Health Care: A Much Different Answer

I am beginning to realize just why this little project I have gotten us into is, in fact, deeply challenging. You and I, two reasonably intelligent adults who share many common beliefs about the proper role of government and of what constitute our major problems of the day, still adopt fundamentally different approaches to one of those major problems. Usually, I tend to disguise my conclusions of an argument until the end so that I can build to it, but let me make an exception in this case and start at the end and then walk through the logic of my thinking-- to use the term liberally -- all while trying to address the points you raise in your post. So, here's the bottom line: I think the only adequate solution to the health care challenge is to move to a single-payer system. Now, let me explain why.

I'll start by challenging your starting point. You claim that most people are satisfied with their own health coverage, but complain that the system itself is broken. I actually think that most people believe the system is broken AND that their own coverage is both unsatisfactory (or at least frustrating) and -- to one degree or another -- at risk. (By the way, the one group for which the complaints about health care system are lowest is among the elderly who benefit from a single-payer system.) If one starts with this premise, it is a lot easier to argue that radical change (though I wouldn't use that term to sell the plan, of course) is needed. I totally agree that single-payer is easily parodied and has lots of interests arrayed against it, but I also think that the reasons why it is not so far fetched to consider is that (a) a majority of the public is already accepting of single-payer of one form or another and (b) the largest interest of all -- buisness -- is quickly coming to the conclusion that the current system where buisnesses are largely responsible for paying health care costs is unsustainable.

Taking these points in order, consider this poll from CBS, where two thirds say that they believe that there should be universally guaranteed health care and that only 8% want the whole system to stay the same and fully 36% want a total overhaul. I know that these type of polls are not totally reliable because they are conducted in a political vaccuum where people only imagine a best-case scenario without considering all the potential downsides, but still, it seems to me that the public is primed for a total re-thinking of the ways in which health care coverage is delivered in this country.

The second point, in my mind, is more important. You argue in your post that we need to avoid making this about covering the uninsured because -- by and large -- the uninsured don't vote. On this I agree, but rather than aiming to satisfy/appeal to the middle class, I think instead that the whole issue needs to be framed as one that supports business growth. This is an argument that has even broader appeal and, actually, is even more accurate. Until we figure out a way to enable buisnesses to get out from under the burden of rapidly rising health care premiums, economic growth is threatened. When compainies like GM, IBM and GE are paying billions every year in health benefits for their employees, they are looking to stop the bleeding. The best way to stop it is not to stem the rise of health care premiums, but to throw off the burden all together. I suppose these large companies could simply refuse to pay premiums any more and risk losing vast numbers of employees, but a much more reasonable solution is to get some other big entity to pay. Enter the U.S. government.

This argument, by the way, to me represents the true $800 screwdriver. When GM is about to enter contract negotiations with the UAW and the main issue on the table is how to cover the rising health premiums -- not wages, not work conditions, not retirement benefits -- then it seems that the general public will begin to appreciate the scope of the problem.

Now, as to how to implement. This, I grant you, is a bit tricky not so much because the idea is flawed, but because you can't very well propose a plan that -- as attractive as it might be to many -- wipes out an entire industry (HMOs). I was going to propose that we need an interim phase where coverage is universal and that the cost burdens are shifted from business to the government, but that preserves the role of HMOs to manage individual plans. I suppose this is the route that Massachusetts has taken. (Details here.) We'll have to see how this plays out. It will certainly help with one of the main issues -- coverage -- but I find it hard to believe that it is going to make much of a difference on business growth matter and, so, does not represent a long-term solution.

Instead, I think we need a plan that simply sets the goal of universal health care coverage by the U.S. government as a goal and builds in a phasing in period where essentially Medicare extends its coverage to ever-greater age range. Coverage should begin first with 0 - 18 and then, for example, could add people within five-year age range increments each year over the next several years. This phase-in period would then give time to (a) HMOs to adjust their services to supplemental coverage -- much as they do for the over-65 set now; (b) the government to build up the systems needed to vastly expand and, as you rightly suggest, streamline the coverage and delivery of health care in several ways (electronic record-keeping, standard-setting, etc.); and (c) buisness to adjust salary structures to accommodate the sloughing off of paying health care benefits. On this last point, I would suggest that any good plan also has to have some regulation built in for how businesses shift monies from paying health care premiums to increased salaries that is fair to both employer and employee.

As for the issue of choice, I've never understood this problem. If every doctor accepts the same payer, then presumably patients would have more -- not less -- choice than they do when some doctors now accept patients from some plans and not others. There would be less choice for doctors, I suppose, but I think it is possible to build in some safeguards to insure that payments are fair and that there is limited abuse. As for rationing of certain procedures, this may be a real problem, but think it will be relatively limited and, if we are able to spread health care dollars more equitably, then it will actually make other problems like better technology driving up costs less dramatic. We could also build in some incentives for getting more primary care doctors into practice to build in more gate keepers into the system

A final detail point about how we pay for all this. Coverage is paid for by an increase of taxes to both employers and employees/taxpayers, but these increases, I am assuming, will be lower overall than current taxes + health care premiums. Even if the total tax/health care burden is reduced by 10% overall, it seems a no brainer. My guess, though, is that there will be even more savings than that, however. I am not sure, but I would think that covering the uninsured will do much to drive down costs. After all, if the uninsured currently use expensive ERs as their primary form of care and do not take preventive health seriously then it just makes sense that they will spend less as individuals with access to regular health care and, so, costs for the whole system will fall, as well. I know that Massachusetts is counting on this phenomenon to kick in. Also, eliminating HMO bureaucracy from the mix is bound to reduce overall costs.

To wrap up, I am both optimistic and pessimistic. On the latter point first, considering you claim that a single-payer system is a non-starter in your view, I'm not sure you and I are going to come up with some consensus plan that satisfies both our perspectives and if we can't do it, then I fear that no one can. If we cannot reach some national compromise, we'll be stuck with some variation of the same mess we are in now. At the same time, I have become increasingly persuaded that we are approaching a crisis moment. As many are fond of saying, the Chinese word for crisis is a combination of the words "risk" and "opportunity". I believe that as the crisis looms larger, the U.S. will simply have to take a more risky, but opportunity-filled step of completely overhauling the health care system. With all due respect, anything else just tinkers around the edges and leaves us in the same sorry state we're in now.

One final -- and tangential -- point that I was going to include in a separate post, but may as well throw it in here since it stems directly from yours. Your notion that there should be a set of industry-based standards of care is, in theory, good, and should defintely be explored within the context of a single-payer system, but I also think that you both overestimate and gloss over the capacity of medicine to adhere to standards. On the one hand, medicine is as much art as science. There may be certain standards of care, but as I see up close, there is also a fair amount of guess work and gray areas that simply cannot be regulated from afar. There may be room for standards, I suppose, but doctors also operate on a case-by-case basis and make decisions with individual patients and so such standards may not be possible to implement absolutely in practice. On the other hand, doctors also can fall into the habit of operating by rote and misdiagnosis or mistreat some condition because they are looking at the problem in a particular way or with a particular set of experiences. Standards may act only to exacerbate such tendencies and may, in fact, make things worse, not better.

I guess that, ultimately, our debate will continue. I only wish that the debate in the wider public sphere would continue with even a modicum of the respect and earnestness we are trying to exhibit here.