Coming to Agreement
by Kate Kinkade

As of this writing, health insurance reform has yet to find its trajectory. The House and Senate Committee bills have enough in common to move forward, but it looks like partisan opposition will make that path difficult, to say the least. At the end of the day,  will our representatives declare that they don’t care whether some Americans have no access to healthcare due to their income level? I really don’t think so. In the current debate, however, that question doesn’t get asked.

While the topic continues to be publicly labeled “healthcare reform,” everything proposed and even discussed has to do with insurance reform. Perhaps that makes sense since insurance is the portal to healthcare today. If the goal is to expand access to healthcare, then expanding access to insurance (in some form) is a logical first step. The problem is that there is no agreement on a goal.
Politicians don’t object to a plan or promote a plan based on a clear, stated goal. Instead, they attack specifics while avoiding the real questions. It is obvious that the wrangling has as much or more to do with party politics than an interest in solving a problem. The Republicans are not arguing against the House bill based on the fact that they don’t want to extend access to coverage. They are arguing against it because (among other things) the bill could provide health insurance credits to undocumented workers.

We need to back up. If we can all agree on the goal of giving everyone access to healthcare through affordable health insurance, we can start a discussion of the inclusion or exclusion of undocumented workers.  In today’s environment, there is little doubt that the undocumented would end up being excluded, but meanwhile, there would be an agreement to extend coverage to all citizens and that’s a huge step.

For a moment, let’s pretend that our representatives care more about the welfare of the populace than they care about their next election. How would they go about resolving the health care insurance dilemma? If the goal is to find a real solution, the process for getting there is the same as it is for any challenging issue. The first step is to get an agreement on the goal.

In our fantasy, there might even be a vote on the goal before the bill writing starts. Are we agreed that a plan must provide affordable access to health insurance to all citizens? If so, what is affordable? The House bill defines affordable as a percentage of income for people living from 133% to 400% above the federal poverty level. This is a great start. Do you agree that health insurance should be available to everyone and, if so, at what cost?

At that vote, you would end up with the core argument; few would be willing to stand up and deny access to healthcare through insurance. The argument would be around costwhat should it cost the citizen? But there is a number in there that will get agreement. Again, few politicians will stand up and say that a worker who makes $15,000 annually should pay 35% of their income for health insurance. They may not be able to agree on 3%, but they will agree on some percent.

That will bring the conversation forward to step two. If we agree that people earning 300% of the federal poverty level (which includes a lot of Americans) who can’t pay more than 10% of their income for health insurance, then we agree that the cost of insurance should be no more than 10% of salary for those at 300% of the federal poverty level. And we agree that we, the people, are willing to subsidize the cost above that number. Those of us with health insurance are already providing a hefty subsidy. When the uninsured go to the emergency room, the hospital passes the cost of uncompensated care onto those with insurance.

Let’s say we agree that a single person earning about $32,000 (three times the federal poverty level) can pay about $3,200 for health insurance. If coverage were not available at that cost, it would be subsidized. 
Step two is that we need coverage to be available at $3,000 through some mechanism since we don’t want to subsidize the $30,000 worker at least I don’t! By the way, this  is probably less than the cost of individual insurance today. None of this is unreasonable. Few could stand up and object.

Next, we address individuals living at  or around the federal poverty level. We would need to agree on what percentage they would be able to contribute to their own coverage. In the House bill, a family of four living on $29,000 or less would pay $440 a year for health insurance with the remainder being subsidized. Before the discussion begins on how to subsidize the remainder (employer mandate, expand Medicaid, etc.) there would need to be agreement that this family should be insured and that this family can only afford to pay X for that coverage.

Once there is agreement on those points, we can move forward to address how to subsidize the remainder. There is an argument about whether coverage should be mandated in some form, which is a discussion point that needs agreement as well.

 Yes, eventually the decisions are hard and eventually the discussion will come to the actual cost of the care as opposed to the cost of insurance. But if the essential decisions are made first, figuring out how will be difficult, but it can be done. There are only so many solutions – all of which interfere with someone’s self interest. When that conflict occurs the argument goes back to the agreements: Do we agree that all Americans should have access to healthcare through affordable insurance? Yes or no? If yes, what is affordable?

Now we are talking about how to subsidize the rest and that’s really where the rubber hits the road.

People talk about backing up and starting this process again. That’s not a bad idea if we insist that politicians answer the core questions first, one at a time, until we get real solutions.
–––––––––
Editors note: To be clear, personally, I would include, in any plan, anyone, whether documented or not, who is working in this country at incredibly low wages providing services many of us take for granted. That, however, is not the popular view and this editorial is not about my opinion, but about working toward solutions.