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.