THE BLOG
09/14/2009 05:12 am ET Updated May 25, 2011

How Not to Do Healthcare Reform

Health care reform is the issue of the day, and President Obama is blowing it. He's trying to reform the health insurance system, not the healthcare system itself; and doing so on the backs of the rich and of small business owners. Mandates on employers will be disastrous for the economy, and for the popular sense of justice. Obama's "reform," as it stands, will set up an infinitely complex government system of regulations that will be inefficient and that, in the end, will dehumanize patients and doctors even more than the present system does.

The whole point of healthcare reform is that health care, like national defense, is too big and too important to be left to private enterprise, but too big and too important to be managed by government. I don't want the government running healthcare. However, it's perfectly possible to have a government-financed system of social insurance, in which government stands back from any medical or administrative role. In other words, we could collectively pre-pay for guaranteed coverage, with the government collecting the payments and responsible for the paying out the benefits; and retain a market-based system for delivery, with the discipline and quality control that that entails.

In previous columns (here and especially here) I've shown how the right-wing hysteria about the single-payer systems of Canada and Europe is not based on any actual evidence. So I am not now going to get into the statistics that show that single payer actually works quite well, contrary to the Republicans "Canadian nightmare." I'd just like to lay out a few necessary elements for a comprehensive program of single-payer healthcare reform.


  1. Subsidized medical education, so that anyone with intelligence, drive and talent can become a doctor or other health care professional.

  2. Salaries, rather than per-procedure payments, for doctors; as is presently the general rule among the best health care clinics and hospitals, such as the Mayo clinic, that put patient outcomes above corporate profits. The salaries don't have to be arbitrary. They can be subject to a very fine-tuned set of criteria, such as years of experience, number of patients seen, specialty, patient outcomes compared with similar practitioners, practice in an underserved area, practice with high-risk patients, patient reviews, etc.

  3. Tort reform, to keep malpractice judgments, and malpractice insurance costs, under control.

  4. Meaningful co-pays, to guard against "moral hazard" (the tendency of consumers to use more of a good than they need when it is free.)

  5. Complete patient choice in doctors, and medical decisions made only by doctors and patients and perhaps hospital boards, but without government oversight.

  6. No denial of coverage for pre-existing conditions or any other reason. Remember that we're not talking about commercial insurance here; we're talking about social insurance.

  7. Financing all of this through new, graduated taxes on income, which for most people would be cheaper than their present health insurance premiums.

  8. Use of the federal government's massive purchasing power to drive down costs of medical supplies. The lack of such a requirement in the Bush-era Medicare prescription plan was a scandal, a pure gift to the pharmaceutical companies at the expense of the public. Obama has said that he doesn't want to require this wholesale discount. Let's hope he reconsiders.

Yes, the young and the healthy would subsidize the old and the sick. That's part of what living in a human society is all about. And it's not even unfair from an individualist point of view, unless the young and healthy believe that they will never, ever be old and sick themselves.

Yes, the employed and the wealthy would subsidize the unemployed and the poor; but we do that anyway, at present, through Medicaid. There are great benefits to all of us from doing so.

Such a plan could really work, and could build, rather than defeat, social solidarity. Roosevelt and the New Dealers insisted that Social Security benefits should not be means-tested. They did this because they understood that if the rich had to pay into Social Security but could not benefit from it, it would become a poor person's program, and would always be politically vulnerable. In making the rich and employers pay for his pathetic "public option" in an essentially private system, Obama completely fails to understand this principle. Health care risks and costs, as well as benefits, should be socialized.

Failure to realize this will come at a great price for Obama. Unpopular, expensive, and overly bureaucratized insurance reform threatens to do for the Democrats what George W. Bush did for the Republicans. We are in danger, in fact, of seeing a far more radical right-wing resurgence than Bush represented, with real reforms discredited and abandoned forever.

Single-payer wouldn't be easy to get, but more and more people are starting to realize that it's the only good option. Against great odds, New York Congressman Anthony Weiner finally forced Speaker Nancy Pelosi to accept a House vote on a single-payer plan. He'll lose this vote, of course; and the right-wing forces will always try to defeat single-payer with lies and distortions about Canada and Europe. But this is a start, and perhaps the attendant debate will educate a few people.

I wish I could say this to Barack Obama: If you're going to risk your presidency, you should at least risk it for something worthwhile, and something viable.

* * * *

Regular readers of this space may recall that I occasionally take issue with Jay Nordlinger, a columnist at National Review who is particularly obnoxious—even for NR—in his smugness, and in his apparent belief that all social democrats are big fans of Fidel Castro. Nordlinger made an observation about multiculturalism the other day that is just too grotesque to ignore.

He writes, here: "There is a kind of 'multiculturalism' I like, and a kind that is poisonous, possibly fatal. May I tell you about a story I saw...? The headline read, 'Sikh soldiers guard Queen Elizabeth II," and I thought, "Uh-oh, watch out, Betty -- remember what happened to Mrs. Gandhi.' But then I read the article."

Here's what Nordlinger read:

Queen Elizabeth II has switched bearskin hats for turbans outside Buckingham Palace, where Sikh soldiers have begun guarding the monarch and her treasures, Britain's defense ministry said Friday.

Signaler Simranjit Singh and Lance Cpl. Sarvjit Singh are the first Sikhs to take part in patrols outside the queen's residence and to stand watch over the Crown jewels at the Tower of London across town.

Guard duties are usually carried out by the Guards of Household Division, famed for their bearskin hats and crimson coats that attract picture-taking tourists in their thousands. The ministry said the Sikh soldiers instead wore turbans and blue uniforms.

Sarvjit Singh, who was born in India and is a member of 3 Regiment Army Air Corps, said he was thrilled to have had the opportunity to guard the queen.

"My experience being a Sikh on the queen's guard is beyond words," said the 28-year-old. "It is a once in a lifetime opportunity. I feel privileged to have this honor."

"Being in London and parading in front of hundreds of people has been brilliant. Being Sikh hasn't made any difference," said Simranjit Singh, 26, from Coventry in central England, who is attached to the 21 Signal Regiment (Air Support).

Nordlinger comments, "You know what I mean? That is assimilation, that is ethnic flavoring, that is harmony -- that is civilization. Unlike . . . lots of other stuff."

I would like to think that Nordlinger is being intentionally provocative here. But, sadly, I don't think he is. I think he is genuinely incapable of seeing what is so wrong with this: The subversion of former colonials to the protection of the symbol of their conquerors, the Great White Mother; a subjugation of other cultural traditions that is so complete it is internalized, worn as a badge of honor. This is Nordlinger's conception of the "good" kind of multiculturalism? As I said, he probably didn't even notice.

I add that I would probably concur with Nordlinger on many "bad" types of multiculturalism. He gives the example of "the blind Briton who refused to budge from the bus, when a Muslim woman was screaming about his seeing-eye dog, complaining that such animals are unclean..." I agree that the Muslim woman's conception of propriety is something we don't need. I am not a cultural relativist, at least not in a broad sense; I believe that we should embrace and encourage those aspects of other cultures that are at least not in conflict with our own democratic values. The Islamic veil, for example, is not compatible with democracy, since it is not possible to be a full civic participant without showing one's face. It should not be encouraged. Any kind of restrictions on speech (including so-called "hate speech") are not compatible with our Anglo-American traditions of liberty, and should not be tolerated, no matter how offended anyone feels.

But for Nordlinger to so confuse colonial dominance—and its nod to, as he quaintly puts it, "ethnic flavoring"—with benign multiculturalism is quite astounding.