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Why We Don’t Trust Politicians (Part II)

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In Part I, we said health care is a major cause of our declining trust in politicians. Our political inability to find a solution has led to massive economic costs, a subsidy-driven public sense of entitlement, and high-profit segments of industry hooked on maintaining the status quo. The situation is truly a mess.

We also promised a solution that might work – but with a challenge to politicians.

Context

America was built on free enterprise and an emphasis on individual achievement. We also have a long history of compassion for the least fortunate (based more on private charity than in some other countries). Both of those laudable goals have been elevated to near-constitutional status: the pursuit of liberty and the pursuit of life, if not of happiness.

The problem comes when the two collide: when some individuals can afford massively expensive healthcare but the collective society cannot.

If we focused solely on the ‘life’ side, we’d get a national health system that would limit choice and proscribe options for all.  That is anathema to the ‘give me liberty’ ethos.

But focusing on ‘liberty’ alone would create discrepancies in health care (imagine ambulances carting one victim of a car crash to hospital while leaving another on the pavement) widely perceived as unjust.

Most other countries have faced this problem.

The most obvious solution is a two-tier system: a public system providing basic and preventive care for all, and a private system paid for with after-tax dollars for those who can afford more. Similar systems exist in Canada and the UK, for example.

While most other countries accept this basic design – which treats healthcare as a universal right – in the gridlocked state of affairs in the present-day US, that solution feels like offending every special interest group in the country.

And so we watch, collectively, as our inability to act slowly freezes our remaining degrees of freedom. And still we don’t act.

The Solution

Any solution must face one certain fact: we cannot afford to give the best possible care to everyone at all times. Canada and Britain have found their version of addressing this simple fact. We need to find an American twist to gain acceptance from our peculiarly American sensibilities.

Let’s be clear: this means, of necessity, a means-tested public system that won’t buy you knee replacements to improve your tennis game, acne treatments to fix your complexion or motorized wheel chairs to get you around your home.  It won’t allow doctor choice or the right to sue.

Instead, it would be take a number and take your seat to see the doctor who, by the way, wants to work an eight-hour day for a modest salary and a regular schedule. It would be a system in which people of means could get more and better care – because they can afford it – and it would require a public ethos that accepts this disparity the same way it accepts Mercedes on public highways.

The private system could be employer-provided (taxable to the employee as compensation), or paid for personally with after-tax dollars. Those who choose not to insure and who don’t meet means-test requirements would be cared for by the public system but billed for services at full retail rates.

Care in the private system would be better in some ways (more time with patients), but worse in others (MRI machines and drugs would lack the cost-reducing scale they enjoy today).

Because people in the private system would pay for their healthcare and people in the public system will face waits and limited services, both will choose to use less of it – and devote more of their income to other goods. Lower utilization will drive down costs. Those in the private system will be more aware of costs. Those in the public system will get necessary care, but not everything they might want. There will be fewer hospitals with sophisticated equipment; fewer stand-alone surgery centers owned by doctors; less research to improve care and treatment; and less profit for the health care industry.

Getting to the Solution

Just as not everyone can be a millionaire, not everyone can have the very best healthcare. Just as some of us have better housing and more discretionary income – so some of us will have better health care.

What is ironic about this approach is that it ought to be easy for Americans. Given the twin ideological goals of equality and liberty, the US has always put more emphasis on liberty, compared to Europe and much of the world. The American answer to disparity has always been the ability to say, “That is today – but I can change this world for the better, for myself and my children.”

Where our politicians have truly let us down, and earned our distrust, is by betraying this American sense of the future. They have been peddling short-term solutions, promising everyone everything, here, now, today.

They are not alone in spreading this bad thinking – just look at banking and housing. But we’re talking about health-care here, and it’s politicians who must let go of promising the greatest possible healthcare to everyone all the time.

Americans know well how to offset inequality with hope. Maybe the ultimate reason we don’t trust our politicians is that they are being un-American, promising us the moon when we know all too well which planet we really live on.

The road to trust, for politicians, has got to go through Truth.

Why We Don’t Trust Politicians: the Case of Healthcare

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Stephen M.R. Covey, in his recent Trust Matters interview, notes that politicians rank lowest in trust among all professions. He identifies counterfeit behavior as the underlying cause.

He’s right; and of all the high-visibility disagreements today – wars, abortion, debt – none has inspired more flagrant counterfeit behavior than health care. It’s a polarizing issue in itself – and its abuse by politicians puts added stress on the social compact.

A Massive Inconvenient Truth

Never mind climate change. Here are a few far greater inconvenient truths that everyone knows, but no one will admit:

  • Only a very small portion of the US population could afford to pay for the health care they have come to expect
  • The health care system as it exists could not survive without massive government subsidies
  • Health care is an economic good – as with housing, food and consumer goods, what you get is what you can afford.

Our collective inability to admit these truths in a socially useful manner means that the cost of health care is killing jobs and crippling American competitiveness.  Like parasites choking their host, the politicians are too tied up with reality-as-we-like-to-pretend to speak the truth – even though we all know it.

Result: bad health care, bad economics – and bad social trust.

How We Got Here

Albeit with the best of motives, Medicare, ERISA, and subsequent regulations greatly expanded the proportion of the population who could seek health care. Health care usage exploded as people took advantage of a service seen as low cost and already paid-for. With that expansion, hospitals, insurance carriers, drug companies, device makers and health care providers were able to train doctors, fund research and invest in marketing programs; all paid for with government and employer dollars.

Laudable though the goals were, the legislation also forced mid-sized and large employers to devote an ever-increasing proportion of their compensation expense to employee benefits – with a resultant decline in real wages. Until the Affordable Care Act, small employers could avoid the non-discrimination rules through the purchase of insured health plans.

The inconvenient (again) truth is: this tangled web of intertwined interests has become so pervasive that the “private” health care industry would implode without the government.  Health care in the US has become an entitlement program for both individuals and for industry – and no longer perceived by most Americans as an economic good paid for with wages or profits.

Where We Stand Now

Health care contributes to both our slow job growth and our growing income inequality. When health care costs grow as a proportion of compensation, rising lower-wage employee costs begin to overwhelm the value they can add. Naturally, employers then shift to exempt part-timers and contractors. Small employers, once exempt from the rules, now simply avoid adding workers.

The experience of every other nation is that health care rationing is an essential element of any solution; we can’t outrun it. We have not faced up to that inconvenient (yet again) truth in the US.

Enter: the Politicians

Health care is a fault line around which our two primary political parties have entrenched themselves. The GOP has the problem in its sights – but can’t stomach the solution. Democrats misstate the problem – and thus propose ever more expensive solutions. Both are hostage to ideologies.

Republicans look knee-jerk to the private sector, touting doctor choice and the doctor/patient relationship as a panacea. Their inconvenient truth is that the system will fail without the government – and that most of their voters will be unable to afford coverage.

Democrats insist on universal coverage with equal benefits for all, and the right to sue if things don’t go well.  Their inconvenient truth is that the system is unsustainable – and that their children will have to disavow it.

Neither solution is viable.  We all know it, but bury our head in ideological sands.  And yet the same time – because we really do know the truth – we don’t trust our leaders because we know they are lying to us. They refuse to speak the truth.

Getting to the Solution

Our politicians give only the answers we want to hear.  We know they aren’t true, but we fear the other side’s answers more, so we cheer for the answers we fear less.  We don’t want to “lose.”  Which means we all don’t trust anyone – and we all lose.

The strongest force against trust is the willingness to leave the truth unspoken.

Is there any candidate, anywhere, willing to say simply that not everyone can have the same health care? Can any candidate achieve escape velocity from our debilitating ideological prison? And would the rest of us be willing to acknowledge the truth if someone had the courage to speak it?

In a following post, we’ll discuss one potential solution and why our politicians will give up our trust in order to avoid it.