Health Care Reform: What Does the Populace Really Want? A Look Back at California in 1994

A couple of weeks ago, I predicted that in pushing through a controversial and arguably ill=conceived health care reform bill, Trump would suffer the fate of Bill Clinton in 1994 and Barack Obama in 2010 — loss of his party’s control of the midterm congressional elections. And just this past Thursday, Peggy Noonan’s Wall Street Journal column explained why. See also Alan Tonelson’s blog post today. (I highly recommend his blog in general. I should cite it more often, but if I did, I’d spend more time citing than on writing my own posts. 🙂 )

Yet with all the hoopla over the health care issue, I would submit that we as a nation have never clearly set out desiradata for it. And, as with most issues, We the People have never been asked, other than the odd state ballot measure such as California’s Proposition 186 in 1994. (More on this below, where it will become the major point of this post.)

I submit the following as axioms:

  • Health care is a public good, just like education. Our nation offers free public education because it benefits society as a whole, and the same should hold for health care. Timely treatment of diabetes, for instance, can avoid later blindness and mobility problems, thus saving on welfare costs and so on.
  • Even before the advent of Obamacare, we had been providing government-sponsored health care for many, many years, via Medicare, Medicaid, tax-loss writeoffs for emergency room care for the uninsured etc.
  • The American people do not want uninsured people dying in the streets.

The ultraconservatives in Congress need to recognize these points, and recognize that the genesis of Obamacare was a proposal by the Heritage Foundation, a prominent conservative think tank, and its implementation in Massachusetts by Republican governor Mitt Romney. The vast majority of Americans would agree to the above axioms. The intransigent members of Congress are letting their hatred of Obamacare (and, perhaps, their hatred of Obama himself) affect their good judgment. Get over it, Freedom Caucus!

For their part, the Democrats are refusing the recognize the failings of Obamacare. To be sure, something had to be done about health care, both in terms of access and rising costs, and arguably the Democrats did the best they could in 2010. But the program lacks long-term viability financially, and is producing victims even in the short term. Open your eyes, Democrats!

Given the axioms, the central question is, just what is it that we all want the government to provide (directly or via subsidies)? Do we, for instance, want to cover maternity benefits and mental health care? It is one thing to force young, healthy people to buy insurance, in order to subsidize the older, more medically expensive segment of society, on the grounds that most of the young people will eventually become seniors. But in this era of declining birth rates, many people will never become parents, or at least will do so much less often than in previous generations. How do the American people feel about that subsidy? What about subsidizing visits to shrinks for those who are merely unhappy, as opposed to those who are alarmingly out of touch with reality? How about the subsidies for heroic treatment of catastrophic diseases? I’ve never seen any polls on such things, but really isn’t this a central issue, Where to draw the line?

Again, arguably maternity care is another public good, as is mental health treatment. But again, where do we draw the line? Many believe the Democrats drew that line too liberally in 1994, and even many of us who don’t hold that view decry the obstinacy of the Democrats in flatly refusing to revisit it, and we resent the failure of both parties to ask us common folk just how much we want to subsidize.

One of the rare instances in which the populace was given a say occurred in California in 1994, in Proposition 186. The much more memorable ballot measure that year was Proposition 187, which would have denied state government services to unauthorized immigrants, but Prop. 186 was quite significant. The proposal would have established single-payer health insurance in the state. California voters, among the most liberal in the nation, overwhelmingly voted No. And though that was more than 20 years ago, my sense is that it would be soundly defeated today as well.

In other words, the problem is less the issue of whether the government gets involved in health care, rather it is, Just how far do we want the government to go?

To make this question concrete, suppose the Republican bill had passed the House yesterday, and later passed by the Senate and signed into law by Pres. Trump, but without coverage of some of the basic types of treatment guaranteed by Obamacare. Would California take up the slack? If there were a ballot proposition to restore all that coverage using taxpayer money,  I submit that the measure would likely be defeated. Again, one of the most liberal states in the Union would vote against (forgive the provocative and possibly unrepresentative example) taxpayer-subsidized use of Viagra.

During that 1994 election campaign for Prop. 186 (on which I voted Yes), there was a striking example of the problem. A Chinese-American physician was a guest on KTSF, a Bay Area TV station specializing in Chinese-interest and other ethnic programming. The doctor was a progressive politically, as was the host of the show, Anni Chung, a Chinatown political activist. The physician was urging viewers to support Prop. 186.

Chung asked the MD, “Would Prop. 186 cover the undocumented?” The doctor immediately answered (emphasis added), “Oh, definitely not. We couldn’t afford it.” In other words, even this ultraliberal doctor was unwilling to draw the line that far.

And that is my point. We the People need to be consulted as to where to draw the line. “All the rest is commentary.” 🙂

22 thoughts on “Health Care Reform: What Does the Populace Really Want? A Look Back at California in 1994

  1. “Health care reform’ like any talk of reform is useless when the system that is being reformed is a one that was created to make people dependent on something that was designed to exploit them.
    True reform would mean questioning every facet of that system in lieu of just the usual ‘lets look only at the payment vector issues’.
    It would require Us to look at hard to understand concepts like ‘transfer of payments’ through regressive taxation to things like base analysis of the true cost components of health care, specifically in a ‘free market’ economy,
    Basically, can we afford to give everyone what they want, when they want and at the cost ‘everyone’ wants.
    If can do that then I can assure you two things will happen, there will be a change in healthcare and there will be a lot of very pissed off formerly highly paid medical professionals


  2. I can’t help but note, Norm, that while I always appreciate your insights and thoughtful comments, you have begun to stray of late rather far away from the topic you are most known for and best qualified to comment on, i.e. the H-1B problem.

    That having been said, I do agree with most of your points, in particular that the voters, by and large haven’t been asked for their opinions on this crucial topic of health insurance. I must say “health insurance” because, quite obviously, we are NOT talking about “health care”, but rather just about how to pay for its ever-spiraling costs.

    And that is, I think, the thing that gets lost in most of these discussions. Neither the Republicats nor the Democrows have either a plan, nor even the vaguest idea, it seems, of how to seriously tackle the trend of ever-increasing inflation in costs… constant year-by-year increases which far outstrip ordinary inflation for all other types of products and services. Instead, vast amounts of time, political effort, and public attention are focused on… and arguably wasted on… endless arguments, around the margins, of how to pay for a set of products/services that are increasingly unaffordable no matter who pays or how the costs are allocated (or to whom).

    So instead of us all endlessly bickering about who is going to pay (i.e. the rich or the poor, the government or the private sector) it really would be much more productive if *some* politicians, at least, would put forward some ideas on how to reduce the costs and “bend the cost curve”.

    None have meaningfully done that so far, except maybe Bernie, who I believe has correctly noted that about 30% of all dollars spent in the U.S. are basically wasted on “reimbursing” health insurance companies for doing little more than shuffling papers back and forth. (As I understand it, when the government provides this same service, e.g. for Medicaid, the overhead costs drop to something more like 8%.)

    So that’s something right there that could save us all 20+%… go to single payer, as Bernie and others have long suggested. The fat cat insurance company executives who are making multi-million dollar salaries won’t like it, but screw them. They have been freeloading on our backs for far too long already.

    But even that is not enough, and just like military expenses in this country, health care spending would still be totally out of control, even if we had single-payer, and for the same reason… there is nothing at all pushing back against rampant waste and absurd year-over-year price increases. The corporations that deliver health care charge whatever they want. Why? Because they can.

    it may be politically difficult to place some sorts of reasonable limits on things like hospital and drug costs, but the alternative, if we do nothing, is clear… if we do nothing about these out-of-control costs, then we WILL have people literally dying in the streets, and within the next ten years.

    I say let’s put off, for now, any more arguments about WHO is going to pay (rich or poor). Instead, let’s try to figure out how we can keep hospitals for charging us $200 for a single asprin. In the end, tacking this part of the problem may prove to be a more productive use of our time and energies. (Unfortunately, this has to come from the grass roots, because our pols are never keen to do anything that might offend a whole big category of well-heeled campaign donors… like health care providers.)

    P.S. Actually, I do disagree with you, Norm, about one thing. I think that California voters actually *would* vote for single payer if they were asked again today. A lot has changed since 1994, in particular, the cost curve has gone exponential.


    • When I started this blog, I hoped to write about a lot more than H-1B. Unfortunately, it has been dominated by H-1B, but I still hope to write more on other topics. I hope that when I have done so in the past, and will do so in the future, I have had/will have something meaningful to contribute. I actually had written a number of op eds before I got into the H-1B issue, presumably because I had something new and valuable to say.

      My social and professional circles include a wide variety of people. My impression is that rather few would vote for Prop. 186 if it were on the ballot today. The mere fact that it is NOT on the ballot today should itself tell you something.


  3. Agreed we the people need to be asked. However, there are problems with that.There is an optimum point where we can get the most bang for the buck. The challenge is in determining this point, in terms of controlling costs (single payer, government negotiated drug costs, etc.) and in terms of controlling services (some costs shared by consumers). If this could be done accurately in a bi-partisan way, the next challenge would be to educate the public about what we could reasonably afford. This really shouldn’t be a political football, with one side ranting about costs and lack of choice, and the other side demanding total coverage. We really need a bi-partisan look at the issue, with good information provided to the public. Otherwise we really can’t make a good decision, and I’m not sure we have that ability at the national level, although some states might manage it.


  4. I recall a time when hospitals were either associated with religious groups or cities and counties. Hospital care was not a money making industry. Medicare and Medicaid date only from 1965. SSI dated from 1974. I doubt at the time that anyone forecast the costs of the programs today. Even in that time period health insurance could be relatively expensive; when both of us were grad students (late ’60s-early 70s), there was no such thing as insurance available through the university; private health insurance cost about 1/4 of our monthly income. Of course, our groceries for a month ran $100-125, about the cost of the premium. Even when I got a job while DH finished his degree, we kept our private insurance so we would be sure to have it. The only cost comparison I remember is maternity care was $3K-5K while now it is often quoted as $30K-50K.

    People were not dying in the streets; prescriptions were much more affordable; people paid off their medical bills over time. I worked in my physician father’s office after school. Some office visits might be $3-5. He would have treated those individuals – mostly children with disabilities – without charge but did not want their parents to feel like they were getting charity. People would pay their bills $5-10 at a time. I don’t know how much was owed to him when he quit practice, but he and my mother, both of whom were children of the depression, lived beyond their wildest dreams – comfortably but not luxuriously (and certainly not a million dollar house at age 35).

    We need to look back in time. I am appalled by the luxurious medical offices and lifestyles of some physicians. There is also the mentality that not enough has been done until every possible test has been run. DH was hospitalized recently; he was scheduled to have both a CAT scan and MRI. Fortunately, the treating hospitalist – gone are the days when a doctor goes to the hospital to see patients apparently – was reasonable; he acknowledged that all of the diagnostic information was available in the CAT scan and we agreed that the MRI was not necessary; this saved thousands.

    The “do everything” attitude extends to long term custodial care without regard to qualify of life issues. The assisted living facility where my 98 year old MIL lives now will not allow her to keep snacks in her apartment – yet they are worried about her losing weight; she is petite and less than 100 lbs. She does not eat much at each meal and got much of her daily nutrition from health snacks as well as her beloved junk food whenever she felt hungry. Of course, if you take away cookies and peanut butter crackers from someone who snacked frequently then both her enjoyment of life and her weight suffer. The regulations and rules to “protect” people from all possible eventualities are both costly to implement and to monitor and cause quality of life to suffer.

    The health care “industry” is reported to be 1/6th of the total economy. The country cannot get the cost of medical care under control until both the medical community and the people come to the realization that there are incredible costs to doing everything possible. In many cases, everything possible will not be enough. I have been in the position to decide whether quality of life was more important than quantity of life; it is not easy.

    If people, health care professionals, researchers and government continue on the current path, no amount will cover the costs of providing health care. I agree with Norm’s comment; the sooner, the better.


    • You are right on the money, my friend, my Dad told me about this big change years ago, when he worked in the health care industry as a computer programmer. Health care for the poor and indigent used to be a case for private charity, NOT a taxpayer-funded blank-check.


  5. Norm, I appreciate your widening the discussion a bit, since many of these issues are related. For example, H1-B is a convenient way for major corporations to keep their workforce average age younger, which lowers the underwriting costs for company-provided health insurance.

    Please note also, that what the ACA brought into play was not just “health coverage”, but also a new definition of citizen — every policy is identical, not just equal. Each person is covered for hair plugs and mastectomies and both male and female operations and such. This is one of the major reasons why the policy cost is so high, because each policy is a “one size fits all” instead of a la carte.

    I honestly believe a low-cost, catastrophic-only coverage, with HSA’s and/or subsidies, would be a universal “safety net”, and everything else could be a la carte. This would mean that a mandate would be unnecessary, because a barebones plan would be cheap enough for anyone. However, this would violate the one and only one “absolute good” of the Left, and that is *absolute* equality. I don’t mean that every liberal wants to go that far, but rather, this is the extreme position and has been driving many decisions for the past 8 years.


  6. A few months ago I advised readers to have a valid passport handy.

    The NYT published an article four years ago about a guy who needed a hip joint replacement. The US hospital said it would cost around $90,000. He had the work done in Brussels for $13,660. This included a hospital room for fives days, a week in rehab, and airfare.

    It can take a long time to get a passport. Do not delay. Some experts advise not to keep your passport at the bank in case you need to exit the country in a hurry.


    • Fortunately, you do not need a passport to buy drugs from Canada. Just today, DS’s prescription was denied approval by his health insurance. I inquired as to the cost of private pay; it was $1300. I found it online from one of the over the border pharmacies with an office in the US for less than $170 including $20 in express mailing costs. So the Canadian version of the brand named drug is less than 13% of the US cost. What a bunch of chumps we are! No wonder there are so many foreign nationals coming to the US wanting to go into pharmaceutical research.


    • The conversations here really highlights our cognitive dissonance with respect to the fair value of a service.

      A comment above suggests ‘medical tourism’ and buying drugs from Canada. Isn’t this outsourcing, going to places where a comparable service is available at a much cheaper cost.

      Also, not all IT professionals will be outsourced because, just like less financially able people who cannot fly out to Ecuador for a surgery – there will be firms who cannot afford the hassle of outsourcing.

      Businesses and individuals will optimize for the best (me and you included). What is really skewing medical costs is the chokehold of the licensing industry creating a scarcity of professionals who will serve, same can be said about the pharma alliances.

      -International Student


  7. The insurance industry shouldn’t be involved in healthcare because healthcare is not an insurable risk. Everybody gets sick and insurance is designed to protect against low probability events. We need a single payer system and we need to make all healthcare non profit.


  8. This is very relevant for IT professionals as we are or soon will be victims of outsourcing. Companies see us as expendable and not worth investing as insured professionals if they think we’ll be replaced soon.

    I used to work in IT for 2 hospitals. The “revenue cycle” was really focused on maximizing reimbursement for every possible patient encounter. CMS and insurers have very specific conditions for reimbursing at the highest possible rate. IT had to be on its toes configuring the EMR to warn doctors to check a list of boxes to meet their standards. Why earn $100 for a 15 minute encounter when we can make it into a $250 encounter due to the doctor doing a “procedure” with some fancy piece of equipment.

    Unfortunately, we got away with it most of the time because the insurers had little leverage to protest. Single Payer would certainly give us leverage, but I can imagine insurers also getting that leverage.

    The poison pill of Single Payer is that we lack the political will to say no to the endless demand for surgeries, procedures and new medications that keep coming out. More homogeneous and less innovative countries might be able to pull this off. I hope we can too some day.


  9. US will never will be able to resolve its health care system unless there is an understanding in the medical industry that providing medical treatment is a civil responsibility and not a profit making venture. On the other hand, US citizens need to understand that a doctor at most times is working for the well being of the patient and wouldn’t be able to work in the best mindset if he/she is consistently under the fear of potential lawsuits (if things do not go as expected).

    My friend who is a neurosurgeon recently moved to the US. He used to make roughly $200K in India but had to visit multiple hospitals in a week and quite a few number of patients. In US however he makes close to $900K with barely any emergency visits and significantly lesser number of patients at a give time? He himself is clueless about what to do with 900K a year when he is already getting significant benefits and a super subsidized mortgage rate. However he did mention it to me that one improper diagnosis or an unhappy patient and there is a potential of him losing everything. Thus the 5 time more salary is a buffer against potential lawsuits rather than a reward for his efforts.

    Even a basic physician in US makes 10 to 15 times more money in the US then in India or Singapore. On the contrary a US physician looks at far less number of avg patients per day compared to one in India. There are also (atleast I am not aware of ) no facts stating the quality of physicians or treatments provided by them is better than that of a qualified physician in India. Even a lower middle-class individual in India can survive malaria, Typhoid or any such mid severe disease without a health insurance. The maximum total treatment cost is not more than $100 . I myself have gone through this and paid out of pocket. Similar lower middle class individual in US with malaria/typhoid would most likely die on the streets without a health insurance.

    The fact that I need or require a health insurance in US to pay for treatment of a common allergic flu speaks volume about how deep in the hole US health care system is in. Bernie is wrong, Universal health care is not the solution. The health care costs for basic treatments such as flus, x-rays, blood tests should be subsidized to a level that most people can pay out of pocket and health insurance is only used or made available for bigger treatments that required you to stay in hospitals for multiple days.


    • This was the norm many years ago. The coverage of everything by insurance has only begun in the last 20-25 years. That is why I said that we need to look back and insure catastrophic illnesses. Individuals would cover ordinary expenses; if they could not afford a trip to the physician in private practice, there would by community funded and based health care at the city or county health department.


  10. Be careful what you wish for Norm – just found this from early March:

    With the current demographics I think this would pass overwhelmingly. And it would fail miserably also.

    Years ago I remember listening to a conversation of Chinese, Indian and a Palestinian H1-Bs complaining about hospital waiting rooms being too full of Mexican immigrants. Didn’t say a word out of fear of being reported to HR.


  11. Thanks for writing an essay about health care without misusing the word, “insurance.” The health care would be much simpler if Americans were permitted to buy a 1950’s hospital insurance plan.


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