You might wonder why I’m still talking about government. Well, because we still have one, even if it isn’t the government some of us wanted, and since these things are on my mind distracting me from writing fiction, I might as well spew them at the world. Sort of like having food poisoning.
This is the really tough one. Nobody wants to admit healthcare must be rationed; nobody wants to stand up and say, you know, you can’t have every conceivable drug or procedure on the taxpayers’ dime. We let for-profit insurance companies do the rationing, with the result that the insurance companies make an obscene amount of money, actual healthcare providers spend more time doing paperwork than delivering care, and patients don’t always get the best possible treatment. At the same time, we let healthcare companies owned and operated by religious organizations, or individuals employed by allegedly secular healthcare companies, deny care based on their underlying religious agenda – and these providers may be receiving federal dollars.
No tax dollars to churches, period – and that means church-owned “public” businesses like hospitals.
A quick look at the numbers. The “budgetary resources” for the Department of Health and Human Services (which includes Medicare and Medicaid) come to $2,063,577,540,241. That is two trillion, sixty-three billion dollars (and change). The 2025 breakdown by agency under DHHS is here.
Basically, almost $2 trillion of that entire number goes to Medicaid and Medicare. And there is no way to balance the federal budget without cutting some of this.
With all that money, many Americans go without any healthcare at all – because they’re not old enough for Medicare or poor enough for Medicaid, and their employers don’t provide health insurance, and public plans are cost-prohibitive. Evidence supports my theory that if we provide basic preventive healthcare services to all citizens, we’ll avoid many illnesses and accidents that can produce costly long-term disability, unemployability, and early death.
Vaccines save lives and prevent disabilities; that’s good for the economy. Hearing aids and eyeglasses prevent accidents, improve education and socialization, facilitate employment, and are therefore also good for the economy. A good set of natural teeth is a prime indicator of long-term health. The nation has a vested interest in those things. But we need to seriously consider whether the nation should be expected to pay for, e.g., cancer treatment, organ transplants, orthopedic surgeries, and elective medications for people past the age of working.
I’m not saying those medications and surgeries shouldn’t be available! Of course they should be! But right here and now I’m talking about the government use of citizens’ tax dollars.
In order to control the federal budget, we must control this part of it.
Every country with a national healthcare program is struggling with the cost of it. Every advanced country is also struggling with the cost of private healthcare. There are whole books about why healthcare costs so much in the US, but ultimately the why is irrelevant to this discussion. What’s at issue are two questions:
First, what is the absolute minimum level of healthcare access that the federal government should ensure for its citizens.
My answer: vaccines, insulin, barrier contraceptives, hearing support, vision support, and dental exams and cleanings, in the interest of a healthy and productive workforce and the suppression of preventable diseases, provided to all citizens from infancy to death.
All of these should be provided for free at point of service. Use of services can be recorded by tapping an individual’s citizen healthcare access card. All of the recordkeeping could be automated. Any citizen’s treatment history could be accessed through their public healthcare number (distinct from their Social Security number) to verify, for example, when they last had an eye exam or a tetanus vaccine.
Second, can that minimum level of healthcare be provided within the existing system.
My answer: easily. The means for managing this already exist and would require only minor customization.
What about old-age care, then? Because my “absolute minimum” list is extremely short.
Aside from the duty of parents to fully support their children, people should have the right not to pay for other people’s elective healthcare. And that means that government funding for healthcare shouldn’t cover much of anything else.
No cancer treatments. No transplants. No heart surgeries.
So that’s where private insurance comes in. Based on their family history, personal habits, and life goals, a citizen might choose a health insurance plan that only covers accidental injuries, or oncology services, or OB/GYN services, or cardiology services, or whatever combination works for them. A person could spend most of their working life with very minimal healthcare expenses – and in this calculus, “healthcare expense” includes “insurance expense.” My employer and I spend ten times as much on insurance premiums as on my actual annual healthcare.
At this time, a business with 50 or fewer employees doesn’t have to provide a group health insurance plan, though many choose to. With free public preventive health services offered to all, the opt-out could apply to employers with up to 100 employees. High-deductible plans and Health Savings Accounts should be promoted for employers whose average employee compensation is over $50,000/yr.
Other big reforms I’d propose in the health category:
All insurers would be required to publish a list of the exact drugs and procedures covered by each of their plans, with the minimum coverage amount for every drug and procedure, which must be the same from state to state;
All healthcare providers would be required to publish a list of the insurance plans they accept and a complete list of their charges for drugs and procedures provided to patients without private insurance;
No preexisting conditions exceptions would be allowed;
Patients would be required to undergo a psychological consult before being prescribed psychoactive drugs;
No approvals process: the care has been provided, the care is covered, therefore the claim is paid. Every insurance plan would issue a member number and healthcare access card used to identify the insured person and track their care. A healthcare provider would simply tap the card to submit a claim, and the insurer would have to pay it within 30 days. All of this technology already exists.
There are, unfortunately, still some illnesses and disorders that require lifetime treatment and are not preventable except through the most brutal definition of eugenics (e.g., forced sterilization of people with cognitive deficits, or whatever other traits a government considers undesirable). Some such illnesses, like cerebral palsy or cystic fibrosis, typically manifest in childhood; others, like multiple sclerosis or schizophrenia, may manifest later in life.
Genetic testing should be available, at cost, to every infant to identify their potential for early-onset lifetime illnesses. Genetic testing should be encouraged, along with a full baseline medical examination, for every citizen at age 18 to identify their potential for adult-onset lifetime illnesses. Informed citizens make better decisions. An adult with a dangerous gene might choose to foster or adopt rather than conceive their own children. Parents could purchase special insurance for their at-risk child.
I would make space for a much broader application of mental health services, the kind delivered by psychologists: counseling, talk therapy, cognitive behavioral therapy. In the modern world, we hear a lot about loneliness and isolation. Paying a psychologist a fair wage to talk to people is a much better bargain, in my opinion, than paying a drug company to medicate people. Plus, even those mental and physical illnesses that respond to medications respond better with counseling.
We must also question whether the other gold-plated Federal health insurance programs (congressional, civil service, etc.) should remain in force. One basic plan for all civilian employees should do. But we have to start talking about this stuff honestly, and we have to weigh what is fair, just, and possible for all.
About half of the $1.3 trillion we need to cut in order to balance the budget would, under the radical proposal herein, come out of DHHS. The rest? DOD. I’ll come back to that pretty soon.
Could we make all these healthcare policy and system changes quickly? No. But we should start talking about them immediately.