Giuliani’s Tepid Health Reform

The health-care primary, Part 3.

“We’ve got to do it the American way,” Republican presidential candidate Rudy Giuliani said as he unveiled his proposal for health-care reform.

The American way is not single-payer, government-controlled anything. That’s a European way of doing something. That’s a, frankly, a socialist way of doing it. That’s why when you hear Democrats in particular talk about single-payer, mandated health care, universal health care, what they’re talking about is socialized medicine. They’re talking about single-payer—government—controlling your health-care decisions.

Oh, please. The American way is to pretend we don’t already have socialized medicine for the elderly (through Medicare) and for the poor (through Medicaid). The only controversy surrounding these programs is the term “socialized medicine” itself. Certainly one hears few complaints, even from blowhards like Giuliani, that Medicare and Medicaid are too socialistic (though the Bush administration and Congress have done their best to screw up the former by mandating a role for private health insurers, who do the work less efficiently).

President Bush is threatening to veto legislation passed this week that would extend health insurance for the working poor to an additional 3 million (the Senate version) to 5 million (House version) additional children. “When you expand eligibility … you’re really beginning to open up an avenue for people to switch from private insurance to the government,” Bush told the Washington Post last month. Let’s have a show of hands. Readers, how many of you get your health insurance from the sainted private sector? If offered the chance tomorrow to chuck that private plan and go on Medicare, how many would refuse? Anyone? Surely there must be one … no?

“Got to have private ownership,” says Giuliani. Let’s see how his plan measures up.

Candidate: Rudy Giuliani.

Elegance: Very inelegant. A few tax breaks here, a few block grants there, a sprinkling of tort reform; he even, if I’m reading this right, would increase modestly the quantity of un-American socialized medicine available through Medicaid. Rudy, you devil!

Market gimmicks: Plentiful. Rudy’s plan promises “visibility of price, provider qualifications, and risk-adjusted procedure outcomes,” all wonkspeak for less games-playing by doctors and insurers about what they charge, what they’ll pay, and the likelihood that any given procedure will yield results. Unfortunately, obscuring these matters is one thing that private-sector medicine has proved exceptionally skillful at. Giuliani also proposes the creation of “interstate markets,” though there’s no explanation of how these would work. He would also expand health savings accounts, which are merely a ruse to make the insured think that when they see their insurance benefits reduced  the fault lies with their own bad consumer choices. In truth, if one is to insure oneself and one’s family responsibly against medical misfortune, there are very few “choices” to make.

Susceptibility to the insurance lobby: Hard to say, because Giuliani doesn’t really specify how he’d regulate insurers. There is, in fact, nothing in Giuliani’s plan that would offend any insurance company, and that may be the point.

Cost: Impossible to quantify, and Rudy doesn’t even try. Media Matters For America thinks Giuliani is getting a free ride on the cost question. Probably, though, it would cost less than the Democratic plans, if only because it doesn’t accomplish very much.

How universal? Not very. See “Cost.”

How socialistic? There is that pesky (and unspecified) Medicaid expansion. The plan includes tax credits and exclusions, but according to strict Republican anti-tax doctrine tax cuts can never be counted as government spending because that assumes the taxpayer’s hard-earned dollar by rights belongs to the government. Back here in the real world, tax cuts do constitute government spending because they have to be offset with tax revenues if the government is to remain in operation.

How disciplined? Not much of an issue here, because apart from the vaguely described transparency requirements (see “Market Gimmicks”), I see any no new burdens that insurers (or even doctors) would feel motivated to evade.

Impact on employers: I will now say something nice about this plan.Giuliani (like Bush before him) takes a step toward leveling the playing field between people who pay for their own health insurance (mainly the self-employed) and people who receive health insurance through their employers. The latter benefit from a tax break unavailable to the former. That’s unfair. Remedying this will accelerate employers’ flight from providing health insurance to their employees, which would be a good thing. Giuliani doesn’t quite have the guts to say that, and at one point he cites increased employer contributions as one of several revenue sources to increase coverage for low-income people. He doesn’t explain how this would work. But to whatever extent Giuliani wants to relieve American employers from a burden of social welfare that ought to reside with the government, I’m for it.

Longevity: Not really an issue here. Private insurers would continue to cover most employees for a relatively short time, either because the employees change jobs or because their bosses switch to other, cheaper providers. Giuliani does, however call for greater investment in computerizing health records, which would at least give doctors a better shot at learning what previous doctors have done to their patients.