#i watched this tank kamala harris's fucking candidacy and i'm still livid about that

[fiddleabout]

are you for or against private health insurance?

i am for fully affordable, fully accessible coverage for every person residing in the united states.  full stop.

but let’s talk for a hot sec about why you felt the need to pose this question the way you did, because it indicates a fundamental misunderstanding of the way the health care system is structured in the united states and what it takes to fix it:

like it or not, the system we have now isn’t going to just go away.  do you remember the aca?  that was the most monumental systemic overhaul of the health care system in united states history, and it didn’t even try to get rid of private insurance in favor of a single-payer system as a way to create universal coverage.  it was designed to create universal coverage via medicaid expansion and individual mandate, and it was gutted from the start by the nascent tea party in 2009.  it was still passed and showed marked improvement in providing health care for people in the us over time, and then 2016 happened and now you have trump’s administration and seema varma, the cms administrator, doing their level fucking best to shit all over it every day until it falls apart the rest of the way.

now. let’s say your best case scenario happens.  bernie wins! (i’m going out on a limb to guess you’re a bernie sanders fan.  no idea why.)  we get a democratic senate and house!  medicare is expanded to cover every person in the united states!  private insurance is eliminated! yay!

this is probably just a weirdly technical hangup but roll with me for a minute: what happens to said insurance companies?  bcbsa has something like 35 companies within it but if they’re all suddenly kaput, where does their capital go?  is the government seizing their liquidity?  what about their debt?  united health group is one of the largest insurers in the united states, yeah, but they also have a bunch of data analytics subsidiaries and clinical consulting arms, not all of which are located in the united states and some of which are heavily intertwined with the insurance branch.  how do you split that up?  what about employees that have been investing their bonuses in stock options?  what about the stock exchange in general if you eliminate an entire multi-billion dollar industry?  does the government cover all of that?

but: now a lot of people are now unemployed.  and i’m not talking about insurance company executives, i’m talking about the hundreds of thousands of admin-level employees.  i used to be one of them and i made barely above minimum wage.  those people don’t have a golden parachute or cushy savings account to fall back on, and now there’s a heavily crowded employers’ market picking and choosing overqualified, nearly retirement-age people who are all looking for jobs.  idk if you remember what the job market was like post-recession in 2009/2010 or.  like.  if you were even out of the sixth grade at that point.  but i was fresh out of undergrad and interviewing for minimum wage jobs against people with 20+ years experience, and basically none of us were getting jobs no matter how much experience we had because there would be sixty people, applying for one minimum-wage no-benefits receptionist job that required you to have a bachelor’s degree and minimum three years experience in an office just to be a mail clerk.  the economy would be crippled.

but let’s say that white jesus has decided that everyone who was working at a private insurance company will be guaranteed a government job of some kind, or like.  just.  any job.  idk.  i’d hope anyone that proposes eliminating an entire industry that employs over two million people would have a contingency plan in place to help them find employment.  but let’s say he does!  now we have a true single payer system, where everyone is covered, and private insurance is illegal, and everyone has a job.  things are GREAT.

okay.  awesome.  but now you have to integrate everything into one system.  there are a handful of major electronic medical record systems– epic, cerner, allscripts, etc.– in the country.  most hospital and provider systems have invested millions of dollars in custom-designed systems that integrate across multiple sites and interface directly into their major insuring partners’ systems. billing is based on icd-10 codes but aside from that unified– and, importantly, clinical, not specifically billing– coding system, billing requirements are wholly different.  do you push everyone onto one system?  will there be subsidies to provider systems who, in good faith to maintain compliance with the government’s ongoing meaningful use requirements to date, have invested millions of dollars in functional ehr systems that they’ll have to potentially completely overhaul now that the billing approach is completely different?  

but let’s say that they figure THAT out.  everything is great.  medicare for all!  no private insurance!  the private companies were broken up completely and amicably and no national, state, municipal, or county economy was crippled!  all of the millions of people who lost their jobs immediately found new ones!  the billing system was perfectly designed and implemented and everything is beautiful smooth sailing!  this is good shit, yo.

not to be a wrench or anything, but: remember that bit up there about the aca being gutted even more once the administration changed?  yeah.  so.  this administration that’s done all of these nigh-miraculous things?  ends in eight years.  then what?  it’s been less than one term since obama was out of office and the system has been put into a steeper nosedive than ever as the shit trifecta of trump/varma/azar pulled back on patient protections and price regulation, started pushing for medicaid work requirements and block grant funding, and generally are doing their damndest to just fuck everyone who isn’t them over.  so what happens when we hit that term limit in eight years after whomever it is–sanders, warren, literally anyone– leaves office?

the backlash against obama came in a myriad of ways– racism and islamaphobia, sure, but also very deeply rooted in values-based (and let’s be clear because i’m sure someone is going to warp this: i don’t agree with those values that say that all-for-me-bootstrap-your-own-way-up, but the fact remains that they are, in fact, value judgments in a value system) policy objections, and the aca was the thing that was most cited against him by rival politicians.  do you really think that an even larger, more drastic overhaul of the system won’t account for more egregious backlash?  i’m all for the importance of ideals and values, but i’m also a fan of things working and surviving.  i’m not even confident we’re going to make it out of this administration with medicaid intact, to say nothing of the way that social security–y’know, medicare– is going to be insolvent by like 2030.  our best case scenario won’t be starting on the foot we’re on now, it’ll be starting five steps back in the midst of a pending economic downturn.

it’d be great if we could get rid of private insurance.  honestly.  like, full stop, no sarcasm.  i have existed in this health care system in so many ways– as a patient when i was fortunate enough to have great coverage; as a patient when i had terrible coverage; as a patient when i had no coverage; as a minimum-wage analyst at an insurance company who had to come into work deathly sick for a month straight just so i could almost make rent; as a consultant working with a bunch of other people who’re doing their actual fucking best to try and make a broken system work in a way that makes it affordable and accessible to everyone. i’m fully away of the problems caused, iterated, and perpetuated by private insurance– and i am painfully, brutally aware of how extraordinarily broken it is.  i’ve had to choose between paying medical bills before they go to collection and paying for rent or food.  i’ve stayed above water solely because of luck and privilege.  my entire career is tied to trying to find a way to fix some of these problems in a way that lasts.

but i also know that the wholesale removal of the private insurance industry is hamstrung by the way the country’s government is set up and that as nice as it is to talk about living in a world where this system– this capitalist, racist, sexist, homophobic, cruel, vindictive system–  the fact remains that this is where we are.  this is what we have, and we have to live with it, and i’d rather fix it right than keep going forward one step and then back two, like what happened with the aca and like i very much believe would happen with a medicare for all implementation.  i’d love to be proven wrong, truly; i just don’t think that i will be.  

so let’s go back to your original question.  maybe you want me to say that i support private health insurance so that you can call me a dirty capitalist who’s been fooled into hating on medicare for all by lobbyists and propaganda.  but let’s go with a few nice and concise tl;dr bullet points:

i think accessible, affordable healthcare is a fundamental human right

i think the united states needs to have universally available, universally accessible, universally affordable healthcare coverage for every person living in the country

“are you for or against private insurance” is a grossly reductive question that presumes that the existence of private insurance is the one fundamental deciding factor regarding the health care debate, and it’s not

so if you’re looking for a simple answer, let’s go with this: universal, affordable, accessible coverage.  that’s what i’m for.