My post yesterday did not go over well with the libertarian and conservative crowd. My facebook page is much longer today with posts on just how wrong I am to consider that car insurance model when I want to discuss a new health care model.  Shocking. 

One asked why we didn't simply open up insurance across state lines.  I don't disagree with that if we are going to keep the same system that we already have (which it looks like we will).  But there have to be more mandates in place than being able to buy with pre-tax dollars and open enrollment with any carrier.  Insurance companies (who, may I point out are middle men already standing between a patient and his or her doctor) don't want to insure people that will cost them more than they make in premiums.  From a business standpoint, that makes absolute sense.  But one's health is not a business.  It's quality of life.  It's being able to live our American dream of wealth, health and happiness (and happiness, it turns out, is derived in large part from the state of one's health). 

At a minimum, insurance companies must insure anyone who wants insurance.  That means people with pre-existing conditions.  Yes, these people are more expensive to insure, but they also need the coverage the most.  Someone else said what about the young, healthy people who don't want part of their paycheck to go toward health insurance?  I understand that people want to keep their money, but without young healthy people paying into the system, expenses go up for everyone else on a plan.  Why?  Because those that are in the plan use its services.  Young, healthy people don't typically use many health care services until they need them.  When will that be?  When they get sick, break an arm, get in a car accident, get food poisoning, cut their foot on a piece of glass...you get the idea.  There's no telling when that will happen.  It may. But it may not. 

My brother needed an emergency appendectomy at 25.  He has been very healthy since - and he was very healthy until his appendix became inflamed.  Just like car insurance, you cannot get retro-active coverage.  You must have the coverage before the accident or illness. 

It there a way to please everyone in this debate? Absolutely not.  Has the current push through Congress been a fair one? No, it has not.  Will the eventual bill that comes to Obama's desk actually help Americans?  I fear it won't. 

Because I worry it doesn't go far enough. Atul Gawande wrote a fascinating article about health care reform for The New Yorker on January 26, 2009.  Here's an excerpt:

"In the United States, our stories are like the one that appeared in the Times before Christmas. Starla Darling, pregnant and due for delivery, had just taken maternity leave from her factory job at Archway & Mother’s Cookie Company, in Ashland, Ohio, when she received a letter informing her that the company was going out of business. In three days, the letter said, she and almost three hundred co-workers would be laid off, and would lose their health-insurance coverage. The company was self-insured, so the employees didn’t have the option of paying for the insurance themselves—their insurance plan was being terminated.

“When I heard that I was losing my insurance, I was scared,” Darling told the Times. Her husband had been laid off from his job, too. “I remember that the bill for my son’s delivery in 2005 was about $9,000, and I knew I would never be able to pay that by myself.” So she prevailed on her midwife to induce labor while she still had insurance coverage. During labor, Darling began bleeding profusely, and needed a Cesarean section. Mother and baby pulled through. But the insurer denied Darling’s claim for coverage. The couple ended up owing more than seventeen thousand dollars.

The stories become unconscionable in any society that purports to serve the needs of ordinary people, and, at some alchemical point, they combine with opportunity and leadership to produce change. Britain reached this point and enacted universal health-care coverage in 1945, Canada in 1966, Australia in 1974. The United States may finally be there now. In 2007, fifty-seven million Americans had difficulty paying their medical bills, up fourteen million from 2003. On average, they had two thousand dollars in medical debt and had been contacted by a collection agency at least once. Because, in part, of underpayment, half of American hospitals operated at a loss in 2007. Today, large numbers of employers are limiting or dropping insurance coverage in order to stay afloat, or simply going under—even hospitals themselves.

Yet wherever the prospect of universal health insurance has been considered, it has been widely attacked as a Bolshevik fantasy—a coercive system to be imposed upon people by benighted socialist master planners. People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse—especially for those who already have dependable coverage and access to good doctors and hospitals.

Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.

Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have. The country has this one chance, the idealist maintains, to sweep away our inhumane, wasteful patchwork system and replace it with something new and more rational. So we should prepare for a bold overhaul, just as every other Western democracy has. True reform requires transformation at a stroke. But is this really the way it has occurred in other countries? The answer is no. And the reality of how health reform has come about elsewhere is both surprising and instructive.