(more) disjointed thoughts about health care reform

1) It isn't that I am eager for the changes Mr. Obama has proposed (what are they again? Does anyone know? Does he?) so much as it is that there is very little about the current health care system that I find defensible. I understand that the Republicans do not want government-run health care (except, you know, when they do) but I am equally perplexed as to exactly what it is that Republicans are defending as I am about what the administration is proposing.

2) I think universal health care is a perfectly laudable goal. There really is no reason we couldn't do it (from a financial standpoint) if we weren't so keen on running a global empire. That said, I have absolutely no faith in the American political system to create and run a Canadian or French-style single-payer system (setting aside for the moment whether I would actually want it to or not). There are too many stakeholders in the status quo...we'd have to have public (only) campaign financing first. And that isn't going to happen.

3) That said, if the goal is actually universal care, then I don't understand why the discussion isn't focused on a substantial (and universally available, if not universally utilized) safety net-type system, built from the ground-up in addition to everything that already exists. (And no, I have no idea how to do this.)

This "public option" which is apparently meant to compete with private insurance and drive their prices down while (simultaneously!) not in any way affecting their ability to do business with the millions of people perfectly happy with their current coverage (like, for example, me)--all while the federal government is going to prohibit private insurers from denying anyone coverage for much of anything--is a bunch of incoherent nonsense. Might as well promise a pony to every little girl in America, while we're at it. (It'd be cheaper.)

4) I do worry about the effect of any reform--including the ones I am very vaguely proposing--on health care innovation in the long run. And you should, too, even if you find the notion of charging people money for life-saving care morally reprehensible.

5) If you think Americans spend a lot more on end-of-life care than the rest of the world now, just wait until the Boomers really start dying off. And if you think that they are going to be the ones to change this, I have an ocean-view condo to sell you. It's in Detroit.


Dave said...

The trouble with health-care reform is that there is no apparent economic circumstance that is going to provide people what they want; namely, unlimited medical care without economic consequence. Especially in terms of end-of-life care, the demand for increased services cannot be met without *some* check on the availability of services.

I understand (better than I did) the lack of economic constraints associated with medical care. My father recently died 15 months after being diagnosed with a brain tumor. (I say this to illustrate my opinion, not to suggest that my opinions carry some special clout because of my experiences. While I feel sorry for 9/11 victims, I do not think their families hold unique insight into matters of domestic security public policy) One reason health-care costs are increasing beyond the rate of inflation is that the capabilities of medicine are increasing quite rapidly. My father's tumor was surgically removed in a procedure where the surgeon was guided by a computer that directed where to cut based on an earlier MRI. I am quite sure that for a similar diagnosis 20 years earlier, the patient would have been provided with some sleeping pills and the phone number to hospice. This procedure was in no way a cure - the oncologist and neurosurgeon were adamant that the tumor would return. But my dad opted for the surgery (along with radiation and chemo) and the insurance paid for it. And he enjoyed a relatively healthy life for about a year. Because of the nature of insurance and our system of ethics, there was never a discussion of whether the extra year of life was worth the money. Later, when the tumor returned, my dad opted for a procedure called a "gamma knife" which I imagine was quite expensive but turned out to be wholly ineffective. Again, even when the probability of success was very low, no one suggested that the procedure wasn't worth the money. Nowhere in this process was there any mechanism to limit the amount of money spent on my dad. But certainly the bills were quite pricey; real money to the insurance company (in this case, the US government since my dad was retired from the navy). Any discussion of health care reform has to acknowledge that at some point unlimited resources cannot be expended on everyone without regard to any financial limitation or consideration of effectiveness.

Our current medical system seeks to use an insurance model to provide sufficient money in order that everyone have some amount of coverage. But increasing premiums and deductibles suggest that the money is running out - there is not enough money available to pay for unlimited treatment. Imagine if my dad's life have been extended another year but at a cost of $1 billion. Now multiply that times the entire population - obviously not sustainable. But that's what the public demands: access to medical care regardless of cost. For that reason, I tend to think that B is quite right. The baby boomers will happily seize whatever money can be found to meet their expectations of unlimited medical care. But the problem with the solutions being offered is that they do not address cost except by mandating others to fund them. And that is where I tend to think B is off-track. Fundamentally, health care reform is about power and control - the ability of the government, under the guise of controlling cost, to mandate behavior. I probably have better health care than 99% of the public (B knows why, its related to my employer - an employer than best remain unnamed due to the political nature of this discussion) so I will acknowledge that I am largely shielded from health care concerns. But the simple fact remains that medical care costs so much more than it did in part because medical advances are quite expensive. And while I understand other people's desires to access that care regardless of cost, I do not think that justifies the seizure of my property or the curtailment of my individual liberty (through mandatory insurance) to facilitate it.

Brian said...

I don't think you'll find any disagreement from me that a possible (likely) outcome of giving the government a vested interest in your health is that the government will become increasingly (and legitimately) concerned with your personal behavior.

I think the only way a universal safety net can is in any way compatible with a libertarian view on personal liberty is that it is: 1) universally available, but not mandatory, nor is it to the exclusion of better, private care; 2) of the "no fault" variety; i.e., delivery of services is in no way contingent on having made good choices about one's health.

Point 1 is clearly achievable; that's essentially the system in many parts of the world. Point 2 is bound to be politically unpopular with nearly everybody. (Like I said--I don't claim to have any idea how to actually do this.)

It does seem the key to the safety net approach is to make it good enough to meet some minimal humanitarian standard, but not so good that people who can really afford better would opt for it just to save money. I'm sure this is a problematic equilibrium, too.

Which really is why I am all over the place whenever I write about this. I have no idea what the hell I am talking about. What concerns me is that I'm not convinced that anyone else does, either.

Dave said...

As a matter of public policy, I don't think there is a fix to the health care issue. It has the potential to consume as much money as can be thrown at it without resolving the fundamental issues. I do know that any plan that is advertised as decreasing costs while maintaining freedom of choice and not restricting behavior is likely a bunch of BS.

What I hear being discussed at the Federal level is a variation on the Massachusetts plan where health insurance is deemed mandatory by the state and those without it are fined. Well, I have a bit of a problem with that approach because I am rather uncomfortable with the government mandating behavior. (Health insurance is not the same as auto insurance - I can always choose to not drive.) But I am also skeptical of the assumptions such a plan makes, most specifically that it is the young that somehow are screwing everyone else over and not paying their fair share by not paying for health insurance when they are young and likely don't need it. First, this categorizes health insurance as an entitlement, using the same rhetoric as Social Security, envisioning a system where a person is entitled to a benefit for having paid in for a specific amount of time. That's not how health insurance works and illustrates that some people either have no idea what they are talking about or exploit the public's misunderstanding for their political gain. Also, from what I can tell from the Massachusetts budget, its just factually not true. Between state subsidies for medical insurance and increased demands of insurance, the state faces a significant and unexpected financial burden that it cannot support. Bottom line - mandating health insurance is a creative way of mandating a transfer of wealth from young to old, something baby boomers (and their parents) are quite good at doing. Compounding this are state policies that prevent insurance companies from setting premiums based on individual behavior but instead price based on a "community standard" or mandate coverage for non-medical emergencies such as IVF or (as in Connecticut) hair replacement.

Neither point 1 nor point 2 are realistic. You cannot make health care universally available while at the same time separating methods of paying for it. If it is always available, why would some choose to pay greater premiums for what is essentially the same service? Point 2 is compelling in principle, but is unachievable in practice. The temptation to use the power of government to reduce costs will be unavoidable.

Bottom line: the public expects unlimited medical service but does not think that a significant portion of their income should have to be used to pay for them. I fear the public has the same entitlement view of retirement and to achieve both will happily use the power of the state to confiscate whatever money is available to make it happen. So I agree with B that this is quite a mess and there probably isn't a good fix. But that won't stop politicians from suggesting that can be easily fixed by taxing someone else.

Brian said...

Neither point 1 nor point 2 are realistic. You cannot make health care universally available while at the same time separating methods of paying for it. If it is always available, why would some choose to pay greater premiums for what is essentially the same service?

Ask the English who opt for more expensive private care over the NHS.

I'm not saying their system is ideal (neither is ours, which is my main point, really) but to assert that any other way of doing it is completely untenable flies in the face of an awful lot of data from pretty much every country in the developed world except this one.