President Obama and Speaker Pelosi have said that they want a health care bill on the floor of the House by July.  A lot has been said and written about rising and out-of-control healthcare costs and the "47 million Americans without health insurance", and the time is probably right for us to finally address this issue.  After all, that we will have a federal healthcare program is not really up for debate - Republicans may rail against it, but Democrats want it and they have the votes.  So really the debate comes down to what it will look like, not whether or not we will have it.  With that as a background, this is the first of a series of articles on healthcare in America, what's right with it, what's wrong with it, and how we should (and should not) fix it. 

Republicans would do well to try to take part in this debate, rather than just holding news conferences and chanting their "Democrats want socialism, we want free enterprise" refrain.  By all accounts, Americans want this bill.  They don't necessarily know what "fixing health care" entails, but they do understand that it appears to be broken.  They know that more and more of their hard-earned dollars go to doctors, pharmacies, and hospitals, and they seem to have little to no control over the healthcare they receive or even the providers they can use. 

You will find no argument here that our present system is not broken - we believe that its flaws are many and deep.  But we fail to see how the current proposals to "fix" the system will in fact address any of its flaws.  Rather, we see that once again there are those who would paper over the real problems with billions or trillions of dollars wrested from the pockets of America's taxpayers, and that the American healthcare consumer, supposedly the beneficiary of all this, will actually be the biggest loser. 

Before we look at solutions to the problem, let's look at the present system and see if we can agree on whether it is in fact broken.  If we can't, then I haven't done my job and my suggestions for solutions don't really matter. 

Health Insurance Today

There are four ways to get health insurance in America today; 1) through your job at a public or private company, if you're fortunate enough to work at a company that provides it, 2) through your job at a government agency, whether local, county, state, or federal; 3) through the government, in the form of Medicare if you're old enough or Medicaid if you're poor enough, and 4) you can buy a private policy if you can afford it; most working Americans supporting a family simply can't. 

Let's look at these separately.

1. Insured through private employer

This is the traditional health insurance plan that most of us think of when we talk about health insurance.  It started in America in the 1930's, gained popularity in the 1940's as an employment tool to attract the wartime "Rosie the riveter" workers, and exploded in the 1950's.  Eventually nearly all large employers offered it.  Today approximately 60 percent of Americans are covered under these health insurance plans. 

What most American's don't realize though, is that this "private" insurance is government subsidized.  The money that employers spend on these policies is deductible, and reduces their income tax liability.  So depending on the corporation's profitability and tax status, up to 50 percent of the cost is actually paid by the American taxpayer.

2. Insured through government employment

Roughly 22 million civilians are employed by the various federal, state, and local government bodies in the United States, almost all with health insurance as an employer paid benefit.  Of course this is entirely paid for by the American taxpayer. 

3. Government programs

These programs are by definition paid for by the American taxpayer.

• Medicare is the medical entitlement program created in 1965 for Americans ages 65 and older, and those on Social Security Disability. It is paid for by currently working Americans through a dedicated payroll tax.
• Medicaid is a need-based medical insurance program administered by the states, and funded by a combination of federal and state taxes. It is generally available to people whose income is below the federal poverty level, and to children of people with incomes up to 2 or 3 times the poverty level, depending on their state of residence.
• Active Military and Veterans. We provide health insurance and services for active, retired, and disabled military members and their families. This is provided through military and VA doctors and hospitals, and through private (civilian) doctors and hospitals through the TRICARE insurance program. 

4. Uninsured

The "uninsured" in this country, 45.7 million in 2007, are the subject of most of the debate about health care in America.  However, this is a very diverse group and can't really be conveniently placed in a single basket.

• Many in this group simply don't want or need insurance, either because they have the financial resources to be self-insuring, or because they are healthy and don't want to spend their money on what they see as an unnecessary expense.
• Up to a fourth of this group, over 10 million people, are in this country illegally or are the minor children of illegals.
• Most of the remainder of this group are working, or out-of-work Americans who for one reason or another don't have access to group insurance.  If they're working they may work for a small company that doesn't provide insurance (most companies with under 50 employees don't), they may be working multiple part-time jobs, they may be temporary, contract, or independent workers who don't qualify for employer-sponsored insurance.  If they're out of work, their COBRA plan may have expired, or it may have been so expensive that they simply couldn't afford it. 

In any event, to tag these people as "uninsured" is a little misleading.  For one thing, despite what Michael Moore may say, by federal law anyone who walks or is brought into a hospital emergency room in the United States and is in need of critical care can not be turned away.  Insurance doesn't matter, nor does ability to pay.  The hospital must perform life-saving and stabilization measures, after which the patient must make some decisions about how and where to seek further care, and how to pay for the care received. 

On the other hand, if you don't have insurance and can't afford to pay the bill up front, you probably won't be able to walk into a doctor's office and receive services.  This means that for many Americans the first time they see a doctor is when they are really sick and there is an emergency.  Many illnesses that could be detected and treated before they become serious, aren't detected until they become life-threatening.

So unless you are one of the few Americans who can pay cash for your healthcare, or can afford to buy a private health insurance policy, the healthcare you receive is already subsidized, or paid entirely, by the federal government.  If you're a free-market Conservative or Libertarian, face up to the fact that you are violating your principles every time you go to the doctor or take a prescription drug.

As we look deeper into the state of health insurance in America, we see that many who are supposedly "covered" still have serious issues with respect to access to health care services.  Their options are limited, and they are frequently told that their insurer disagrees with their doctor and therefore won't pay for services or prescribed medications.  More on that in Part 2 in this series. 

Please send this on to everyone you know.  This is an issue that no American can afford to ignore.  This year Congress will enact, and the President will sign, legislation to dramatically change health care delivery in the America.  With all of its shortcomings, American health care is still the best in the world.  Let's not let them take it down to the Canadian and European "ideal".