Gutting the Health Care Plan: The Scorpion and the Congress

Will serious health reform meet the fate of the
scorpion and the turtle? In that fable, the scorpion pleads with the turtle to
carry him across a river. The turtle resists, fearing the scorpion's
sting, but the scorpion reassures him that he'd do nothing so foolish,
since both would drown if he did. Finally the turtle agrees. Halfway across,
the scorpion betrays his promise with a lethal sting. As the turtle begins to
drown, he asks why he took both their lives. "It's just who I
am," the scorpion replies.

I fear we're about to get stung again. When
people look back at the failure of the Clinton-era health care initiative, they
point, accurately, to an opaque process that produced a baroque Rube Goldberg
mess that satisfied no one. That happened even before the insurance industry
went on the attack with their Harry and Louise ads. But another missing element
parallels our current challenge-appeasement of the insurance companies as
the plan's centerpiece, and the inevitability that these same interests
will betray us again.

The Clintons
assumed the insurance companies were too powerful to confront, so the plan had
to go along with them. But once they assumed any bill had to get the
companies' approval, no plan could work, because it had to build in ways
for the companies to maintain their profit margins and the immensely wasteful
overhead they spend on advertising, processing claims, and turning down as many
sick people as they can. Their approach also creates corollary wastes, like the
third of the expenses of the average medical office that go toward dealing with
insurance company paperwork.

Our health care crisis is so dire that the simple
single-payer approach, as in Canada,
should be at least seriously debated. Compared with us, most Canadians are
satisfied with their system, in contrast with a recent US poll where 49
percent said our health system needed fundamental changes and 38 percent said
it should be completely rebuilt. Canadians get a full choice of doctors (unlike
in the US,
where households have to switch doctors when employers change their insurance
or insurance companies change their preferred provider lists). Tommy Douglas,
the Canadian New Democratic Party leader who pushed through national health
care in the mid-60s (replacing a system like ours), was recently voted Greatest
Canadian in a recent contest, beating hockey star Wayne Gretzky and Prime
Minister Pierre Trudeau.

Even if single payer isn't politically
achievable yet, there's no reason to take it off the table from the
beginning. Doing so means most Americans never get to hear the contrast in cost
savings, in allocation ease, in impact on ordinary citizens and their health
outcomes. They never get to hear the story that might allow them to overcome
current fears about losing the health care they have, being unable to see their
preferred doctor, or being condemned to the Purgatory of endless waiting. Maybe
we've been so conditioned that we can't quite get the support for a
full-fledged switch. A recent Kaiser Foundation poll still gives
single-payer a narrow 49 to 47 percent majority, vs 67 percent for including a
fully competitive public option, and maybe that isn't enough. But at
least we need to tell the story, so the probably inevitable compromise works
down from full public coverage, as opposed to considering options that gut even
the option of serious public coverage entirely.

Instead, because we've accepted the premise that
the private insurance companies have to be included, we're now starting
to consider including a public option only if it includes poison pills that
will doom it to fail, like requiring it be triggered by a set of exceedingly
unlikely circumstances
deferred to the indefinite future. Or requiring it
to play by rules so onerous that it can't achieve its straightforward
cost savings. Or turning it over to the states, so Big Pharma and Big Insurance
interests can simply, as Robert Reich warns,
"buy off legislators and officials as they've been doing for

But why assume that the insurance
companies are our friends? Why appease them at all? It's not as if
they've played a helpful role in our current system. Rather,
they've gamed it in every possible way, leaving our country with the
highest health care costs in the world and worst health outcomes of any
advanced industrial country. While they've made promises to cut costs,
their promises are only that (like the scorpion's), and they're
already lobbying with everything they have to gut any seriously competitive
public option. Add in examples like former HCA/Columbia CEO Rick Scott. after
his company paid a $1.7 billion fine (the largest in US history) for defrauding
Medicare, Medicaid, and the program that serves our armed forces, he is now organizing
attacks on any public program (hiring the PR firm that coordinated the
"Swift Boat" attacks on John Kerry). We need to challenge the
insurance companies, not appease them. There's no evidence that suggests
they're constructive players, or are likely to do anything except defend
their own parochial interest.

The insurance companies and other major financial
interests are talking a good line of late. They have no choice if they
don't want to be cut out of the game. But ultimately, they are who they
are, and their behavior reflects this. It makes no sense to embrace a partner
who you know will ultimately betray you.

Maybe the public private mix is the best compromise we
can get at the moment. But we must raise our voices now to demand a full
debate on the other alternatives, like single payer, and then if necessary
settle for something that gives a public option a chance, under equitable
rules, to see how it plays out in efficiency, service, and cost. Trusting the
insurance companies and stacking the deck to guarantee that private options
will prevail merely assures we continue our dysfunctional system until its
human and financial costs drown us all.