If you want to listen to it in podcast form but don't want to listen to my preamble (details about North Korea, Iran, and myself - hmm, great company?), the article actually starts around the 11 minute mark. Stay for the outtakes, too. :) They're hilariously inappropriate.
I am starting a blog post on healthcare somewhat reluctantly. The last 24 hours were completely insane for a number of reasons but because of all of those reasons I don’t think I can coherently put it all into a blog post or podcast. To explain why, let’s go over the synopsis of what happened.
A large section of the county isn’t pleased with current healthcare legislation (don’t know if you heard about that). The Affordable Care Act (or ACA), somewhat antagonistically called Obamacare, is a large piece of legislation that has broad effects on nearly every American. Given the current state of political discourse, delivering anything resembling contrary points of view is akin to punching someone’s grandmother. As a result, the Democrats frequently overstated how good the ACA would be and the Republicans matched that with stories of complete and total doom. Now, full disclosure, I have a side in this. However, I’m realistic about the side I take. So with that in mind, my next few paragraphs will sit slightly closer to the left margin.
Except the indentations – which lean to the right a bit.
First, we have to talk about the healthcare system itself. It’s complicated, but not as complicated as you might think. An analogy is best served to provide some groundwork. I’ll keep dollar amounts low so as to avoid any confusion. Obviously this will be over-simplified, but I will make an effort to explain that when I apply the analogy to the actual healthcare system. I will also be re-visiting this same analogy to explain some of the critical moments related to the ACA and how they were talked about in public. Though I will also admit that I’ve come to the healthcare-understanding game a bit late and so my facts will need to be checked (which I am doing to the best of my ability as I write this).
So picture yourself in a village. There are 100 people in this village and they each make different amounts of money (shut up, money simplifies this enormously). Some small amount of these villagers have noticeably bad health problems they cannot afford to fix. You, in the middle of the pack when it comes to money (that puts you in the middle class), occasionally see these people suffering but for the most part you only hear about it when the “town crier” gives you the news. Now the town crier charges people to listen to him and you think his work is important so when you see him and have some change, you give it to him and he gives you the news. No big deal, it lines his pockets so he can keep people informed and you’re willing to give up a little to let him do that. You pay your tax to keep everyone safe, the roads paved, and the lights on (it’s a super-modern village, shut up).
Occasionally he gives you a piece of information so interesting that you hang around for every last detail. “And then what?! Well did she get the operation?!” “How many goals did Ronaldo score?!” Et cetera. It is through this system that your normally simple life is occasionally interrupted with a story of someone’s plight. They’re sick or they’re dying and because they don’t make much money they will die.
Let’s pretend for a second that everyone in the village actually understands market economics and knows that there will always be poor people – people that make significantly less than those that make a lot. After all, for someone to make a lot of money they have to give something and get more in return. That means someone is getting that something and giving up a lot. This is the free market. Let’s avoid going into what that minimum amount the poor should make (see: “universal base income” if you’re interested).
A few of the people in the middle pool a little bit of their cash – maybe give less to the town crier this time around – and the person gets helped. Everyone feels good, the town crier gets to tell people about it and makes a little extra because the story was so good now everyone wants to hear his news. All is well, everyone makes out better. Even though you gave up some money (maybe some food, too?), you feel good about the difference you make.
Next month five people come forward and you realize there’s no way people can pool enough money together to pay to keep all five people healthy. This is where the moral dilemma comes in. You can only pool enough money to save two people. Do you do it? How do you pick which ones to save? What do you tell the three you did not choose? What if there were triplets? It’s getting awfully hard to justify this “pool money together” scheme. So you go visit the bigger huts and ask the bigger earners. There are only 10 of them, but all 10 make more than the remaining 90 villagers combined. All it takes is one kind soul! And you get it! All five people are saved! The town crier gets a little extra from the kind (rich) soul to tell the story and lavish a few harmless details about how dire the consequences were and how important the kind soul was to the community.
Next month 1 poor person is sick, 2 average-wealth people are quite sick, and 1 rich villager is deathly ill. We won’t go into the gymnastics here but it quickly becomes obvious that pooling money together as more and more people get sick is riskier and riskier. Especially since the village got that nice new Pepsi machine put in the village break room and now everyone is getting a bit fat and unhealthy. So one month you have 2 sick villagers and you can hack it and the next month something bad goes around and it’s 20. People start dying or having terrible deformities because there just isn’t enough money to get everyone healthy. This is a dilemma.
One of the rich villagers has an idea. It’s a good business idea for him but then you expect that, that’s how he got rich. He says everyone pays into a pool. We use the pool to treat the sick people and if there’s extra money in the pool at the end of the month we just keep rolling it over to the next month just in case more get sick. At first, this seems like a good idea. Everyone agrees to pay in equally and anyone who doesn’t pay in doesn’t get access to the system. This does mean that the poor (the only ones who cannot afford it) will have to adjust their lifestyle so they are less likely to be sick or injured. This idea strikes you as somewhat uneasy but somewhat fair. I mean, we can’t save everyone and saving some people is better than saving no people, right?
This scheme is working wonders and the pool of money is growing as people are generally healthier as a result of all this cash sitting in the pot. You can see a doctor whenever you want and it costs very little to you personally! It’s great! Last month your friend Tammy was working in the field and caught her leg in a ditch and broke it. The money covered her miraculous new miracle surgery and she was back in the field today. Modern medicine is cool! What’s better, more healthy people means they all work more, make more money, spend more money, and build things to improve the village themselves. No tax increase! Super!
Then next month there is a bad outbreak. A lot of people get very, very sick. The rich benefactor running the scheme announces there isn’t enough money in the pool to pay for everyone but no matter! He will cover the difference! What a kind soul! In return, over the next few months everyone will pay just a little bit more to cover his losses. He won’t make a dime extra on the deal, he promises. In order to ensure everything is on the up-and-up, he says two people will be paid to count the money every night completely blind to each other (as in, each night the people are chosen at random and nobody knows which two). This makes it so no one person has total access to the money and everyone gets to keep eyes on it. There’s no chance for anyone to steal anything because it would be incredibly easy to catch them. But these people are being paid to do this so everyone has to pitch in just a bit more each month to pay for this administrative cost.
You start to see this add up but it’s not so devastating that it matters. You don’t mind making a little bit less each month if it means everyone is doing okay. This system is wonderful still!
The village is doing well! The poor are starting to make more money, more of them are able to afford the pool and so they begin to pay in and get cared for. The rich kind soul has been paid back in full and because more people are joining the pool, you are paying less money! This is terrific! To boot, the things you used to worry about costing so much cost a lot less. Sure, there are still devastating illnesses that come in and you deal with the deaths that come from them as a community. The pool helps keep these poor souls in relative comfort until they die, of whatever age.
Suddenly, those diseases start affecting more people of all income levels. At first, the pool can cover everyone. Then, the pool becomes less and less able to keep up and we can all see the inevitable happening – if we got at the current rate, the pool is going to empty. The rich kind soul sees this and is willing to step in for a short time but eventually we’ll have to do something. So he does – and so you pitch in more money, too. You’re fast approaching a point where you cannot give anymore. The cost to stay in the pool is so expensive again! Something must be done!
The village chief holds a meeting and announces his plan. Since we harvested a shit-ton of apples last month and installed that super-awesome laser fruit-grabber-thing, we have something to trade with another village every month! Apples this month, wheat next month, lab-grown meat the next (shut up, we’re agrarian Pepsi drinkers in a village). The extra money from the sales can go towards the pool and now more people can get help to stay healthy! The rich kind soul is happy because he doesn’t have to risk any more of his money and you’re happy because not only does everyone get to stay healthy, but it costs you less money! Super dandy!
Not all is ice cream and merry-go-rounds, though. Some villagers are not on your monthly pool scheme because they don’t want to be. They become insanely ill and then show up and ask to be a part of your pool. The administrators counting the money aren’t quite sure what to do as this person hasn’t put any money in but will almost immediately bankrupt the pool! “But, I’m allowed to use it if I pay in! I should be able to be taken care of!” The village chief decrees that this person cannot, as they have a “pre-existing condition.” This sets off an uproar in the village. What does that even mean? And what is considered pre-existing or not?! For now, the definition is fairly strict and is designed to keep incredibly sick people from suddenly joining and gaming the system. In this instance, you can see this person is clearly trying to take advantage of something they have invested nothing into. You’ve put hundreds of pesos (yeah, you thought we were using dollars! Dirty ethnocentrist…) into this! They’ve put none! Blasphemy! Get out of here!
Here’s where it get’s complicated.
The village chief set up an emergency service because all of these new-fangled devices (like a miniature golf course!) tend to catch fire or stab people on accident. Those who have been unfairly burned or stabbed certainly have a right to be taken care of – even if they don’t have money in the pool! So they’re stitched up and covered with Super Burn Fixer Upper and are left with a bill to pay. Super Burn Fixer Upper is amazing stuff but it costs a lot to make. The makers of Super Burn Fixer Upper are expecting some pesos from the doctor who prescribed it who is expecting pesos from the person who was hurt who is… no expected to have any pesos. It’s not their fault they were burned by a defective ring of fire on Hole 7. Well Hole 7 has a bad month and burns 5 people and stabs 1 (the ring of fire snapped and became a projectile! Burning stabbings!). Three of these unfortunate golfists are uninsured. The makers of Super Burn Fixer Upper need money or they’ll go out of business. The hospice needs money to buy more stuff for Super Stab Hole Closer. The poor person lacks money. The village chief comes to the rescue again but says we’re running low on extra stuff to trade to the next village. Rather than make everyone directly cover the costs of the medical treatment for the poor people, he says he’ll give a little bit more of the extra trade money as long as everyone pays a little more in tax.
The tax is where things get weird because nobody likes it, right? But put it this way, he can match every dollar you give in tax money (instead of health pool money) with extra money from trading apples and hybrid pear-bologna sandwiches. This means you have to give a lot less money in the end. Sure! Take my money but take less of it! Poor people without insurance whose fault it isn’t should be taken care of!
Guess what happens next month? The guys selling hybrid pear-bologna sandwiches are tired of giving away so much of their extra harvest to people who aren’t doing any of the work. They want to keep more of the profits. More poor people are injured out on the miniature golf course (they fixed Hole 7, but now Hole 13 keeps falling into the ocean for like, no reason). The village chief says there’s no more money to give and so the rich kind soul that started everything says everyone has to pay more to keep the whole system in balance so the Super Burn Fixer Upper people can make the stuff that the doctors need to treat the people who are paying. Poor people give up on the pool altogether and decide life sucks anyway and seem to get themselves in more trouble (now that they are pretty much screwed for the misfortune of being born poor. Should have been a slower sperm, I always say!).
The village chief has an idea.
His name is Aboma. Eh hem.
Now is not a good time, but I’m going to explain why the etymology of the guy Aboma killed, “Osama” bin Laden couldn’t actually be correct. You see, in Arabic, there is no “oh” sound. They wouldn’t say “Oh-SAHM-Uh BIN Lah-Din.” The first letter is an “oo” sound. So it would be “Usama bin Laden.” But then the world’s most notorious terrorist has a named whose first three letters are “USA” and that’s just unacceptable. Moving on.
The village chief says the only way to stabilize all of this MacGubbins is to make sure everyone pays into the pool and is therefore covered whenever something bad happens. He realizes not everyone can afford to pay into the pool and so proposes that the rich villagers pay a little bit more in taxes (for a while) and some of the extra pesos we have lying around from all of those badass Wrist-Mounted Highlighter Pens will pay for the poor people’s share. Further, all of those people who were kicked out earlier for having “pre-existing conditions” are more than welcome to get in on this cuz it’s gonna be lit.
Straight away the rich kind soul and the makers of Uber Stab Hole Remediator (new IPO, great product, fantastic management) freak the holy f(bleep!)k out. So all of these pre-existers (let’s call’em Pee-ers) have to pay some pesos into the pool to cover their costs but the makers and doctors and administrators have no clue how much to charge them. I mean, it seems fair that they should have to pay more because they’re going to be using more of the system, right? But it can’t be SO MUCH more that they can’t use the system at all. What do we charge them!? If it’s too much, they stop paying and lose their coverage, if it’s too little then the makers of Ultra Disease Response (meh) will go bankrupt and no one will get their great, but poorly-branded product.
Enter this Obama Aboma character again.
At this point in the story it’s probably important to interlude that this Obama guy wasn’t sitting around tossing a ball at the wall thinking of all the ways to make people healthy and happy and full of pesos. He was watching this thing and going to village chief conferences (TEDx Village Chiefs) where they talked about cool shit their villages tried. He actually met one of his own village’s retired Cool Law People there who showed him a parchment with a plan he proposed to an old village chief named Lick Swilly, who was trying to get everyone on a single-payer system. Nothing got passed and and Lick Swilly got in trouble for dipping his pen in village ink. But that parchment made its way back to the village…
Where was I? Oh, what to charge people that totally smelt like disease! Too much or too little?! What do we do, man!? Obama has an answer for that, too! He says if they charge too much, then the extra money they get from that disease-smelly person will go into a separate pool. The peeps that charge too little (give us ten pesos a month and you’re covered – oh shit, it cost 2000 pesos to fix your face!) would be paid out of that pool. Now he knew that this pool was gonna go uuuuuuup and doooooown all the time and who knew if you needed to pay the pool or the person?! So the rich kind soul said we can make up the difference if everyone pays more into the pool. Now wait a minute…
You look at all of this and you realize (you’re super thoughtful in all of this, I’d just like to say. You’re doin’ great) that if a whole lot of sickly, disease-ridden poor people suddenly need help and there’s not enough pool money, you’re going to have to pay more. And what happens if the number of sick people and insane Pee-ers just continues?! You’re going to have to pay a ton and it’s never-ending!
Okay, back to Obama (I’m not even trying to maintain an analogy at this point). He says that inevitably, yes, you will be forced to pay more cash-ola, especially up front. In fact, the first few years are going to suck major field rat teet. In further fact, it will suck so much that a lot of people – good intentioned, hard-working, heart of gold people in the middle – are going to give up on the pool altogether and maybe start pooling their own money together in small groups to cover just the people they like. Obama says “don’t do that! I’ll set up a separate pool designed to cover the difference of all the variables for the first few years and that pool will be paid for with taxes not paid by the cool people in the middle that I like. And Ken.” And this pool basically covers it so that your pool payments (let’s call them… hmm.. can’t think of a word. I guess I’ll go with “premiums”) stay the same or go up very slowly over time so that you can better prepare for the future or, hopefully, your village sells more of those insane boxer-briefs with the hole in the back for pooping! Then you make more cash and it’s like the premiums didn’t even change!
Are you with me? Breathe. We’ve come a long way. What I just described above is the essence of ObamaCare or the ACA.
Here’s what you need to know about everything above. The system you are currently in – the healthcare system the United States currently engages in – does not have any of the supercool pool protections I spoke of. That separate pool that’s supposed to stabilize your premium? The Republicans, very much not liking what this plan did for some of the people they represent, did away with that pool. To be honest, that’s all they needed to do to get you – the awesome person in the middle – to feel the pressure of the system. Your premiums went up and you hated this Obama guy and his lack of cool peso-driven ideas.
Now I give you that entire analogy above because I happen to belief that a lot of people watched this Obama guy and looked at the village pocketbook (made by Mead – great notebooks and binders). They looked back at the Obama guy and back to the pocketbook. After admiring the very nice cover design and quality of the binding, they looked back at the Obama guy and said “wait a minute. This uh… you carried a zero here and that’s… no. You can’t divide by 0. Or is that pi? Why would you divide by pi?! We need to talk.”
To break from that analogy briefly, I often liken government policy to one of my favorite scenes (or sequences) from Apollo 13. If you’ve seen the film, you know that the missions goes horribly wrong and the astronauts are forced to shut down the capsule in order to conserve power and oxygen. Meanwhile, back on Earth (I’ve always wanted to say that), two guys are working on a way to turn everything back on without shorting out the battery. They have a “budget” of volts they have to stick to and so have to not only work out which systems they can reliably turn on, but what order and what things they can leave turned off (things like heated seats and the DVD player). At one point the astronaut says to the nerdy math dude “I need all of these systems!” to which the bespectacled geek says “We do NOT have the POWER, KEN!” The second appearance of Ken in this is merely coincidence.
Republicans are the nerdy math dude and the Democrats are Ken. The Democrats are trying to talk about what things we as a government and society need to fund and foster for growth. The Republicans are the ones that say “absolutely not, we don’t have the money for that.” Ideologically, this is somewhat untrue as the Republicans believe we shouldn’t use the government for any money like that but the Democrats believe we should use all of the money for things like it. You might say those are the two polarizing ends of the political spectrum – total libertarianism and total communism – but in these trying times those polarizing ends and extremes have become the rhetoric they have used almost exclusively. The Republicans say we can’t afford programs like Inner City Arts and the Democrats say they’re racists. The Democrats say we need to provide a social safety net for the poor and Republicans say they are “bleeding heart liberals.” Both are completely wrong and disingenuous for lumping an entire swath of the country (consisting of a shitload of people) into a hive-minded group. Any of us that have actually been to a meeting with people we like know that even people we see eye-to-eye with on almost everything can get into arguments that destroy friendships. MLK said “there can be no disappointment where there is no deep love.” That was the quote from the last podcast. We are complicated. All of us.
So back to the analogy? Only briefly. The “pool” that Obama created that was destroyed by the Republicans severed the one link people had to a stabile medical future and renewed confidence in the ACA. Now they will argue that their hand was forced because the Democrats “rammed” the ACA through. I have genuine ideological differences with that description due to the extensive amount of hearings and amendments to the ACA despite the Democrats enjoying a majority in congress and having a President in the executive branch. The Republicans continued to play the rhetoric game and told us that not only was the ACA a disaster, but it was a disaster that was forced on us without proper procedure and adherence to customs. All of that political momentum was what crashed upon Capitol Hill on July 27, 2017. Even though they were trying to distance themselves from it (find one senator saying anything positive directly about the “skinny repeal” bill they were trying to pass – none of them even verbally said “aye” in the chamber), they still tried to pass it because that’s what they thought they were supposed to do. They still might, by the way.
What we need is to acknowledge that at one point in the analogy, when they were looking at that stunning Mead, Inc. village pocketbook cover, they were absolutely right to say that the numbers don’t add up and down the road the pool is going to disappear unless people start paying more money or the economy grows considerably. Gotta sell more of these convenient-for-pooping boxers. If we don’t, then the system gets ugly and people will pay out insane amounts. The proposal, the skinny repeal, was not skinny and would have exacerbated the problems. Kicking 16 million people off of the healthcare books is not just callous (something the Democrats were none-too-slow to point out), it’s fiscally irresponsible. With so much uncertainty, the insurance companies would begin to charge more to insulate themselves against a total dropout of their income stream (cash flow) and your premiums would be absolutely insane (the Congressional Budget Office – an independent reviewer of all House and Senate bills – estimated they’d go up by 20% each year).
I have learned more about health insurance in the United States in the last month than I have probably learned about any other topic in my life (not including Lord of the Rings – the Silmarillion really was a treasure trove of life-changing and inspiring stories of how to get your hand bit off while stealing jewelry). It was so frigging worth it because as many people pointed out and as many of the villagers in our analogy began to notice – the ACA was less about health and more about financial stability for the economy. It is effectively a budget that protects against sending people into loan debt so great they can’t actually engage in the economy and buy things. In that way, it is an enormously important piece of legislation.
So important, it simply cannot be subject to the whims of partisan asshattery. The ACA as it currently stands will not send us to total doom but will also not launch us into a world of endless pleasure and popsicles. So it needs to be updated but if the public is not informed of the inner workings of this enormously important issue, then our votes will only cause the problem to become worse.
And we really can’t afford for it to become any worse. There are much bigger monsters lurking around the outskirts of our village.
Like Hole 7.