Be careful what you wish for

The big development this week in the health care debate is that it looks like the senate will move ahead with a public option, i.e, a plan via which the federal government will offer medicaid or medicare like insurance to anyone willing to pay the premiums. Presumably, these premiums will be priced well below premiums of private insurers, since the government doesn't need to worry about running a profit or deficit spending. If a private insurance company ran a deficit of a trillion bucks, it would be shut down. If the government chooses to run such a deficit, there doesn't seem to be any realistic opposition to this. Both political parties are dominated by people willing to spend without raising revenue. Republicans didn't say a word about deficit spending as they voted to fund two wars. To hear them now profess concern for deficits feels a bit disingenuous. They seem stuck on the notion that tax cuts are the key to balancing the budget. Since Ronald Reagan first championed this idea, we've had three decades of deficits. Even the "surpluses" of the Clinton years were actually deficits, since we were only ahead if the social security "trust funds" were counted as revenues (which they are, obviously, but the theory is they are to be saved, not spent as quickly as they come in, which is what actually happens).

But, I'm getting sidetracked onto a deficit rant, when I really want to discuss health care. For a long time, the public option has run very high in the polls. It's been a very strange paradox in this health care debate: Polls show rather thin support for government reform of health care, but usually show very strong support, well over sixty percent, of a public option. Why? I think the answer is fairly obvious: most people who support a public option do so because it's a vaguely defined term that they are free to pour any meaning they wish into. It would be very interesting to see a poll that asked people what they believed their monthly premium would be under a public option. My suspicion is, most people equate a public option with "free." Again, I have no polling data to actually back this up. I just sense from talking to supporters that they imagine that the public option will work like health care in Canada or the UK. You'll just go to whatever doctor you want, get whatever services you need, and won't pay a dime for it (or maybe a small co-pay).

But what if the public option comes with a premium of $100 a month, per person in your family? Would support still be as high? This is certainly cheaper than almost any private insurance. Still, my gut instinct is that a lot of people who support a public option would change to opposing it if they found they would actually have to pay for it. And, I could be way wrong as to what a public option would cost. Maybe it would be set at a flat ten percent of income. Maybe five percent. Maybe you'll pay $9.99 once a year, and it comes with a free pony! Right now, there's no way of knowing. The bills creating a public option don't talk about actual premium costs; these will be figured out down the road. But, if people are willing to support it thinking it will be free, then I guess I'm free to oppose it thinking it's going to come with a non-trivial price tag.

The price tag is going to be important because the bills are also going to include a second element: a personal mandate to purchase health insurance. Right now, this is turning out to be a toothless mandate. Early versions of the bills were discussing sizable fines for people who didn't buy health insurance. Now, the fines have been reduced and loopholes are being added for millions of people who won't get fined at all. But, of course, these people will also be uninsured. The personal mandate is the only cost saving measure currently being proposed. Currently, a significant chunk of people who don't have health insurance are young, healthy people. If we force these people into the insurance pool, presumably that will help control costs, since you'll have a large population of people who are paying premiums but not using much in the way of services. Very few twenty-five-year-olds have heart attacks or cancer. (Obviously, yes, some do, but compared to people who are sixty-five who develop these problems, the numbers are tiny.)

But, I look back on my own life, and wonder about the different choices I might have made if I'd had a mandate to buy health insurance. I used to work for a company that I just hated. I really wanted to quit my job and make a living writing. This was about fifteen years ago; I was only thirty. I scrimped and saved for a few years in my late twenties to get debt free and build up a little buffer of savings. Then, I quit. I made it almost year without taking another job, even though my writing income that year turned out to be nothing. But, I had carefully designed my life to cost as little as possible. My car was paid for, I was renting a space not much larger than a shoe box, and I ate a steady diet of Sam's Club frozen chicken breasts, which were something like 30 cents a pound back then. I still look back fondly on that time. But, if I'd been forced to spend a few hundred buck a month on health insurance, I don't think I could have made it as long as I did. It's true, if I'd developed cancer or been in a car wreck during these months, I would have wound up saddled with far worse bills than the insurance would have cost. But, I knew this; I had the freedom to choose to take that gamble. I still have that freedom; I just think that, at 45 (and thirty pounds heavier), my odds have changed.

To me, it feels fundamentally unfair to impose a personal mandate to buy health insurance. Some people argue that it's no different than the personal mandate to have car insurance. But, if I wanted to skip car insurance, I could just not own a car. I don't have any realistic option to not have a body.

I also have to admit, I'm thinking about this from the perspective of a man who doesn't have children. If I had kids, I think that a mandate requiring that I insure them would be perfectly sensible, no different than a mandate that I make sure they get an education.

Still, right now, I'm nervous about both the public option and a personal mandate. This doesn't mean that I don't want to see health insurance reform. I'd love to see a "catastrophic option" at least discussed, where people are responsible for their own health care for most services, but the government would step to pay for medical bills that fall beyond a certain lifetime limit: Say, $200,000. In other words, the government wouldn't pay a dime for me to have my appendix removed or to mend my broken leg, but they would step in for a long term, chronic cancer or heart disease. I'd also love the very common sense reform of making privately purchased health insurance tax deductible, the way it is when businesses purchase it. And, of course, I'd love to see the government doing more to facilitate medical research. One way to reduce the breathtaking cost of cancer would be to cure it.

Since I opened this post complaining about deficit spending, I feel like a hypocrite to end it calling for more government spending. So, let me propose some ways to pay for them. First, there have been trial balloons from the Obama administration about taxing soft drinks. There seems to be very little support for this, but you can count me among the enthusiastic proponents of this. No one needs a Coke or a Pepsi. And few people bat an eye at paying $1 for a two liter in a grocery store, but paying $2 for a glass of soda in a restaurant. We could raise billions by charging a quarter a quart. If you want to avoid the tax, don't drink soda. It seems to me no more onerous than a tax on cigarettes or booze. I'd also be fine with taxes on most fat foods and snack items. A potato chip tax, maybe. And, finally, obesity is a real risk factor for all sorts of disease. I say this as someone who is, no big surprise, obese. So, though it goes against every libertarian instinct I may have, why not have a fat tax? Every year on tax day, you go get weighed. For every pound you are overweight, you pay a dollar. This offsets some of the additional cost and risk that carrying around an extra fifty pounds adds to society, but isn't going to bankrupt anyone. There may be one or two circus freaks who see their tax approach a thousand bucks, but most people would be paying under $100. And, maybe the thought of saving ten bucks a year would be the push some people would need to lose ten pounds. I'm not proposing this as a punishment for obese people, just as a way of some reflecting that, long term, all of society pays for me weighing more, so why not chip in a little now to offset the costs of my eventual health care expenses?

Of course, I should be careful what I wish for. Five years from now, when I'm shelling out $5 for a coke, I'll be the one grumbling loudest. But, people who are supporting the health care reform bills now before the house and senate should be careful too. Our current health care system is, no question, a real frying pan. I just worry that any government intervention is going to be a fire.