Jim Crow Healthcare

Graham-Cassidy comes up for a Senate vote next week. Here’s why I hope it does not pass.

First, and initially foremost, it will make health insurance harder to get for tens of millions of vulnerable Americans. In ten years, when Medicaid funding is further reduced, it will essentially gut the system we have laboriously established over many decades to take care of those who cannot take care of themselves. Medicaid is not a perfect system, but it’s there, and it works.

Second, The ability of the states essentially to opt out of pre-existing condition protections will return us to our darkest, and least-humane period. Got cancer? Oh sorry, good luck with that, but you’re going to have to pay more for your coverage now, a lot more.

Finally, and this is almost as big a reason as the first two, health care should not be left to the states. With few exceptions—I’m looking at you Massachusetts, with your Obamacare precursor that is working so well—they have a bad track record. Why is that? I’m not sure. Overall—and you can note my preconceptions in this—I think health care is too complicated and requires too much expertise to be handled locally. There’s a reason we all go to major medical centers for major surgery and not local clinics. Size and scale, managed correctly, beget expertise and good results. Google. Facebook. Amazon. 

Why do I think the feds can manage a large healthcare program, either insurance or single-payer-based, better than states? Two reasons:

Big problems with big societal consequences attract big thinkers. We don’t ask states to manage national defense. Making good medical care broadly available is a challenge that requires the heavyweights of policy and process.

The second reason is that although national management of issues has its own risk of bloat and inefficiency (which, incidentally, I don’t think is any greater than on the state level), it has fewer racial and economic biases. This is why we needed federal Civil Rights legislation a half-century ago. Because of racial prejudice, the southern states were making a hash of it. Not only were they not helping, they were making things worse for blacks.

Why do I think prejudice might impede good healthcare decisions by states today? Just look at the large number of states that refused to expand Medicaid under Obamacare. The expansion would have benefited their poor and would have been almost entirely paid for by the federal government. Yet they passed. They said they didn’t like the future costs. They said they didn’t like the constraints. What I think is that they just didn’t think it was important to help their poor if it meant letting the federal camel get its nose under their tent. And the fact that many of those poor were black? Coincidence?

Milton Friedman, the famous economist from the University of Chicago, was more of a libertarian than I am. He thought government should be as small as possible. And when government had to be involved, he believed that the best decisions were made locally. He saw centralized government as the beginning of the end of liberty.

He was right, in principle. Especially when the choice, as it was for him, was between capitalism and totalitarian control of the economy. But even he acknowledged that it is the proper role of government to enable us to do collectively what we cannot do individually. Healthcare is a perfect example of such a need. It requires that we share our healthcare risks broadly among us, so that no one of us is left to bear the full furry of bad genes or bad luck. The bigger the risk-sharing pool, the better that system will work.

Identity Theft

Can you hear it, the flapping of little wings as the youngsters leave the nest? We have a number of friends this year who will be participating in that poignant ritual. Participating in the sense of shopping for college-dorm-room sheets and reading lights and standing on the outside of “The Gate of Tears,” which is what the University of Chicago calls the final portal through which freshmen pass and parents may not.

I had kids under eighteen in the house for so long I hardly knew what to do when I didn’t. I started this blog then. Writing about my feelings helped. 

I haven’t tried my hand at advice to new empty-nesters. Throw yourself into your work. Travel. Make love in places you never could before. If you have a dog, be nice to it, as it will become your replacement child.

This too will pass, I could say, except that I’m not sure it’s true.

When your kids leave home, it’s a form of identity theft. You are no longer who you were, no longer snack-maker, homework-nagger, chauffeur and spy. The role of parent is not one you play, it is who you are. When they leave, you are still that, but you have no duties to perform. You are consigned to straightening the comforters on their beds, dusting their trophies, hoping they will call.

If someone steals your credit card or your social security number, they can steal your money. We call it identity theft, but it isn’t really that. Only your children can steal your soul.

It won’t pass—at least it hasn’t for me, even after seven year—but it will get better. The pain will dull. The longing will abate. You’ll begin to share in their lives and achievements in different ways. You’ll meet them at lake houses and invite them to join you in Paris. They may not, but even the hope of it will be exhilarating. You’ll remind them to renew their passports.

It will get better, but it will always be there, that small empty spot. Like the damage to your self-confidence when you tried out for football in eighth grade, like the BB-sized hole in your heart from your first lost love. The scar will fade so that you’ll hardly feel it except on sad, rainy days. Or on sunny days, when you’re sitting alone on a bench in a park watching a scrum of third-graders in a soccer game and your foot twitches as if to kick the ball, a reflex called up from a time when you knew with certainty who you were.