On Universal Healthcare

Healthcare is in the political news in a way I didn’t expect. Of course we’ve all watched the GOP rants against the Affordable Care Act, and Congress’s repeated votes to repeal it. They are like this guy, and just as successful:

I was prepared for more of these antics, and we will probably see them. But what caught my attention this week was the debate between Hillary Clinton and Bernie Sanders: what is the correct path from what we have today to the longstanding Democratic Party goal of true universal healthcare? Sanders is going all-in with a model he calls Medicare for all. Clinton is being more pragmatic and risk-averse and wants to “build on” the Affordable Care Act rather than “replace it” with a different program. Sanders cites gaps and inefficiencies of the current model; Clinton cites the divisiveness of the last healthcare debate and the risk of Republican attacks. Sanders and Clinton both make valid points.

I have decided which approach will get my support, and maybe I will write about that another time. But for now, can we just cut through some of the mythology that surrounds the terms used in this debate? Can we be clear about what the goal is?

In my view, healthcare means health services. It means affordable and local access to the medical professionals and facilities that my family and I need to live healthy, productive, and long lives. Health insurance is protection against financial ruin. It puts a cap on the costs that a family might pay for health services, whether that’s regular doctor visits or more extreme or costly treatments in the event of an accident or severe illness.

Fine, a health insurance policy might include some health services, like regular checkups for children, just like some auto insurance policies include free windshield repair or roadside assistance. But the existence of policies that deliver such benefits leaves us far short of truly ensuring that all Americans have access to affordable health services.

When progressives talk about universal healthcare, they need to ask themselves whether they really mean universal protection against financial ruin. If they do, they are much more likely to accept a step-wise, patch-work, and unfair model of coverage. As long as we reduce or eliminate medical bankruptcies, we’re good! Right? We just need to “cover” more and more people, no matter how we do it.

And fundamentally that’s the problem with the discussion of this issue: everyone has a different definition of what it means to be “covered” and has had a different experience with the way “coverage” and “services” are delivered. People with employer-provided insurance, and especially those with high-end plans that ask for only small personal contributions, have no idea what it’s like for a person buying his own coverage, or coverage for his family. People with high-end employer-provided plans have no idea what questions an insurance consumer needs to ask himself when he is shopping for a new policy:

  • Can we afford a premium of $785 for my family of 3? Sure, no problem.
  • That plan has an annual family deductible of $7,500. Seems like a big number.
  • We’re pretty young and healthy, will we really go to the doctor so much that we would have to spend that $7,500 before the insurance kicks in? No, doesn’t seem like it. (Then what are we getting for our $785/month?)
  • But if something terrible happened, like a car accident or a severe illness, could we come up with $7,500 (every single year until we’re healed)? Or could we afford that number if we have a baby? Yes, I guess so. [Contemplates draining savings accounts and dipping into retirement funds.]

These questions are like the life-and-death versions of “is my car nice enough to carry collision insurance?” My guess is that most Americans have never had to go through this process, and if they did they would feel as uncomfortable and as exposed as my family did when we bought our own insurance policy for a short time in 2014. (And by the way, there is an equivalent fear framework for those Americans with employer-provided plans: what if I lose my job?)

Universal healthcare needs to be better than this. It needs to be easier, more affordable, and… more universal! When we envision a population-wide healthcare program, we should not have Americans asking themselves these questions, making decisions about health and quality of life based on affordability and the likelihood of an accident or illness or job loss. Universal means the same high standard for everyone. The question is how we get there, and when, and whether it’s possible to achieve that universal standard in a system of for-profit insurance and pharmaceutical companies.

Disclosure: I am originally Canadian and I grew up with universal healthcare. I moved to the United States in 1990 and I became a United States citizen in 2010. Despite now living in the United States for longer than I ever lived in Canada, framing the healthcare debate in terms of bankruptcy-prevention and for-profit insurance companies just feels… foreign.

The Place for Military Strength

Allow me to summarize the ISIL discussion we will hear from all of the remaining debates in the race for the Republican Presidential nomination: troops here, troops there, ships here, ships there, bomb this, bomb that, military funding big, bigger, biggest,…. The candidates will position this discussion as a strategic one, as one about American strength, and debate moderators will let them get away with it. Hours will be wasted on muscle-flexing, on stern looks, and on one-liners about that weakling at 1600 Pennsylvania Avenue.

We voters should not fall into that trap.

What is strength? Even if you agree with the content of the discussion, to debate military funding, targets, and troop and equipment placements is to discuss tactics and operational details. It’s not a strategic discussion, not the kind of discussion that presidential candidates should really be engaged in, not the kind of leadership that we select presidents to deliver, and not the kind of leadership that really makes America “strong”.

Presidents should decide what priorities to pursue and where to allocate resources across ALL of the functions that make America respected and exceptional in the world: diplomacy, justice, treasure, commerce, natural resources, infrastructure, science, health care, social programs, the arts, and YES THE MILITARY. The combination of those functions makes America great, the envy of the world, and a magnet for immigration. To flex one’s military muscles, and no others, is to scavenge for the largest club and then declare dominance. The world is more complex than that, and America’s exceptionalism flows from more than that one source.

The GOP candidates will say that President Obama lacks a strategy on ISIL. They will say that Americans should fear a Democratic president because Democrats are “weak on defense”, or “soft on ISIL”. Not true, if we’re talking strategy. President Obama and ALL of the presidential candidates from both parties have declared that ISIL is a strategic threat that needs to be addressed. The only difference across the candidates is how they choose to respond to that threat, the operational details, and I would argue that the vast majority of voters are not in a position to decide which of those approaches will be effective.

Seriously, try to imagine a twenty-something voter in Omaha or Grand Rapids or Salt Lake City making an informed choice across questions like whether Bashar al-Assad is a necessary evil, or how we should engage with Russia, or the number of troops that should be on the ground in Syria. Candidates who frame the election predominantly in these terms are looking for opportunities to talk tough and sound presidential with all the usual phraseology: boots on the ground, red lines, no-fly-zones, threats to the homeland. One of my favorite tweeters David Roberts put one such phrase in its place this week:

The next president, from either party, will take action against ISIL. You could make the details of his or her approach the basis of your vote for the Presidency. Or you could ask yourself what America really stands for, what makes us multi-dimensionally strong, and whether pursuit of ISIL as a number one priority really delivers the durable day-to-day world leadership that America is so fortunate to enjoy.

I argue that ISIL is a threat but not an existential one and not one that deserves a dominant place in our discourse or our allocation of resources. I argue that defeat of ISIL is (1) important but not the most important priority for the country; and (2) going to come from more than just a display of military might.

To be clear: I believe in a strong military. I’m proud of America’s fighting force and I’m humbled by the sacrifices that troops and their families make on my behalf. In fact if my daughter (now nearly 4 years old) grew up and wanted to join the military I would not only support her I would encourage her act of selflessness.

I just don’t think a military-first discussion is very helpful in choosing our next president. In fact I think that one-dimensional, sub-strategic focus fools some of us into thinking “strength” when really it should signal “weakness”.


We the Oppressors

There are two kinds of people in this country: people who see government as THEY, and people who see government as WE.

The former, the THEY-ers, like to use terms like the government(!) and tyranny and they see state and federal institutions, and their leaders, as nefarious and oppressive and untrustworthy. THEY-ers see themselves almost as unwilling subjects ruled by a separate entity that needs constant reminders of how useless and unfair it is.

The latter, the WE-ers, use terms like governance and reform. They see government as a set of institutions and processes that we citizens own, staff, and fund. WE-ers may not like every aspect of how government works, or every leader in it, but they understand the system is something that multiple generations of “we” created and that it’s ours to either accept or fix through debate and political processes.

Count me among those who believe government = WE. For one thing, I just find that outlook to be more pleasant and optimistic and in line with my tendency to act rather than complain. We have this thing, needs some work. Can we fix it? Sure we can! What can I do?  And, government = WE is the approach you will find most common and effective in the real world. Employees of big companies, for example, don’t last very long if they think and act like powerless ruled subjects under an autocratic empire.

Disgruntled rancher Ammon Bundy presents himself as a THEY-er. He and his gun-toting buddies made a miscalculation in their decision to turn a peaceful protest into an armed occupation. They will not get what they want, they already look like fools, and they may also end up dead or in prison.

But let’s use this THEY-er of the week to make two larger points:

Point 1: the character difference between a THEY-er and a WE-er is accountability, one’s ability to look at a problem and ask, “what could I have done differently, or what can I do now, to improve the situation?” A THEY-er will point at an institution and say “that needs to go” or “that’s out to get us”. A WE-er will point at himself and his neighbors and say, “this system that we all own isn’t working well for any of us, we can do better here, and here is what I propose…”. (There are legitimate reasons why the federal government owns so much land in the West. If Bundy and his crew were WE-ers, they’d propose changes to the system and drive those changes politically and legislatively so that the outcome is fair for all citizens and not just the ranching crowd. True, huddling around fires at a vacant bird sanctuary looks better on TV.)

Point 2: the Second Amendment, which provides Mr. Bundy’s ability to carry a gun, was itself a creation of WE-ers for a population of WE-ers. It was a mechanism for a young country to self-defend against insurrections, not a mechanism for a population to fight and overthrow its own government. The historically accurate narrative has been stolen by THEY-ers and reworked into fear-based variants of the government is coming to get your guns, and the result is that nothing gets done to properly regulate the firearms in this country (something most of the WE crowd are actually demanding).

In this political season, we should all be wary of candidates with THEY-er tendencies. (Looking at you, nearly every candidate for the Republican nomination, but especially Carly Fiorina and Ted Cruz.) Low-accountability people should be in low-responsibility jobs. They can do real damage in leadership roles (or simply fail to show up). And by the way, what is it about these people that makes them simultaneously hate the government and also want to lead it? That mentality can’t be good for any of us.