Barack Obama’s health care proposal is the kind of bouquet you would buy at CVS if you were running late to a date: you’ve seen each flower before, it seems mildly appealing at first, and clearly a lot of thought has gone into making sure it doesn’t offend anyone. But you’re going to spend a lot of money and you’re not going to get the results you want. As you go home disappointed that night, you’ll realize that you should have spent the time and money, gone to a florist, and gotten a real bouquet instead of looking for a quick, popular fix. I can only hope that the American people won’t put out for this kind superficial gesture, despite Barack’s undeniable “study session hook up” appeal. With a palpable change of winds gripping Washington, it is time for America to open up a serious and complete dialogue about our health care system. In the wake of Jack Kevorkian’s release from prison,¹ it is time to face the fact that any serious and complete dialogue will have to involve a discussion of values and not just efficiency.

The United States spends 16% of its GDP on health care, considerably more than the runner-up, Germany, which spent 10.9% or Canada, which spent 9.9%.² And yet, the US is tied with Portugal in 40th place in terms of average longevity (77.9 years) behind all these countries.³ Where is all this money going to, if not to better health care? Some of it is certainly tied up in inefficiencies such as IT investment, lack of preventative care, and the cost of footing the bill for the uninsured who can’t pay. But there is also an ideological hazard plaguing any hope of reducing costs: Americans will not accept that, at some point, it is time to die, and as a consequence spend exorbitant sums to prop up the elderly for a few more weeks. By not confronting this issue head on, Mr. Obama compromises where he needs to stand tall. If we are going to fix health care, we cannot half-ass, we cannot cower from the pro-life movement, and we certainly cannot leave unresolved issues that cost billions of dollars a year.

Mr. Obama would like to keep our private, employer-based insurance, with a few tweaks.⁴ He wants to subsidize small businesses trying to offer insurance, and tax the payrolls of companies that choose not to. There would also be a committee, the National Health Insurance Exchange, set up to regulate the price and quality of private insurance. The centerpiece of the scheme is his proposal for a governmental insurance company, which would insure the stragglers not picked up by the measures to extend private insurance. Nota Bene: under his plan, insurance would be universally available, but not universally mandatory, as with John Edward’s plan. This means that the government will still be bailing out uninsured people for expensive ER visits. The only real argument you can make against mandatory insurance is a foolish libertarian one based on the premise that some people would rather, and should be able to, leave their health (and everyone else’s money) open to chance.

Mr. Obama has identified, along with everyone else, two areas of health care that are needlessly expensive and in need of a long-overdue overhaul. The first is the sorry state of IT in the medical infrastructure, which has contributed to expanding bureaucracy and costs of 25 dollars per information transaction, versus pennies per transaction in the more IT-savvy finance sector, according to Mr. Obama’s literature. He also noticed that billions of dollars of health care costs could have been averted with much less expensive prevention schemes, and so promises to institute these schemes, right down to making sure everyone lives near a playground.

In addition to this, Mr. Obama has proposed a slew of smaller initiatives that are hard to argue with, such as reducing mercury and lead poisoning. Making mandatory coverage for children a priority, as he has done with the KidsCare program in Illinois,⁵ will certainly be a crowd pleaser. These measures are salutary and necessary, but they are not the main point, and they are certainly not revolutionary.

Am I being too tough on the guy, then? These policies seem well thought out and well-compromised, in the usual style of the Professor, and what’s so bad about playgrounds? Though I am personally in favor of a single-payer model, I can certainly see how a private-public scheme aiming at universal coverage would be a good idea and more in line with mainstream American thought. My home state, Massachusetts, set up just this kind of system recently (under the visionary leadership of Mitt Romney, the mormon who saved us liberals from ourselves) and it seems to be working out all right, even though Massachusetts was rich and widely-insured to begin with. And I certainly have nothing but praise for an emphasis of prevention over treatment. So what’s the problem?

Obama would like to reimburse private insurance companies in the case of catastrophic illness in order to lower private insurance premiums. This may not seem such a big deal, but it is in fact a deal-breaker. Catastrophic insurance, which basically means very expensive payouts, accounts for a huge percentage of health care. About half (49%) of health care costs go to 5% of patients, many of whom fall in the category of “catastrophic.”⁶ To make the federal government shoulder that kind of burden would be a catastrophe.

Beyond the enormous financial strain this plan would put on the government, catastrophic reimbursement is indicative of exactly the kind of thinking that has America spending outrageous fees for dismal care. The “catastrophic” category consists of two different kinds of high-expense healthcare, and they need to be treated in very different ways. The first kind is major traumatic events that people can recover from with much expense, as in the case of a young person suffering a stroke or heart attack. Although it would be very expensive, I could be persuaded that it is a good idea to reimburse these expenses for the sake of lowering premiums for everyone. The other kind of catastrophic insurance is traumatic events in people who are clearly on their way downhill, as in the case of an 80-year-old suffering a heart attack. These kinds of operations account for a significant portion of our health spending, and the reward for our dollars are a few more days of watching Uncle Milt decompose alive. The ethos behind all of this has been described as the “culture of life”, and it is the reason that my grandfather got a nosejob a few months before his death, at great expense. Welcome to Terry Schiavo country.

Phillip J. Longman⁷ puts it well when he says:

This gets at an important truth about the role medicine plays in public health—it is concentrated primarily on the elderly, who consume about 38 percent of all health-care dollars, yet account for just 12.4 percent of the population. By definition, the elderly have fewer years of life to extend than the young. This simple fact goes a long way toward explaining medicine’s modest role in improving life expectancy: It cannot stop aging.

This is a moral issue, and not a technical one, and no amount of efficient governing can get around the problem, despite Mr. Obama’s hopes. The culture war meets the federal budget crisis, and Americans are going to have to dig deep into their souls and wallets to find the solution. Any serious plan for reducing health care costs must include some sort of triage system, in which people on the verge of death are allowed a dignified, pain-free end in a hospice with their families. Before you rush to condemn triage as barbarous and brutal, consider that the 45 million uninsured Americans today have essentially been ruled out by an economic triage. Is it less brutal to deny care to the poor or to immediately hopeless cases?

Currently, many people who are clearly about to die are being subjected to dozens of expensive surgeries which extend their lives by a few more days, which may consist of soiling themselves as they drool in a recovery room, never to recover. Legalization of euthanasia and physician-assisted suicide would reduce health care costs and provide the elderly with the right to choose how they want their lives to end. However, I will concede that legal death would probably act as a political wedge issue against Mr. Obama. Democrats would be wise to stick to triage. Even with the release of Dr. Kevorkian, America is not ready to kill [white] people, though it is ready to let them die.

If you were thinking that Mr. Obama, an open and active Christian, has taken a pro-life stance, you would be wrong. In fact, during a Democratic debate,⁸ he claimed that his biggest mistake so far was not fighting harder against Republicans on the Terry Schiavo case. If he is already talking the talk, and thus foregoing the pro-life vote, why has he failed to walk the walk?

Why did this inspiring man give us such an uninspiring health care plan? Atul Gawande⁹ went a long way towards explaining this in his recent op-ed piece in the New York Times, saying that candidate policy proposals of this kind

…are treated, by campaigns and media alike, as some kind of political G.P.S. device - gadgets primarily for political positioning. So this was how Mr. Obama’s plan was reported: it is a lot like John Edwards’s plan and the Massachusetts plan signed into law by Mitt Romney last year; and it has elements of John Kerry’s proposal from four years ago. In other words - ho hum - another centrist plan. No one except policy wonks will tell the proposals apart from one another

On this point, I believe Mr. Gawande is right on. Mr. Obama is concerned with keeping his campaign alive, and so he has made the political decision to mix together the kind of proposal that will not raise any eyebrows. The insurance companies, and their lobby, must be thrilled at this, especially since he plans to subsidize many of their more expensive claims. Also pleased are business conservatives, who like to see the private sector solve problems, Christian conservatives, who grumble at Obama’s Schiavo regret but see no actual policy threat to the culture of life, and small-government conservatives, who would go apeshit at a single-payer policy. Mercury, lead, and obesity, all to be battled, are worse foes than even videogames and pot in the minds of suburban mothers. Liberals are happy to see universal coverage on offer, and centrists are happy that everyone’s happy. I never said that Barack Obama wasn’t a smart guy.

Until he confronts head-on the costly and questionable “culture of life”, however, Barack Obama will leave important work undone. The lack of a legal obligation to be insured will also be pricey. This policy proposal has a whole lot of good ideas; it would only take a braver stance on a few issues to make it golden. But maybe that’s why he’s promised to pass his health care legislation at the end of his term, rather than the beginning.

1. Kevorkian Is Released From Prison, New York Times, 1 June 2007. ↩
2. OECD in Figures 2006-2007, OECD. ↩
3. “Pocket World in Figures,” The Economist, 2007. ↩
4. Barack Obama’s Plan For A Healthy America. ↩
5. Governor signs legislation expanding KidCare and FamilyCare, IGNN, 1 July 2003. ↩
6. Stanton, MW, Rutherford, M. The High Concentration of U.S Health Care Expenditures. The Agency for Healthcare Research and Quality, 2005. ↩
7. Longman, Phillip J. The Health of Nations, Washington Monthly, April 2003. ↩
8. What Was Your Biggest Mistake?, MSNBC, 26 April 2007. ↩
9. The Obama Health Plan, New York Times, 31 May 2007. ↩