Maggie Mahar -- What if conservatives ran a single-payer health-care system?

By Maggie Mahar
Sunday, November 15, 2009

If you're a progressive like me, and you're upset by the Stupak amendment, which bars federally subsidized insurance from covering abortions, consider this: What if we had a single-payer health-care system and someone like Jeb Bush or Sarah Palin were running the country?

Many liberals remain angry and disappointed that single-payer legislation never stood a chance in Washington. To them, a government-run health-care system seemed an obvious way to put patients ahead of profits.

But a single-payer system would have put us at the mercy of whomever happened to take control of Washington. I'm very happy to have a public plan as an option. But since I don't know who will be in the White House in the years to come, I'm glad that government-run health care won't be the only game in town. If you're not happy about the Stupak amendment, imagine what other limits a conservative government could impose on our health care.

Parts of the country remain more conservative on issues of life and death than many progressives remember. When single-payer advocates imagine single-payer health care, they often look to Canada as an example of how it would work. But America isn't Canada; many of our fellow citizens are more conservative than the average Canadian. Moreover, in the United States we have let the dividing line between church and state blur. Christian conservatives are a political force in their own right, and the U.S. Conference of Catholic Bishops has felt free to weigh in on health-care reform. Under a conservative president, such beliefs might be reflected in single-payer health policies.

With such an administration in power, social conservatives might move to exert pressure on health-care decisions beyond abortion. For example, could women be told that their government insurance won't cover birth control? In 2001, President George W. Bush proposed eliminating the requirement that all Federal Employees Health Benefits plans include coverage for contraception. At the time, Susan Orr, who would later become Bush's deputy assistant secretary of health and human services for population affairs, applauded the president's suggestion, saying: "We're quite pleased because fertility is not a disease. It's not a medical necessity that you have [contraception.]"

In fact, the private insurers who cover federal employees were not required to reimburse for birth-control pills until 1998. Congress didn't like the idea of making the pill part of the package. Until then, 10 percent of federal health plans offered no contraceptive coverage, and 81 percent of plans did not cover the full range of prescription contraceptives.

Or take end-of-life counseling, and hospice and palliative care. Do you remember how Jeb Bush, then governor of Florida, responded when Terri Schiavo's husband fought for her right to die? It's quite possible that under a single-payer system, conservatives would push to overturn laws that allow physicians to withhold food and water if this is what a dying patient has requested. Recently, Rep. Charles Boustany Jr. (R-La.) raised this issue, objecting to the fact that the House's health-care reform legislation does not prohibit the use of federal funds to pay for end-of-life care that involves denying nutrition and hydration. Boustany, a surgeon, doesn't want patients to have that choice. So much for death with dignity.

And what about fertility treatments? This month, the Conference of Catholic Bishops plans to vote on a document reaffirming the Catholic Church's opposition to in vitro fertilization, or IVF. No one elected the bishops to Congress, but the conference has already made its influence felt in the debate over the Stupak amendment. Under a single-payer plan, would the bishops persuade Congress that IVF should be prohibited?

Today, a dozen states mandate that carriers that offer group insurance reimburse for IVF. This may sound costly, but there is a clear health benefit. Because IVF is so expensive, couples who must scrape together their own money for the procedure are often tempted to implant as many embryos as possible in the hopes of not having to undergo the procedure a second time. In countries where the procedure is covered, however, women are far more likely to have just one embryo implanted at a time, rather than risking a multiple birth. This is safer for both mothers and children and is ultimately much less expensive.

Finally, if fiscal conservatives were in charge of a government-run system, they might decide that we all need to take more financial responsibility for our health-care decisions -- in the form of, say, $75 co-pays to visit a doctor. Never mind research suggesting that when we shift the financial burden to patients, they aren't likely to forgo just unnecessary treatments -- they are also likely to defer necessary preventive care.

I strongly support increasing our government's involvement in the health-care system by including a public option in the reform package. I believe that if Congress passes legislation that includes a public option, that option will be stronger than many pundits suggest. Such a plan could help lower costs while lifting the quality of care, and would provide serious competition to private insurers.

But I'm also wary that in four or eight years, someone else -- someone less sympathetic to my views -- may be in the White House. And conservatives could once again control Congress. So I am relieved that we don't seem to be headed toward a single-payer system. We simply cannot count on "good government" overseeing our health care. One never knows who the American people will choose to elect. As a progressive, I have been stunned by the people's pick more than once in the past 30 years. Democracy offers choices but makes no promises.

So I want to hedge my bets. I want alternative insurance options, especially from nonprofits such as Kaiser Permanente. And I don't want to find myself locked into an insurance plan run by conservatives -- or Democrats -- who feel they have a right to impose their religious beliefs on my access to care.

Maggie Mahar, the health-care fellow at the Century Foundation, is the author of "Money-Driven Medicine: The Real Reason Health Care Costs So Much."

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