Byzantine Structures and the Splitting of Hairs

It is my firm conviction, firming up as this campaign year proceeds, that the fundamental problem in US health care -- one which none of the mainstream reformers ever address -- is the ubiquitous assumption that there are and as a matter of fitness there ought to be four distinct parties to a health care transaction.

Routine medical transactions in the US involve (a) an employee [if it is a covered family member of an employee this is a five-party model], (b) employer, (c) a health insurer whose direct relationship is with that employer not with the patient, and (d) the actual care provider, who is looking to that insurer for payment.

This byzantine structure is a legacy of the wage-price controls the feds imposed on the economy during WW2. Anything can be justified when there's a war on, right? but it had lasting effects. We ought to rethink the thing from its foundations.

In the meantime, we have the sort of insane debates we've seen recently.

Is Obama 'getting all Henry VIII' on the Catholic Church?

Not really. Nobody is going to have to put his head on the chopping block, a la Thomas More.

But consider ... the Church controls a variety of entities, notably hospitals, many of which compete with various secular entities in the business world, and it has through these entities a lot of employees, including many non-believers, whom it insures in accord with the four-party model above. It wants examption from the general requirement of insurance insofar as such insurance will cover matters prohibited by Catholic doctrine.

The administration says, 'okay, here's a compromise. We won't require that the Church provide or pay for these services. But we will require that your insurers do so.'

Now, I'm sorry, but that sounds like the splitting of hairs. Given the four-party structure, there is ony a difference in verbiage between the following two propositions:

1) You, as an employer, are required to insure your employees as to health services A, B, and C, even though you object on grounds of conscience to C.

2) You, as an employer, are required to insure your employees as to health services A and B -- we will allow you an exemption from providing C -- but we will require that insurer to pay for C anyway.

I agree with all parties in this exchange -- there is nothing to be gained but confusion by pretending that the difference between (1) and (2) is a difference of principle.

The problem, here, though, is that we take for granted the central role of the insurance industry, and of employment, and this warps all our other thinking and makes absurdities seem plausible. As John Stewart said on The Daily Show recently, if a Church or anyone else simply gave its employees cash the question wouldn't arise.  That's the great thing about cash -- it's the universal medium of exchange. What bills you pay, pills you buy, with the cash your employer has just given you isn't any of said employers' concern.

Furthermore (and given my libertarian sympathies I hate bringing this up, but for purposes of completeness I must) -- even if the government by force of law coerces employers into paying more money to a specific set of workers, as it does every time the minimum wage is raised for example, we would not generally assume that the coerced employer has anything to say about how the 'extra' money was to be spent -- on birth control pills, on Viagra, on sex toys, or even (another subject of some religions' scruples) on firearms. That becomes the employees' concern. There is no accomodation.

Were the US government to order all hospitals to increase the pay of their employees by x%, rather than imposing an insurance mandate that would cost the hospitals x% ... there would be various arguments you could make about that order of course. But the employees would be free to buy birth control pills (or Viagra) with that new x% and no one would say a word about religious "accomodation."

The whole issue of a religious 'accomodation' only arises -- and thus the hair-splitting between propositions (1) and (2) above only becomes possible -- because we're saddled ourselves with this four party paradigm.


This is all one of many many good reasons to get rid of that!