It's so big!

One of the objections often raised to the healthcare reform law (hereafter to be referred to as the Affordable Care Act or ACA) is that it's around 2000 pages. After it was passed, there were cries of "nobody knows what's in it" and "nobody read it before it was passed."

Obviously somebody knew what was in it because it didn't write itself. To those who objected because their representatives did not read all 2000 pages, you might be surprised to know that a) many bills are large, because Congress deals with complicated stuff and b) most of the time your representatives rely on their staff to tell them what is in the bill and what it does. Truth be told, they spend a good portion of their time raising campaign funds, not reading every page of every bill.

Having said that, let's address the reason why the ACA needed to be so large: America does not have one health system, it has several and all needed to be dealt with in the bill.

Back in June of 2011 I did a series of blog posts concerning our healthcare problems and how healthcare was handled in other countries. (The first was here, you can find the rest from the sidebar once you're at the first post.) After laying out the various healthcare systems in other countries, I asked which system was used by the USA. That turns out to be a trick question. Here's part of that post:

[NOTE: "Reid" below refers to Washington Post Journalist T.R. Reid whose work is extensively quoted in my blog posts, NOT Senate Majority Leader Harry Reid.]

"You will recall that there are basically 4 healthcare financing systems in use. Here they are again, along with the countries that use them:

Method 1 - In countries that follow this model, both healthcare providers and payers are private entities. The model uses private health insurance plans, usually financed jointly by employers and employees through payroll deduction. Your doctor's office is a private business, and many hospitals are privately owned. (Germany, Japan, France, Latin America (to a degree). I didn't ask about them, but Belgium and Switzerland fit in here as well.)

Method 2 - In this system, healthcare is provided and financed by the government through tax payments. There are no medical bills; rather, medical treatment is a public service, like the fire department or public library. Many (sometimes all) hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. (England, Italy, Spain, Cuba and most of Scandinavia. Hong Kong also has a version of this system.)

Method 3 - The providers of healthcare are private, but the payer is a government-run insurance program that every citizen pays into. The national, or provincial, insurance plan collects monthly premiums and pays medical bills. (Canada. Taiwan and South Korea has variations on this system.)

Method 4 - Most medical care is paid for by the patient, out of pocket, with no insurance or government plan to help. (Cambodia, India, and most other poor countries of the world.)

When we left off yesterday, the question was which of these models does the USA use. Here's what Reid has to say on that subject.

1) "For most working people under sixty-five, we're Germany, or France or Japan. In standard Bismarck Model [NOTE: that's the real name of this model first put together 125 years ago by the German ruler of that name] fashion, the worker and the employer share the premiums for a health insurance policy. The insurer picks up most of the tab for treatment, with the patient either making a co-payment or paying a percentage."

2) "For Native Americans, military personnel, and veterans, we're Britain, or Cuba. The VA and much of the Pentagon's Tri-Star system involves doctors who are government employees working in government-owned clinics and hospitals. Following the Beveridge Model [NOTE: Named after William Beveridge, the reformer who inspired Britain's National Health Service] Americans in these systems never get a medical bill."

3) "For those over sixty-five, we're Canada. U.S. Medicare is essentially a National Health Insurance [the official name of this model] scheme, with the near-universal participation and the low administrative costs that characterize such systems. Americans with end-stage renal disease, regardless of age, are also covered by Medicare; this group had enough political clout to get what it wanted from Congress, and the "dialysis community" opted for coverage under the government-run NHI system."

4) "For the 45 million uninsured Americans, we're Cambodia, or rural India. These people have access to medical care if they can pay the bill out of pocket at the time of treatment, or if they're sick enough to be admitted to an emergency ward at a public hospital, or if they have access to a  charity clinic."

5) "And yet we're like no other country, because the United States maintains so many separate systems for separate classes of people, and because it relies so heavily on for-profit private insurance plans to pay the bills. All the other countries have settled on one model for everybody, on the theory that this is simpler, cheaper, and fairer. With its fragmented array of providers and payers and overlapping systems, the U.S. healthcare system doesn't fit into any of these recognized models."

That's why the bill needed to be so large. Herman Cane said that if he were president he would not sign a bill longer than 3 pages. If Cane could do the ACA in 3 pages I wouldn't vote for him as president, but he'd make one hell of a find for a congressional staff.

This post is a little longer than I would have liked, so I will stop here and get back to the raw factfinding in a couple of days.