We have heard from every side on the Internet. We have not heard from the side of those not on the Internet, those who need health care most, the poor.
I am tired of hearing about how competing HCR proposals will affect insurance premiums. I am tired of hearing about the "middle class." I am tired of hearing about the "working class."
Most Appalachians are not "middle class" and they are not "working class," because they do no or little work for pay, on the books. They do not care about "employer mandates," because they have no employer. They will not abide by individual mandates, because it violates their concept of liberty.
These are the individuals almost totally excluded from the "HCR" debate. Why don't we talk to our congressman? Because our congress-entity is Jean Schmidt, elected by voters from the far wealthier non-Appalachian suburbs of Cincinnati.
More below the fold.
Though I am not Appalachian by origin, I live by choice in a poor Appalachian community. I talk to my neighbors. I organize. I agitate. I'd venture to say that a majority of people in my community don't care about insurance premiums, because they don't pay them. They have no health insurance, and many never had health insurance.
When they get seriously ill, they go to the emergency room, if they can drive and afford the gas. Some have babies, just so they can qualify for Medicaid, which, like many other welfare benefits, is only available to families with dependent children. A friend of mine who has been campaigning door-to-door reports talking to an extraordinary number of chronically-ill people who sit in their living rooms, waiting to die.
I've seen this kind of situation before. Read on to find the source of my deja vu.
Nate Silver has admirably presented the argument for the weakened Senate bill, based on it's pronounced advantages for "a family of four earning $54,000" and purchasing insurance on the individual market: http://www.dailykos.com/... Good for you, Nate. Now show me the chart for an unemployed alcoholic single woman of 45, who gets hit with a penalty because she failed to file for subsidized mandated insurance, in an area where no private insurance company wants to advertise.
Markos has presented the counter-argument for killing the Senate bill unless the mandate is removed: http://www.dailykos.com/... Markos is correct that the government cannot require that people buy a private product, any private product. With due deference to the scholarship of our President, a mandate without a public option would be blatantly unconstitutional, and ought to be struck down by the Supreme Court, were it to pass.
But I don't want to talk about that, because no proposal now being considered in Washington is remotely responsive to the health care needs of the poor, and especially to the needs of rural poor communities like mine.
Why do I single out the rural poor? The urban poor certainly have a bad situation, but the social safety net in cities still exists. There are free health clinics, and rehabilitation programs, and active family service agencies, and effective neighborhood organizations in the cities. Poor Appalachian communities often have none of that.
So let's back up. The Universal Declaration of Human Rights, passed in 1948 as a foundational document of the United Nations, declares that "health care" is a universal human right. The United States has remained a signatory to that document for 61 years. Yet, the United States has made no serious move to provide or protect the right to health care for the domestic poor. And that includes all the current commotion in DC.
Am I talking about a single-payer system? No, I am not. This may come as a real shock to you self-proclaimed progressives, but "single-payer" is very far from the kind of radical health care overhaul that the current domestic situation and the Universal Declaration both require.
"Single-payer" is essentially a formula for having the government copy and bolster the inequities and inefficiencies of the private insurance industry. Even the pie-in-the sky solution offered by "progressives" as some goal for incremental approach presumes the continuance, even the preeminence, of the very entities that have created the problem.
In order to provide health care as an equitable and universal human right, the institution of private health insurance must be demolished, with no apologies to the state of Connecticut and its elected politicians.
The aim must be a No-payer system.
What the heck am I talking about? How can you operate a health care system without insurance?
Well, this is where the average impoverished Appalachian is a lot smarter than most of you. When you get real sick, you go to the hospital, and get treated, as is your right. Simple as that.
When this is done "around" the system, it creates all kinds of distribution problems. Rural hospitals that provide such treatment do so at their own financial peril, a point consistently raised in the HCR debate by neighboring Democratic congressman Zack Space.
The answer is to make it the system, cut out the insurance middlemen, and have the government pay hospitals and providers directly. This is the essential strength of the Dutch health care system, one that works so well, you never hear Republican fear-mongers warning about the dangers of "going Dutch."
I am no expert on the Dutch system, but my basic understanding is that the government funds health care through general taxation, as makes sense. The government then distributes health care money to local or neighborhood clinics on the basis of demographic need. The clinics then have wide discretion in how to use these funds to best serve the needs of their communities, with significant involvement of community oversight boards. Reportedly, this has produced astoundingly high rates of satisfaction among Dutch patients and doctors, both. Health insurance companies in the Netherlands are not unhappy, because they don't exist. A private health system exists there, but only to provide elective procedures like cosmetic surgery, on a fee-for-service basis.
The Soviet Union had a system vaguely like the Dutch system before 1991. It was far more centralized, with little local autonomy and virtually no community oversight, but it did provide a world-class level of care far in excess of what the Soviet economy would otherwise support. Also unlike the Dutch system, the Soviet system was radically bifurcated, with much better standards of care available to urban elites on the basis of party privilege.
In 1991, the Soviet health care system collapsed along with the country, and former Sovs got a good taste of privatized health care American-style. I do have some expertise on that transition, since I lived for a few months in Kazakhstan during the 1991 transition, and later directed a foundation that attempted to build health clinics in remote areas of the former Soviet Union.
During that time, I knew numerous physicians, who resorted to prostitution or selling cars in order to keep their clinics and laboratories open. I knew chronic disease patients whose care was terminated with no hope of restoration. And I knew corrupt politicians, who diverted foreign medical aid to support the old elite channels of the Nomenklatura (why our efforts to open rural clinics ultimately failed).
In short, I saw the future of Appalachia in Kazakhstan. Privatization is incompatible with health care as a universal right. The insistence on preseving the institutions of private health care means that the poor will be left to die.
As a solution to the current impasse in Washington, I offer this: Attach an amendment to the Senate HCR bill, calling for renunciation of the Universal Declaration of Human Rights by the United States. Because that's what the Senate bill will amount to.
Collectively, we have a world of experience with health care systems that work, and those that don't. This isn't rocket science, it's a whole lot harder, but only if our politicians keep acting like Russian black marketeers.