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Phil's Rambling Rants
September 23rd, 2005
02:53 am


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Ideas: Universal medical care
Essentially all of the rest of the industrialized world, and a lot of people in the US, think it's a disgrace that we don't have universal medical coverage in this country.  We spend much more per capita or as a fraction of GDP than any other industrialized country, but our overall statistics are pretty bad because the best-in-the-world health care system is only open to people who can pay for it.  I could go on for hours, but I think we can stipulate for the sake of the argument that it needs fixing.  The question is how do we do it, in the real world where somebody has to pay for it?

Back in the beginning of the Clinton Administration, there was real talk about trying to improve the situation, and one of the boogeymen the people who supported the status quo scared the people with was the dreaded Two Tier Health Care System.  I never really understood what they were talking about.  We already have a two tier health care system -- just ask someone who doesn't have insurance.  And while the wonderful American idea of equality may be offended by the idea that not everyone will get equal health care, it simply defies common sense to imagine that the CEO of Exxon would ever not have access to better health care than the school bus driver.  Even if it were possible to spend as much money on the school bus driver as the CEO will spend of his own money, the CEO is going to have the connections that make sure he gets in with the best doctors in the best facilities in the country.  As long as humans are involved in delivering care, there will be some who are better at it than others, and as long as there are powerful people, they will be the patients of the best doctors.  What we need is not to try to avoid having an unegalitarian two tiered system; what we need is to acknowledge the reality that there will be a two (or more) tiered system, and concentrate our efforts on making sure that the bottom tier is good enough.

So what's a good, working definition of good enough?  You can try to have a bunch of medical experts define a minimum standard of care and a schedule of treatments that they'll pay for, but it's enormously complex; it's prone to mistakes that tend to push too many doctors and hospitals into some areas of practice and leave too few in others, and it's very hard to keep it up to date as medical technology advances.  It's also hard to control the costs, since the medical experts decide what should go in the standard more on the basis of medical effectiveness than cost effectiveness.  Alternatively, you can just set a budget for the National Health Service and tell them to do the best they can for everybody, but the National Health Service is likely to be chronically underfunded.

I think the key to keeping the government-provided system at a fair level is to have it operating at the same time as a mostly-free-market system.  The government system is free; the private system is top-notch but expensive.  It's properly balanced (according to my definition) when 75% of the people are on the free system and 25% are opting to pay for the private system.  When the successful upper middle class are split on whether it's worth paying for the private system, that seems like a good guarantee that we're not treating the poor who don't have a choice too badly.

There are a ton of details that would have to be addressed to make sure people aren't gaming the system, and there's still the problem of making sure that Congress actually does their part and budgets the money needed to keep the free system good enough to stay in balance.  The only point I'm really trying to make is to suggest the outline of an objective way of deciding when the free system <b>is</b> good enough.

I perhaps ought to quit now, but I will continue with mentioning a few of the details.
  • Private insurance must take all patients and cover all medical needs with no pre-existing condition limits.  They can base their rates on age, and include moderate surcharges (on the order of 10% or less) for major voluntary risk factors like smoking, but they have to take everyone who can pay.
  • Employers aren't allowed to make health insurance a hidden benefit with special tax status.  If they want to cover health insurance, they can add the cost of the premium onto the employee's salary.
  • People on the free plan can't sue for money damages for malpractice.  Bad outcomes in the free system are investigated by a system that works like the NTSB does for air travel that objectively determines what went wrong and modifies procedures to make mistakes less likely.
  • To prevent healthy rich people from staying on the free system until they find out they need a tricky, super expensive new treatment, the private insurance system can require a long term contract that you can't get out of unless you prove you can't pay.  You can switch private providers, but you can't just drop back to the free system when you're healthy again.


(3 comments | Leave a comment)

(Deleted comment)
[User Picture]
Date:September 23rd, 2005 07:25 pm (UTC)
Why can't a universal health system just cover everything that's non-optional?</i? Very little medical care is really optional, in the sense of it being a luxury. For everything else, it's a question of level of care. If the $100 treatment usually works, but it has drawbacks (like it is very painful for a long time, or a small percentage of the time it has serious side effects), and the $10000 treatment has fewer drawbacks, is the $10000 treatment necessary or optional? The CEO certainly thinks it's necessary. When you're talking about health care for a whole country, there isn't enough money in the country for everyone to have the CEO treatment every time, but that doesn't mean the CEO's treatment is frivolous. It means that, however much it sucks, many people must, one way or another, miss out on care that could actually help them. I can't fix that. I just want to make the bottom level as good as it can be.
[User Picture]
Date:September 23rd, 2005 07:46 pm (UTC)
WTF? There was an answer under the quoted text when I posted that.

It's not a question of whether it's optional to treat a condition or not, it's a question of how much treatment that is clearly medically worthwhile we can afford. Especially since there are often treatments that are somewhat better and a lot more expensive. The universal system should cover everything except really frivolous stuff, cosmetic surgery to keep people looking younger, but it has to be limited by cost. The way to make sure that we're not saving too much money is to make sure that some people who actually have money think it's good enough. The way to make sure we're not really spending too much is to make sure that some people are willing to buy their own care.
(Deleted comment)
[User Picture]
Date:September 23rd, 2005 08:36 pm (UTC)
No treatment is perfect; there are always possible side effects, complications, and drawbacks. A more expensive treatment that has less side effects may be a luxury if the side effects avoided are more annoying than severe, but a lot of the time you really want the better treatment. If it is affordable, it should be included in the standard level of care.

The higher level of treatment should be covered by some kind of insurance, because if it's not, the one person in a million who would benefit from the million dollar treatment won't get it. It is possible for the extra care handled by the private insurance to be delivered at the same facilities by the same doctors as the free basic coverage, but I think the rich people will want to pay the extra cost to have separate facilities. I think the system should be structured so that those separate facilities are available for the well off who want to use them, not just the super rich.
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