Review of New Way to Care: Social Protections That Put Families First, Independent Institute, 2020, By John C. Goodman, 372 pages, $28.95
One of the bitter ironies of the nation’s experience with COVID-19 is that emergency measures taken to stem the spread of the pandemic led to more meaningful health care reforms than were delivered by the Affordable Care Act (ACA), aka Obamacare.
The same society that, under the pressure of the Trump administration’s Operation Warp Speed, developed three effective vaccines against the novel coronavirus in an astounding eight months is saddled with a Medicare system that has yet to enter the twenty-first century.
“Until the coronavirus hit, Medicare had missed out on the use of the phone, email, Skype, Zoom, and hospital-based telemedicine,” notes author John Goodman in his new book, New Way to Care: Social Protections That Put Families First. “It still does not pay for Uber-type house calls and other services that modern technology is making possible for the rest of the country.”
Goodman, president of the Goodman Institute for Public Policy Research, a senior fellow at the Independent Institute, and co-publisher of Health Care News, delves into the many problems plaguing the American health care system in his book. Rather than view health care in isolation, however, he places it within a larger mosaic that includes the nation’s vast apparatus of social insurance: Medicare, Medicaid, Social Security, and Social Security Disability Insurance.
Combined with Obamacare and thousands of federal and state health care rules and regulations promulgated over the years, all administered by a slew of bureaucracies, these government programs comprise a system that baffles even the mathematically gifted. Social Security, Goodman notes, currently has 2,728 rules and thousands of codicils that supposedly clarify them, leaving many Social Security Administration employees unfamiliar with many of the rules they are supposed to explain and thus ill-equipped to serve the public.
Oppressive, Regressive System
A system this complex can’t possibly be efficient, and it isn’t. The public and private resources it wastes are incalculable. What is conspicuously lacking, Goodman notes, is choice. The patient, the doctor, the hospital administrator, and even the insurer are constrained by a government-mandated system at odds with the simple needs of ordinary people.
Defenders of the status quo are quick to point to the social benefits of these programs. Goodman, however, argues Social Security and Medicare are inherently regressive. People receiving the highest Social Security benefits live in the same ZIP codes as those getting the most out of Medicare. They’re the same well-heeled people.
People of lesser means must make do with the inferior care provided by Medicaid, and the older ones receive smaller Social Security payments. Furthermore, inflexibility in Medicaid’s income eligibility standards makes it difficult for families to find long-term care for the elderly.
“In areas with few nursing homes, one may be hard-pressed to find a good-quality facility that accepts Medicaid patients,” Goodman writes.
Medicare pays a primary care physician $111.36 per patient visit, whereas an ophthalmologist rakes in $836.36 (including the patient’s copayment), Goodman notes.
“Is there any wonder why the shortage of primary care is reaching crisis proportions in many parts of the country, while cataract removal is available at the drop of a hat?” Goodman asks.
Lack of Markets
Given the distortions that Medicare and other health care mandates have created, Goodman asks rhetorically, “How can you have market prices when no real market exists?”
Markets and choices are inseparable, so the only way out of the current dilemma is to introduce choice into the equation. Goodman’s book, which is supported by numerous graphs and charts and 45 pages of endnotes, includes a host of recommendations for bringing much-needed common sense to the current system. Here are three:
- People should be able to substitute private savings, private pensions and annuities, and private insurance for participation in Social Security.
- People should be able to substitute private insurance and private health care savings for participation in Medicare and in the federalized health care system known as Obamacare.
- People should be able to substitute private savings, private pensions and annuities, and private insurance for participation in Medicaid’s long-term care insurance.
Big Reform Bust
Prospects for carrying out these reforms are at best hazy, Goodman writes.
While continuing to defend Obamacare, Democrats are ready to move on to “Medicare for All” or a “public option” that would crowd out private insurance with taxpayer money, leading ultimately to a single-payer system. Goodman shows how Medicare for All and socialized medicine (single-payer) would be terrible for patients and undermine public health.
Republicans, Goodman argues, blew their chance of repealing and replacing Obamacare during the first two years of the Trump administration when they had the votes to do so. With tight margins existing in both houses of Congress, the Biden administration will be hard-pressed to do much legislatively.
Piecemeal Progress Possible
If those intent on a federal takeover of health care can be held in check, opportunities for piecemeal improvements do exist. States, for example, can roll back certificate-of-need laws that limit the number of providers that can serve the public. COVID-19 has led to substantial growth in direct primary care, where patients pay a monthly fee and have access to a physician 24/7. This simple, patient-friendly model was, until recently, illegal under Medicare. Similarly, telemedicine has become wildly popular in the age of sheltering in place and is now allowed under Medicare.
“The coronavirus forced politicians to deregulate the delivery of medical care,” Goodman writes. “Although much of the deregulation was intended to be temporary, it’s hard to imagine that voters will be willing to allow their newfound freedoms to be taken away.”
The status quo is unsustainable. Revenues from the already high payroll tax will not cover the cost of Social Security, Medicare, and Social Security Disability. Raising that tax or reducing benefits will be politically unpalpable. Goodman’s roadmap points us in a much more promising direction.
Bonner R. Cohen, Ph.D., (bcohen@nationalcenter.org) is a senior fellow at the National Center for Public Policy Research.
