Vouchercare, schmouchercare

President Obama arguably scored only one point in the first debate with Republican opponent, Mitt Romney. It was getting the former Massachusetts governor to admit that his team's proposed Medicare reform amounts to providing a $6000 annual voucher for the under-55 crowd to buy private insurance.

Given how high health insurance rates leap from year to year, the vouchercare scheme merits that band-aid-slapped-on-a-hemorrhaging-wound kind of metaphor.

What such policy debates always overlook is the assumption that health care should be dispensed primarily as a commodity rather than as a necessity.

Even President Obama affirmed that the conversation would steer clear of questioning healthcare's profit-driven structure. Marking a crucial difference between Medicare and the health insurance industry, the president acknowledged that "private insurers have to make a profit. Nothing wrong with that; that’s what they do."

Certainly, nothing wrong with that--unless one considers the industry's practice of denying coverage to patients with "pre-existing" conditions; or worse, refusing to pay for life-saving treatments.

"All the incentives are toward less medical care, because--the less care they give them, the more money they make." So said White House counsel John Erlichman to President Richard Nixon back on February 17, 1971, about the beauty of Kaiser Permanente's HMO model. Consider it as a pivotal moment in the history of health care in the U.S.

The Nixon administration had looked to the HMO as means of containing inflating cost of medical care, without ever questioning whether or not it should be embedded within a transaction for profit.

This is the starting point for any serious conversation about health care affordability that can produce action-worthy conclusions.

A sincere debate begins by posing the following question: If private industry's primary aim is profit making, how will it muster the self-restraint needed to deliver health care at an affordable cost?

Affordable Care Act--DOA (dead on appeal)? Does it matter?

As pundits jockey for position in anticipation of the US Supreme Court's decision on the Affordable Care Act, the outcome of the court's call matters little because the parameters of healthcare debate will continue to overlook what exactly drives costs up.

The topic remains so unspeakable--even suppressed--as if to illustrate its taboo status. However, without integrating it into the conversation about healthcare's (un)affordability, all ideas on how to control costs are, at best, acts of pantomime.

Healthcare's prevailing assumption reads something like this: medicine's success in curing humanity's ills depends on its profitability as an industry; its delivery, as a product or service, must be structured, without limit, for profit.

John Ehrlichman, special counsel to President Nixon, put it in much simpler terms. "All the incentives are toward less medical care," the aide confided to the president in a February 17, 1971 conversation about Kaiser Permanente's for-profit health maintenance organization, "because the less care they give them [patients], the more money they [healthcare providers] make."

President Nixon signaled his approval of such an arrangement and went on to make it public by signing into law the Health Maintenance Law of 1973. It brunted an effort by Sen. Ted Kennedy, who sought to legislate universal health coverage with his proposed "Health Security Act". Eventually, Kennedy came around to support Nixon's HMO bill--a decision the Massachussetts senator later regretted.

Such details help define this nation's healthcare legacy, orienting the debate away from the privileged place profit making has enjoyed for decades; moving the conversation toward the civic or humane values that our national character depends upon.