicking out the insurance companies and going with a pure government-funded, single-payer system. Why not? He mentions the Massachusetts plan in a favorable light a number of times in the book, but that plan still leaves large numbers of people uninsured, despite the "individual mandate" that all residents must buy insurance. People do not comply because they still can't afford the premiums or feel the skimpy coverage is not worth the price of the monthly premium.

If you postulate a plan that says "we'll use private insurance, but we'll subsidize people below a certain income level" then you have to have some way to determine who qualifies for the subsidy. You have to create a bureaucracy to constantly requalify people based on their income. You have to make some provision for the fact that people can lose their income and it doesn't conveniently happen at one time of the year when policies come up for renewal. Someone with a job today can pay his premium, but next month when he's laid off, maybe he can't. How fast can you get him a subsidy? Insurance companies cancel people when they don't make a payment. Since peoples' circumstances can change, you will still have people jumping from one plan to being uninsured to another plan, back and forth. The lack of continuity in our coverage is a major problem with what we have, and why I don't buy the argument that "some people like what they have." Do they like that they can lose "what they have" as soon as they can't make a payment or lose their job? Why adopt a system that perpetuates this problem?

Daschle also talks about expanding use of the Federal Employees Health Benefit Plan (FEHB), but he doesn't explain what this is except to call it "a menu of private health plans." If it is just more private insurance, how can it help us out of the mess we have now?

It seems to me that if you polled the American people and asked if they prefer "what they have" to a plan that requires no monthly payments and can never be taken away, you'd hear a giant whooshing sound as Americans rushed to Washington to demand such a system from their representatives.

REAL HEALTH SECURITY MEANS AUTOMATIC, CONTINUOUS COVERAGE

What is health security? Is it just being able to say "I have health insurance?" I may have it today, but I can lose it tomorrow. Real security is a plan in which you are automatically enrolled and from which you can never be cut off. A plan that offers continuity of coverage and of care, that does not require you to requalify or recertify to stay in the plan. It means never having to worry about being bankrupted by sickness. And, in my humble opinion, it also means never having to deal with an insurance company. They are in the denial business, taking your money every month, then doing their best to deny you care when you need it. They have shown they cannot be trusted and they have no interest in building a system of universal health care coverage. Their purpose is solely for making profits and perpetuating their existence. Mr. Dashle, how can you support the concept "build on what we have now" when what we have now has failed us so badly and is so expensive it threatens our total economy?

The cost of health insurance will consume 100% of household income by 2025 if current trends continue.