Wednesday, July 03, 2013

Healthcare V: What now?

In my meanderingly roundabout way, I have finally come to the place where I can delve (tiptoe?) into actual applications of moral theology on the current healthcare situation in the United States. There has been a systematic method to my madness because I felt I needed to give a little historical background as well as a basic primer on applicable church teachings on economics. As healthcare, for better or worse, is inextricably linked to the almighty dollar in this country, I felt I needed that background before I launched headlong into critiques of Healthcare reform.

In my last post, I finally explained the need for both subsidiarity (i.e. the lowest level of governance that can adequately deal with the problem is the best option) and solidarity (i.e. Christian charity that has a preferential option for the poor) as pillars of a just economic society. The two have to be balanced, lest an economic policy or economy become either completely centralized or dictatorial, which does not respect individual rights and due process, or it becomes too out of touch with the common man, which often leads to being a system that is oppressive of the poor.  These ideas, I believe, are crucial in evaluating the current system of healthcare and any subsequent reforms thereof.

First, for purposes of this blog entry, let’s look at the current system of healthcare to try and gauge whether, given these parameters, how close this system is to being a just system. Some in this country prior to the Healthcare Reform Act thought the system was fundamentally just. Others thought it was fundamentally unjust. I think many were somewhere in between, believing the American system needed some reform, but not so unjust that we needed to completely scrap the current system and install something completely new and radically different from scratch.

 There are many ways an analysis of this could be done at this point. I tend to be a person who likes to consider as much background information as possible before jumping headlong into trying to fix a current issue. I suppose I like to look before I leap, which I think is what hamstrung the healthcare reform act because Americans have the collective patience of toddlers who have not had their naps: we want a magical fix and we want it right now. As such, I am going to choose to look at various other healthcare systems in other countries and then delve into an analysis of our current healthcare system.

I bring this up because I have really been thinking about this for a few months now, predating my current occupation. When I was in Israel back in late February, our tour guide, Ezra, made an interesting offhand comment as we were driving around in the tour bus. Someone had asked about the price of housing, and Ezra launched off into a discussion of prices in Israel. Housing prices are much higher in Israel, as whole extended families tend to live in one complex. As the family grows, a new room is added onto the building because no one can largely afford a private residence unless they are extremely wealthy. As he was explaining this, we happened to pass by a hospital in Jerusalem and as a comparison in pricing, Ezra told us that though housing prices were extremely high, healthcare was extremely low. Ezra said he probably paid a premium of about 65 to 100 dollars for he and his wife for the entire year. I queried Ezra privately at our next stop about this, and he said the 100 dollars was technically closer to a tax that goes into the national health insurance fund, not a premium, but “Americans don’t like taxes, so I said ‘premium’ to avoid an argument.”

When I got home, I researched the Israeli  system in more detail. Technically, Israel’s system is socialized, though it is not a pure socialized medicine scheme. Before the British mandate, Palestine largely had no healthcare system of any kind. There were a few charity hospitals left over from the Middle Ages, but largely public health was abysmal. To combat outbreaks of Malaria and Smallpox, the British instituted a healthcare system in league with some of the local labor unions. A Charity Fund was created to fund the system, and only members of the 4 major labor unions could get membership in what would now be recognized as a proto-HMO (Health Maintenance Organization).

After Israeli became a nation in 1948, the system evolved in 1973 to model more of an American style employer-based system where all employers were forced to pay taxes into the Health Maintenance Fund to fund the Israeli healthcare system.  

The following I wrote in the Wikipedia article on Healthcare in Israel, so I suppose is copyrighted but I wrote after researching this in Israel:  In 1995 the National Health Insurance Law came into effect in Israel, which made membership in one of the four existing Health Maintenance Organizations compulsory for all Israeli citizens. The law determined a uniform benefits package for all citizens – with a mandatory list of medical services and treatments which each of the Health Maintenance Organizations is required to fund for its members. Additionally, certain services were brought under the direct administration of the State, usually by means of the Health Ministry. In addition, the law set out a system of public funding for health care services by means of a progressive health tax, administered by Bituah Leumi, or the National Insurance Institute, Israel's social security organization, which transfers funding to the Health Maintenance Organizations according to a certain formula based on the number of members in each fund, the age distribution of members, and a number of other indices. The Health Maintenance Organizations also receive direct financing from the states money.

Also, from Wikipedia (via me): There are also private health insurance plans which citizens may participate in in addition to the compulsory participation one of four national health insurance institutes. They provide coverage for additional options for treatments. For example, in the area of elective surgery, a participant in a private insurance plan may choose the surgeon, anesthetist, and hospital anywhere in Israel or around the world. In the area of transplants, unlimited funding is available to ensure a donor is found and the procedure is done without the need for government approval. In the area of medications for serious illnesses, while the "basket of medications" which are funded by the national HMOs is large and updated regularly, private insurance companies give access to a wider range, as the Israeli government is not financially capable of covering all or even a major group of medications. All major Israeli insurance companies provide a health insurance plan. In comparison with health insurance in other countries, private health insurance in Israel is considered comparatively cheap, but premiums are based on age, gender, and previous medical history.
So, as I said, Israel has a weird system that is partially socialized, but is not a complete governmental monopoly like the NHS in England. Likewise, there are options for private, supplemental insurance for things that the government and the National Health Maintenance (which is similar in some ways to American Medicare but for all citizens regardless of age) fund do not cover, or for people who choose to opt out of the system (they still have to pay the tax, but are free to find other insurance policies if they want to pay for them). In other words, if you want more, you can pay for it, but everyone is entitled to basic medical benefits through the tax system. Even within the National Health Maintenance fund, there are still four competing plans that citizens can choose from.  

Is this a just system? I would say that it is, if you are an Israeli citizen. Israeli medicine is some of the best in the world; it is affordable, gives choice both within the governmental program and the option of additional supplemental insurance for those who can afford it. Most of all, the poor have equal access to it. Because the four Health Maintenance Funds are privately governed, there is not the level of autocratic governmental bureaucracy that allows for subsidiarity.  

If you are a Palestinian who is not an Israeli citizen, perhaps the system is not just. Many Palestinians go to Israeli hospitals, and if they have a referral from the Palestinian Authority, the expenses are reimbursed from the Israeli government. If they do not, they are largely stuck with Palestinian hospitals which are mediocre at best.  

Would such a system work in a large country like the United States? Possibly, though I have trouble believing a Federal Empire would not completely centralize and become dictatorial in such a system. Perhaps a system on the state level would be a better option if the US would adopt this model. I am also somewhat concerned that the thuggish nature of some labor unions in the US would also contribute to corruption, as the Israeli system is largely from union roots. But, those are just my political opinions coming through there.

I present this information as a way looking beyond the capitalist/socialist model that is largely presented as an either/or model for healthcare reform in this country. 

One can have a hybrid system that is neither one nor the other. 

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