Friday, March 10, 2017

Let's talk about health care

I'm old enough to remember 10 years ago, when health care was about insurance, and insurance was so valuable it was often reason enough on its own to take a job.

I'm an expat enough that I've been out of the country for most of the time the Affordable Care Act has been in effect.

I'm cynical enough to understand that "access to health care" is basically meaningless when it is shorthand for, "if you can afford it, you can buy it."

A lot of people smarter than I have written on this topic, so I'll keep this short.

Health care is not a luxury (like, say, a new iPhone) America as a country has strong incentives to have a healthy population--there is close correlation between health and economic productivity. All Americans benefit.

So given that, how do we make sure Americans are healthy? For most of my life, the answer was to have a government program that paid for health care for the very poor (Medicaid) and the old (Medicare), and everyone in between was left to fend for themselves. This was fine as long as you could either a) afford to pay your medical bills on your own, b) could afford insurance on your own or c) had a job that offered insurance.

The reality was that the simple expense of medical care and insurance was too much for many, and so millions of Americans went without either. This is an absurd thing to type considering the U.S. has the largest economy in the world by a huge margin, but there we were.

The Affordable Care Act tried to address that by (in simple terms) making health insurance mandatory and creating a system in which it was affordable. The mechanisms for both are of course incredibly complex. The results were pretty easy to see, with the number of uninsured Americans dropping dramatically.

The current plan to replace the ACA, for no real reason other than partisan spite, uproots a lot of what made the ACA work. It promises "access to health care," and its chief proponent, Paul Ryan, said the problem before was that healthy people subsidize sick people, which is both literally true and spectacularly dumb, considering people whose houses don't burn down subsidize firefighters to help those whose houses do.

Anyway. This brings me to Hong Kong, where I live now. Life expectancy and health in general are good in Hong Kong despite occasionally awful pollution. A large part of that is the public health system, which is staffed by well-trained doctors and is free. There is a private health care system too, as well as an insurance market.

First of all, it's important to note that even though the U.S. economy dwarfs that of Hong Kong, the 'Kong has extra money around because it does not fund a military. The current public medical system is largely a legacy of British colonial times but it is funded by current taxes, and Hong Kong, which is terrible at budgeting efficiently, always has money left over anyway.

The public system is effective. What it's not is friendly. You will feel like a number, you often will wait a long time for non-emergency care and you will not feel particularly comforted by your surroundings. You will also pay nothing, or very little, for your care. (Delivering a child and spending a few days in the hospital costs, all-in, about US$30.)

The private system is effective too--and friendlier, although bedside manner isn't really a thing in Hong Kong. What it's not, is cheap... let alone free. Getting a dose of oral vaccine for your kid at a no-frills clinic will run you about US$250 plus a consultation fee.

In my experience, doctors in the United States are more engaged with their patients and think more critically about their cases. A system that gives all Americans access to their expertise would benefit everyone.

You can see where I'm going with this. A system like Hong Kong's that allows private medical businesses to offer services while also guaranteeing free medical care to anyone who needs it--not just the poor or old--would be a huge positive for America. This is not a full-throated endorsement of medical care in Hong Kong, which can be frustrating and demeaning and even ineffective, but of the system that gives everyone access to a doctor.

Replacing the ACA because it was "the other guy's" idea is dumb and harmful. Improving it so every American gets health care, not just access to it is not.

In my experience, the latter can be done. It's a shame the Congressional majority is too focused on negative partisanship to realize that, or even try.