It’s interesting to listen to educated women talk about important issues of the day. This eavesdropping was about health reform. One would expect the discourse to be filled with insights and nuanced arguments, references to law and ethics, comparisons to other health systems and how the new reform movement will help (or hinder) members of our society. And we do. But one would also expect that there could be some form of consensus about how to proceed for the betterment of all.

One would expect that. But one would be wrong. It’s not that educated women aren’t concerned. They are. But the dividing line between their arguments cuts along rhetoric rather than reason. We are torn between our hearts and our pocketbooks.

None of us want to live in a country where everywhere we turn we are reminded of the discrepancy between have’s and have-nots. We ache at the visions of children broken by malnutrition and disease. We cry for people who, through no fault of their own, are devastated by disfigurement or congenital conditions that marginalize them from mainstream society, jobs, security and self-esteem.

Women are generally nurturers and caregivers. We can’t stand to neglect the suffering of children, the aged or people who are truly victims of circumstances beyond their control. We want there to be many options available depending on one’s ability to pay.

Women believe that health care is essential for everyone. Philosophically and morally, women don’t like the notion that affordable health care is unattainable. But agreement then diverges into whether healthcare is a right or a privilege. Should people, regardless of age, viability, potential for a positive outcome or ability to pay have the right to as much healthcare as they want, or does society have the right (and responsibility) to ration its resources according to need?

The fault lines occur when the ideal: universal entitlement, gives way to the real: implementation. It’s one thing to say everyone should have access to affordable healthcare. It’s another to insist that you and I pay for it.

But if God is in the details, let’s listen to what these women are saying.

• If everyone is entitled to health insurance (which seems to be an unchallenged premise), then does that mean those of us who do pay for health insurance have to carry those who don’t? (“I work hard to pay for my health insurance. Why should I have to pay for someone who just uses the system to sit on his ass and smoke cigarettes?”)
• What if the “conditions” are caused by lifestyle choices such as smoking, obesity, drug addiction? (“Why should we be required to pay for insurance for people who use their food stamps to buy Twinkies and beer instead of health care?”)
• If one champions free enterprise and a market-based economy, how can insurance companies be forced to cover patients considered bad risks? (“They should cover everything. They make enough money!”)
• If we live in a free country, how can citizens be forced to buy insurance coverage if they can’t afford it, or choose not to allocate money toward it? (“If they don’t have insurance, we pay for it anyway in the form of utilization of emergency rooms.”)

As responsible taxpayers, each of us makes financial decisions every day. Can we afford this? Should we pay that off? We know how much of our paycheck or bottom line goes to pay taxes, and we complain that so much is taken out of our income and that this curtails our ability to purchase things we want. That’s why it’s easy to be magnanimous in theory about universal healthcare as long as it doesn’t translate to the practical reality of increased taxation.

Listening in on the conversations people are having about health reform tells us one important thing: there is little understanding about what it is, who it will affect, and importantly, who will bear the brunt of the costs. And until we start conversing in ideas versus sound bites, we will remain ignorant of the consequences of acting on misinformation. At least women are talking with each other. It’s what smart women do.

We currently have an interesting hybrid system of care:

• Medicaid (For the poor)
• Medicare (For those over 65)
• AARP Supplement (For those over 65 who need to augment what Medicare pays)
• HMOs (Managed Care)
• PPOs (Managed Care with Choice)
• High Deductible Health Savings Accounts (Individual plans purchased for catastrophic care and where everything else is paid for out of pocket)
• Fee for Service (Cash)
• Concierge Medicine (Premium service for the wealthy)

Those who are very ill and without insurance utilize the emergency rooms of hospitals for their care, and we end up paying for it through taxes. This “uncompensated care” represents a tax burden on those who pay taxes. And a philosophical burden on those who have to make the decisions, apportion care and provide for the needs of those who show up at their doors.

Medicare recipients are entitled to health care if they can find a doctor who will accept Medicare payments (often too little and too late) because many good doctors are refusing to accept Medicare patients at all.

HMOs and PPOs are usually paid for by employers, and now more and more employers are requesting that their employees contribute. In other words, they have to have some skin in the game, and many employees (especially unions) are fighting back.