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The latest Republican strategy – cutting off your nose to spite your face.

No, this is not about plastic surgery.

The phrase refers to one who attempts to do harm to another, but in so doing harms themselves

Yep, we are talking about health reform.

The Affordable Care Act as Republican policy

President Obama has rebutted criticism that his health care reform was too radical by arguing that it is modeled after successful legislation that became law in Massachusetts under then Republican Governor, Mitt Romney – and that was based on ideas originally proposed by the Heritage Foundation.

From the perspective of the ivory tower of the Heritage Foundation, or from the myopic world of Republican health care policy, there may actually be some arguable distinction.

But from the perspective of real health care reform, say single payer, it is a distinction without a difference.

The only thing that separates Obama’s Affordable Care Act from Mitt Romney’s Massachusetts imitative is the political affiliation of its author.

As soon as Obama and the Democrats signed on, Romney signed off.

The Affordable Care Act as Democratic policy

But Romney wasn’t the only one to turn and run from an idea they once embraced.

Tim Pawlenty, a Republican contender for president briefly, thought Mitt Romney was on to something in 2006, the year of the Massachusetts healthcare reform law.

He expressed openness to the concept of the individual mandate and support for the idea that everyone should be in a health care plan.

Likewise John Huntsman was an eager proponent of health reform measures that would expand coverage.  He openly supported the individual mandate until it was obviously going nowhere in Utah.  He settled for a more modest version of the insurance exchange concept that distinguished Romney’s legislation.  Utah and Massachusetts are the only working models for the other states trying to implement health care exchanges.

The pickle

Three of the current field of Republican candidates endorsed in some way, the concepts central to what is now derisively referred to as Obamacare – individual responsibility, make the markets work better, allow for profit insurance companies.  Don’t they sound like concepts that are more likely to come from the Republican side of the aisle?

But they have the name of the current President associated with them and for that reason, Republicans will not allow them to succeed.  It’s personal, you see.

State Exchanges

Take the state health insurance exchanges.  Another idea that is more likely to be associated with Republicans than Democrats – allow each state flexibility in setting up their own exchanges.  But if they don’t create their own exchanges, the federal government will do it for them.

This seems to put some Republican governors in a rather curious pickle.  If they do create an exchange for their own state, they would be adopting values traditionally associated with Republicans:  individual responsibility, the growth of a new market for insurance companies, local autonomy.  The alternative is generally not attractive to Republicans – let the federal government do it.

But there is a catch.  It is a catch that some Republican governors just cannot bring themselves to overcome.  By consenting to the creation of their own exchange they would be acquiescing to the will of President Obama.

It’s personal, you see.

Kansas Governor, Sam Brownback (R) turned down federal seed money to start its exchange.  He piously asserts that, given pressure on the federal government to reduce expenditures, states should not rely on the feds in setting up their own exchanges.  But the absence of federal funds has halted Kansas’ progress to create its own exchange, which may prompt a federal takeover.

Oklahoma Governor, Mary Fallin (R), turned down federal money to help it build its own exchange.  Sounds noble enough.  They want to do it themselves.  Or do they?  According to the Governor, she was “pleased to announce this agreement that accomplishes my goal from the very beginning: Stopping the implementation of the President’s federal health care exchange in Oklahoma.”

Florida Governor Rick Scott (R), has declined federal funds to set up an exchange in Florida, an exchange the state has yet to authorize.  Remember Rick Scott? – the guy who made his money as the head of a for profit hospital chain that pleaded guilty to defrauding the federal government and paid almost $2 billion dollars in settlements.

Texas Governor, Rick Perry, (R), presiding over the state with one of the highest rates on uninsured residents,  has vowed to oppose any effort to create an exchange in Texas as long as the legal questions around the Affordable Care Act are unresolved.  That does not mean he cannot accept the grant money handed out by the feds to create the non-existent exchange, not to mention $60 million in Early Retiree Reinsurance program grants – also a part of the Affordable Care Act.

Louisiana Governor Bobby Jindal (R), has also refused to set health care insurance exchange in his state because it would advance Obamacare regulations.

It’s personal, you see.

It doesn’t have to be rational.

Photo Credit:     FLICKR  Sara_Mc

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Paul D. Ryan (R-WI)

Boy do I have a plan to fix Medicare.  Well, actually, it’s not my plan.  This guy, Paul Ryan, thought it up.  He’s some kind of chairman in Washington.

Medicare is the program that pays for health care for old people.  Also disabled people, but mostly old people.  It seems it is going broke.

That’s what this guy Paul Ryan says.  His logic is a bit hard to follow but it goes something like this.

Too many old people

There are too many old people.  The government spends too much on their health care.  The government isn’t smart enough to fix it, so it should turn the money over to those old people.

Of course, the old people can’t do it by themselves, so they have to buy insurance from insurance companies.

Since the insurance companies have lots of money and the government doesn’t this makes perfect sense.

But here is where it gets confusing.  The insurance companies have lots of money because they don’t pay for health care and the government doesn’t have money because it does pay for health care.  So won’t this situation just reverse itself in a few years?

Old people aren’t too keen on this idea.  They think the insurance companies will continue to not pay for health care.  I’m not sure I get that. If the insurance companies have all this money, why wouldn’t they spend it on health care.  What else are they going to spend it on?  Themselves?   That’s stupid.

But hey, this is where this guy Ryan shows his smarts.  I mean the guy is no dummy.  You see his plan won’t take effect until 2022.  That means it won’t effect anyone older than 55.   I think he figures they aren’t paying attention.

Time to save

And here is the beauty of his plan.  They will have 10 years to save the extra $182,000 the plan will likely cost them in retirement.  Of course, they need to be paying attention to that part; otherwise they may forget to save that much.

Extra is the key word here.  Everyone knows it is going to cost them between $330,000 and $390,000 to pay for health care in retirement under the current plan.  Presumably, these under-55 year olds have that much stashed away already.  So they will just need to save about an extra $15,000 per year until they reach 65.  How difficult can that be?

But wait!  If it looks like you aren’t going to make it, you could try going out on social security disability before 2020.  Then maybe you can get into Medicare under the old rules.

Some people just don’t get it.  It’s all about Medicare.  It’s not about people.  Some people have this silly idea that government is supposed to be here for people in need.  Remember what John Kennedy said, “Ask not what your government can do for you.  Ask what you can do for your government.”

Well our government needs us to stop asking it to do things for us.  That way it will be able to do things for people who are not in need – the rich.

This is an idea whose time has come.  Its beauty is in its simplicity.  Those who need, pay; and those who don’t, get tax cuts.

The Republicans may be backing away form this Ryan fellow, because they think people are against the idea.  But they’re just kidding.  Elect them and find out.

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In a recent discussion someone posed the question, “Is health care a right or a privilege?”

This should be the wrong question!  In part, because those opposed to health care, tend to be opposed to any expansion of “rights.”  It should be the wrong question, because people should feel embarrassed to assert that health care is a privilege.

Rally in Vermont

The right question is, “Is health care a private good or a public good?”

It is the right question because proponents of expanding health care have already won it, even if those on the other side don’t know it yet.

Health care is a public good

If health care is not a public good, why do we have a Surgeon General and the U.S. Public Health Service?

Why do we have a Center for Disease Control?

Why do we have the National Institute of Health?

Why do we have the Agency for Health Care Research and Quality?

More importantly, why do we have Medicare?

Why do we have Medicaid?

Why do we have the Indian Health Service?

Why do we have the Veteran’s Administration?

Why does Congress pass laws like the Women’s Health and Cancer Rights Act, or the Mental Health Parity Laws?

All of these government agencies point to one inescapable conclusion – the citizens of this country have consistently supported what they thought were expansions of health care.  They have consistently stood on the side of the principle that says – keeping you healthy is in my interest.  Keeping everyone healthy is in my interest.

As one wag put it, we recognize the state’s role in educating the public, but frankly if I were sitting next to you, it is far bigger concern to me whether you are healthy than whether you are smart.

Health care is not a right

The right to health care grows out of the recognition that it is a public good.

The bible does not ask the sick to stand up and demand to be cared for.  No, it says “care for the sick”. “As you did it to one of the least of these my brothers, you did it to me.”

The first hospitals in this country were established not because the sick insisted on being treated, or because they demanded health care as a right.  They were established by communities that felt a responsibility to care for those who needed it.  Health care was perceived as an obligation, not a business model.

The public good in the private sector

The concept of “public good” extends to the private sphere.  Does anyone really think that when employers endorse wellness programs in the workplace, they are doing so to respect some “right” to a healthy life style?   No, instead, they recognize that the individual welfare of its employees serves the welfare of a larger group of people; in a sense a broader “public” good. It serves the corporate bottom line by lowering health claim costs, decreasing injuries, decreasing absenteeism and presenteeism. Yes, in this example, it is not quite “public” as an economist might understand it.  But it is definitely no longer a “private good” whereby an individual’s actions have no impact beyond his or her own life.

For the same reasons, corporations endorse disease management programs that attempt to engage employees much more proactively in the management of their own chronic conditions.  Some employers will go so far as to make participation in such programs mandatory.  Isn’t this also a recognition that health care is not a private good?  Just because it occurs within the sphere of the employment relationship does not make it less a “public” good.

Employers recognize that they need healthy workers, but keeping the workforce healthy means taking care of them when they can’t work.  And that, by definition, cannot occur within the employment relationship.  Health care is a public good.

Health care is not a right!  It is an obligation.  We have a collective obligation to make health care available to others and we also have an obligation to take care of ourselves.

The health care as a right or privilege debate taps into the same common theme – the focus on me.  Who is more important – you or me?  If we are going to break the conservative ideological hold on debate in this country we need to change the way the debate is framed.  The focus should be on we, not me.

Nothing scares conservatives more than the idea that all Americans would share something in common.  A national health care system could unify Americans in ways that truly frighten them.

But let’s face it.  “Health care is a right” does sell.  Just ask the people in Vermont.

Photo credit:   Health Care is a Human Right Campaign

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The phrase “Arizona shootings” will forever be associated with Congresswoman Gabrielle Giffords (D-AZ) and with young Jared Loughner, and with even younger Christina Taylor Green.

The gunfight at OK Corral is history.

“Cousin-in-law” and author of the Nelson Report, Chris Nelson, described the incident as the “deadly intersection of three horrible moral and political dilemmas which are a genuine cancer in this country”.  Chris is not the only one to cite the contributing causes:

1. The issue of access to effective treatment for mental disorders
2. The lack of willpower to enact meaningful and rational gun control laws.
3. The rising vitriol of US politics.

I will leave gun control to others and instead, focus on the intersection of the first and last.

Vitriol as culprit

Is the rising vitriol of US politics to blame?  I come down firmly in the camp of those who say yes?

Is civility the answer?   Maybe.  But so may agreement on access to effective treatment for mental disorders.  I don’t say that to impugn the mental state of those on the right for whom I would normally spare no vitriol.  But stick with me.

There are those for whom a black man in the office of President of the United States is their nightmare come true.  It is an even more haunting image than Black Panthers with guns.  It is Putney Swope in the White House.

But this is not 1960.  This is 2011.  Political correctness may be disparaged and ridiculed, but it has sway.  One treads lightly when being racist if one wants to garner the attention of the mainstream media.

So they attack the President’s key legislative initiative – health care.

Competing visions of America

But this is also a lot more than racism. Racism is just one stream feeding this river.  It is about two competing views of America, two competing views of freedom, two competing views of government and society.

I may take a broader view than Paul Krugman who is also exploring this idea.

One view of America sees it as a nation of individuals, where freedom of the individual is paramount, especially freedom of the corporate individual.  Government is perceived as an impediment to that freedom.

The competing view of America sees America as a community coming together to support each other.  Economic freedom is defined in terms of freedom from want and need, and access to equal opportunity.  Government is seen as an ally in that process, a power that can balance the accretion of power to private interests.

One camp falls back on the image of the supportive village community.  The other would borrow from Lucy in Peanuts to insist, “We love America, it’s Americans we can’t stand.”

Has America lost its way?

These are not new divisions; they underlay the very foundations of the United States Constitution.  I would argue that there are several things that distinguish the current environment.

First, I would argue that American capitalism has lost its sense of direction.  For roughly 150 years it was driven by scientific and engineering discovery.  By discovering and harnessing the laws of nature they were able to increase the abundance and support the needs of society.  America was the land that was the first to accept new ideas from Darwinism to Freudianism to Relativity.

I see that loss sense of direction in the Republican Party.

It was the Republican Party that saw the disconnect between slave labor and a free labor market.  As Marlon Brando said in the movie Burn, “Why own a slave, when you can rent one?”  Breaking down old barriers and old ideas was the key to modernizing the United States economy.

I am admittedly on thin ice here, but I think there is a connection between today’s resistance to ideas like global warming and even evolution to American capitalism’s lost sense of direction.  I toss that out for other minds to ruminate.   If Democrats want to gain the upper hand they should clarify a new enduring vision of the American economy.

Second, these fundamental differences used to be found within both parties. Southern Democrats had more in common with conservative Republicans and likewise northern Democrats allied themselves with progressive Republicans.   Bipartisanship was essential.

Today, these differences have been sifted into their respective parties.  Has this made notions of bi-partisanship obsolete?  After all, many modern democracies seem to succeed by allowing different parties to take turns governing.

Health care as the link

Third, health care is a fundamental challenge to these competing views of America.  It is such a fundamental challenge that conservatives dare not face the consequences of their own arguments.  The conservative view would argue that health care should only be available to those who can afford it.  It is obvious through decades of public policy decisions agreed to by both parties, that not all Americans can afford health care.  To argue otherwise is to also argue that doctors and hospitals should deny health care to those without money or insurance.  Have we sunk that low?

Can these views be reconciled through civil discourse? Perhaps not in the short run.  But our Civil War should be an example, first, of the death toll cost of hard line positions, and second, the long term seeds of discontent sown by “reconciliation” by military conquest.

Next week the Republicans will make their move to repeal health care. The Republicans will not be proposing that our fragmented and broken health care system be replaced with a more rational single payer model.

If the current legislation is flawed, it is because it is the best that could be agreed to in a political climate that allows a minority opposed to health care reform to impede progress.

Next week – uncivil content

Next week the Republicans will make their move to repeal the very legislation that might have given Jared Loughner access to some mental health benefits. Unfortunately for the six dead and 13 wounded, not soon enough.

They will be arguing that it is better to turn lose the Jared Loughners of the world rather than to extend them a helping hand by allowing them to gain health benefits through their parent’s plan.

They are not proposing a better idea; they are proposing nothing.

The idea that all Americans should have equal and continuous lifetime access to affordable high quality health care does not fit with their view of America.

They may moderate their tone.  They cannot and will not moderate the content.  And it is the content of their argument that is fundamentally uncivil.

Photo Credit: JL McGee

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The National Public Radio news program “All Things Considered” declared 2010 – The Year of Mean.

NPR, not a media outlet to go too far out on a limb, couched their declaration in a bit of tongue in cheek satire.

But even NPR couldn’t shy away from the question underlying the truth of their observation.

Brute

What kind of country are we becoming?

I toyed with a number of labels for this “mean” movement.  Evil-doers was already taken.  Tyrants or oppressors?  No, not yet.  Pigwidgeons had some appeal despite its association with Harry Potter.  A pigwidgeon is described as a stupid and contemptible elf.  But pigwidgeons are not normally nasty, just stupid; so pigwidgeon may work for a certain ex-half-governor but not for the broader movement.

Meanie is too wimpy.  The word caitiff has some appeal.  Webster describes it as a “base and despicable person, a mean and wicked man”.  To add to the word’s appeal, it also describes a certain kind of vampire.  But this blog is not likely to catapult the word “caitiff” into the popular lexicon.  So I continued my search.

Ruffians didn’t seem inclusive enough.  It may describe some of the gun-toting extremists in the movement, but not John Boehner.

So I settled on brutes.  I am open to other words, but for now, it’s brutes.

Brutes

2010 saw the brutes attack a variety of issues and concerns of working Americans, but my focus is health care.

Their cause gained some momentum in the first month of 2010 when the Democrats lost the seat held by the long time champion of universal health care, Ted Kennedy.  Scott Brown (R-MA), with support from the brutes, ambushed the Democrats by upending their  feckless candidate, Martha Coakley.

It is a sad commentary on American politics when a Senate majority of 59% is not considered a safe margin to pass anything.

Are we becoming a country of minority rule instead of majority rule?

The Brutes and health care reform

Health care reform ultimately did pass in 2010.  It was indeed an historic achievement.

It was not a great bill, but it does make an effort to expand access to care, contain costs and improve health care quality.  Given its poor foundation (the current health care and insurance industries), it should be no surprise that the result is less than ideal.

It was an important milestone in American politics.

One of the groups that stands to benefit significantly is young Americans.  Employers are now required to permit young adults to stay on their employer-sponsored plans to age 26.  Together with other significant reforms, the bill supporters claim that it will cut the number of uninsured in America by half.

The Brutes and working Americans

Almost all of these people are on the fringes of the working middle class.  They may work for an employer, sometimes several employers, but none of them offer health insurance.  They may be sick and trying to get back to work.  They may be young and trying to enter the work force.  They may be entrepreneurs who are not only drawing on their bank accounts to start new businesses, but also banking that their health will sustain them until their businesses can.

The brutes don’t like these Americans.  They prefer tax breaks for the rich.

Are we becoming a country that is turning its back on the people whose backs build this country?

The Affordable Care Act has a number of initiatives designed to make the market for health insurance more transparent and therefore more accessible.

The brutes don’t like government regulation.  Therefore they want to repeal the Affordable Care Act.

Are we becoming a nation that places ideology ahead of practical solutions?  Isn’t that what toppled the Soviet Union?

The future of America?

As a result of the 2010 Congressional elections the brutes will now be able to parade their disdain for working Americans and their bias for the rich and powerful on a more prominent stage.  I don’t expect 2011 to be less mean.

I can only hope that the true nature of the brutes will become exposed for all to see.

Maybe then we can cast the meanness and the brutes aside and move America forward.

Photo credit:   Lonnie Dunkin III

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Imagine that an employer can hire professional talent for a day, a week or for years and not have to consider health care as a fixed cost.

Imagine that same professional talent is without work, whether through illness or simply lack of work, and yet does not have to worry about paying for health insurance.

Sound like a health reformers ideal.  Provide employers the flexibility to hire talent as needed.  Provide health care for workers even when they have no income.

This model exists now

This is the model of the multi-employer health & welfare plan.

Multi-employer plans are common in those unionized industries with seasonal or irregular employment: transportation, needle trades, construction trades, and theater trades, for example.  They are governed by a board with equal numbers of employers and union representatives.  Employers pay a negotiated rate per hour worked into the Fund and the Fund provides benefits through periods of employment and transitional unemployment.  Some funds are fiscally sound enough to provide benefits through retirement.

But this is not a competitive model.  Not when your competitors provide few, if any health benefits.  The unions with benefit funds are more sensitive to the cost of health care than many of the industrial and public sector unions.  They negotiate a total wage package and see more clearly the trade-off between wages and benefits.

During the last decades they have seen medical inflation eat into their real income.  It is no wonder that Unions for Single Payer includes many unions more who traditionally have not been at the leading edge of past union struggles for health care reform.

The multi-employer fund as model

As employers increasingly abandon employer sponsored health plans in their never-ending race to the bottom, the multi-employer plan stands as a model for all of America.

Employers pay for health care only while workers are working.  They pay enough to cover workers when they are not working.  As a national model, employers would pay a percentage of all compensation, including part time wages, compensation to free lancers, bonuses, commissions and any other form of compensation.

Workers would give up a portion of their wages only while they are working.

Employers would gain unprecedented flexibility in hiring.  Decisions about part time work, part year work, job sharing, work hardening, phased retirement would not be encumbered with the fixed cost of health care.  Because workers would have equal access to health care; employers not offering health insurance now would have access to a larger labor pool.

Workers would be free to choose job opportunities or a career path or even an entrepreneurial enterprise without regard to an employer’s health plan offering.

How does this multi-employer model match up to the single payer model?   Pretty well.  They both would enjoy a near monopsony – a single buyer purchasing from a multiplicity of sellers.  Governance would be different.  The multi-employer plans would be regional private funds with local employer-employee governance.

Government would still play a significant regulatory role.  Several large regional plans would create a national system that encourages delivery system reforms and payment system reforms tailored to the unique requirements of the local economy.

It’s a model that has worked well for some Americans in the past and can be a model for all Americans in the future.

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Retired Steelworkers and single payer advocates rest after a long day rallying and lobbying for health care on June 25, 2009.

The Senate and House are preparing to reconcile two modestly different approaches to health care reform.  Charges and counter charges continue to swirl around like New Year’s Eve confetti.  Are we on the verge of an historic breakthrough on health care reform?

What lessons have we learned about ourselves and our government?  Let me suggest six.

1.            America matters more to some than Americans.

The target of health care reform is Americans who are in the margins of our workforce.  They earn too much money to qualify for health care programs for the poor – state Medicaid and Children’s Health Insurance Programs (CHIP).  They work for small businesses who cannot or do not provide health insurance coverage.

As a society we have already agreed to provide health care to the poor, the old and those who work full time for profitable companies.  Why is it so difficult to fill the remaining cracks in the system?

Yet opponents of reform frame their arguments as a classic American struggle against big government.  The stories of very real Americans facing death by neglect or medical bankruptcy don’t seem to resonate as much as the conjured images of America challenged by fictional tyrannical death panels and giant government databases.

2.            I got mine – go get your own.

Very few people with health insurance pay anywhere close to the full cost of health insurance.  Less than 10% of adults under 65 obtain their health insurance in the individual market where they have to pay the full price.  73% of those who tried to buy individual insurance gave up either because it was not available to them or it was too expensive, according to a study by the Commonwealth Fund.  For the rest of us, our employer pays the majority share, or the government for those on Medicare and those on Medicaid.

Yet extending the same helping hand to those who may need health insurance to continue to participate in the workforce is tantamount to terrorism or tyranny, according to certain news commentators.  That may be an extreme view, but the noise it generates is dead weight that drags the center of political discourse away from constructive and meaningful reform.

3.            Money talks

Despite the clamor from the right, polls consistently show strong support for health care reform and even for the “controversial” public option.  Recently, I described how opinion pools show strong support for a single payer system.

So why are Democratic politicians having such a hard time getting “on board” with health care reform.  Countless stories have documented the amount of money the health care industry has spent on lobbying members of Congress.  One is reminded of my home town’s favorite son, Simon Cameron, Lincoln’s first Secretary of War, who once said, “An honest politician is one who when bought, stays bought.”  Only when some politicians began to realize that actual voters are behind those poll numbers did the public option begin to show renewed life.

Sadly, the Senate result reinforces the impression that money talks.

4.            Symbols matter

There is not a whole lot of evidence that the public option by itself will make a meaningful dent in the number of uninsured or in medical cost inflation.  But it is a powerful symbol reflecting one’s viewpoint about who should be the intermediary between the patient and the health care system – a government or quasi-governmental organization, or a private health insurance company.  There is clearly little appetite or political will to take on the insurance companies directly with the kind of strong and consistent regulation found in other countries.  The best that Democrats can offer is the threat of weak-kneed competition.

5.            Why do simple when complex is so – complex?

There is much ado about the nearly 2,000 pages of the health care bill.  When Congress tries to fix 1/6 of the American economy, it can’t be easy.  An analogy can be made to taking your tired old clunker to the repair shop.  It is too expensive.  It can’t haul nearly as many people as it was supposed to.  But you love it to death.  Your favorite repairman could hand you a ten-page estimate and tell you it will still be expensive and still won’t carry the all the passengers you would like.  Or he could hand you a one-page invoice for a new car.  HR 676, the “Medicare for All” legislation and beloved of single payer advocates, is 27 pages long.

6.            Who does Congress love most?  Not you and me.

Do you doubt the devotion of Congress to the insurance industry?  If so, the provision in both the House and Senate proposals to require an 85% medical loss ratio should say it all.  The law requires that at least 85% of premium income be used to pay for medical claims of covered participants.  Even the most conservative estimates put Medicare’s loss ration in excess of 90%, some argue in excess of 95%.  If the government can spend premium income more efficiently why let the private insurers in?

What next?

It’s no longer a safe bet that health insurance legislation will succeed (It does not deserve to be called health care legislation).  It is criticized from the right and from the left.

As feeble as it is, it will be a significant achievement given the long record of historical (and hysterical) opposition. Calling it reform will be the challenge of the spin-doctors.  Already there are estimates that it will leave a significant number of people still uninsured.  It doesn’t do enough to manage costs.  And there will undoubtedly be a backlash for a variety of reasons, some of them legitimate.  The question will be, how soon before Congress will have to revisit this issue?

Photo by JL McGee

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Premiums absolutely should be based on income and absolutely should not be based on age.  I say that not just because I am in the 60+ age bracket and you likely are not.  I say that because of my 25+ years in employee benefits.  However, I do agree that there should be a penalty for delayed enrollment similar to what Medicare Part B imposes.

When you come right down to it, the whole health care debate boils down to two issues.  How do you expand health care coverage and how do you pay for health care.

Expanding coverage is important because it spreads the risk among the sick and the healthy equally.

Make it straightforward and uncomplicated

But when it comes to paying for health care we are locked into a conversation that is driven by the cost of health insurance for an individual or a family.  Consequently, in efforts to get money where it is needed we come up with goofy schemes like taxing “Cadillac” plans.

Instead we should think collectively.  How do we transfer money from those who have more of it to those who have less of it?  This is a principle we have already agreed to with Medicare and Medicaid and some employers charge their employees on a percentage of income basis – some even on a sliding scale.

The simplest, most straightforward, uncomplicated approach is to pay based on ability to pay.

My idea is that employers be charged a flat percentage of total compensation for health care.  Total compensation needs to include all forms of compensation and should include payments for contract labor (sometime referred to as free lancers or consultants).  These payments would be reduced by payments made for employer sponsored health care.

Focus on the main issue

The immediate consequence of this approach is twofold.  High wage earning industries would subsidize the health care costs of low wage earning industries.  Employers not providing health insurance would be paying a “fair share” for health care costs.

Several numbers could guide the actual premium rate.  Health care consumes about 18% of GNP.  According to the Employee Benefits Research Institute, employers in 2008 paid 7.9% of total compensation for health care costs.  Employees paid between 65% and 75% of health care costs.  That puts actual health care costs somewhere around 12% of total compensation.  By my calculation, that puts the employee share at around 3% of total compensation.  (I would appreciate any comment on the calculation of these numbers.)

So 6% is low as a percentage of total compensation, but high as a percentage of employee share.

If we want to lower those percentages, then we need to lower that first number – health care costs as a percentage of GNP.

To the extent that older workers tend to earn more than younger workers, there is an inherent age bias to this approach.    But not all old people earn more money nor are they always sicker.  Certainly, I am not sicker (knock on wood).

If the goal is to transfer money from those who have more of it to those who have less of it, then don’t confuse that goal with other objectives such as punishing only those over a certain income threshold or punishing the recipients of “rich” benefit plans.

This plan does not address the complications of how very small businesses should pay their share.  But if we can agree on the first two goals I outlined above this should be a manageable challenge.