13 January 2007

Universal Health

Wowie. Since the Democrats came back into the majority, it seems like the intertubes are suddenly choked with competing plans for universal healthcare coverage.

Senator Wyden of Oregon led out of the gate with an ambitious plan to dissolve the nation's employer-based health financing system in favor of individual mandates and community-rated plans. I like this idea, though it has enough unanswered questions to raise doubts whether it would work if enacted. It has sweeteners to bring employers, doctors, and insurers on board, and more importantly, it has the vision thing -- a big, bold plan which is simpler and much more palatable than HillaryCare. I suspect it will go nowhere.

In California, the Governator has followed in the footsteps of Mitt Romney by proposing a plan which would essentially force employers to pay for health insurance, either directly, or indirectly into a state-run health plan. It also inlcudes subsidies for the poor and community rating of plans to prevent insurers from trying to select out the sickest patients. However, the benefits are rather stingy, and for some reason they chose to ensure the health-care industry's opposition by taxing the income of doctors and hospitals to fund the state plan. There are rumors of price controls in the plan which sound ominous, but I have no direct evidence of. In the end, as Ezra points out, it is a great proposal from a Republican, moves the discussion left, and is unusual in that it is likely to be enacted in some form.

Representative Pete Stark and the folks at the Economic Policy Institute have a fascinating proposal of a hybrid national public-private system. It's simple and elegant. To crib from Ezra: "The government will create a new, Medicare-style health plan that's open for enrollment to any and all individuals interested . . . all employers will be required to offer insurance as good or better than the new government plan. If they don't want to contract out with the private sector, they'll pay 6% of payroll to enter their workers into the government plan. The unemployed and self-employed will have to buy coverage, and there'll be heavy subsidies tied to income." I suspect the insurance industry would fight this tooth and nail, but there's a lot here to like. This plan would essentially compete the private insurance industry out of business, I think. The net effect would be a gradual transition to a single-payer system, or one in which the private insurance industry is either much smaller or much less inefficient. As a doctor, I am not sure I like it, because Medicare is a terrible payer and there is a clear implication of cost controls, but from a national health policy perspective, it is pretty appealing.

And then there is the old favorite, "Medicare for all." A true single-payer system. It would be the cheapest and most efficient way to fund healthcare, would preserve the dynamism and vitality of the American health care industrial complex, and would ensure that every American had equal access to health care, without rationing. However, it would require taxes, and would essentially dissolve the insurance industry at a stroke, and would certianly draw fierce opposition from the physician's lobby, as Medicare is such a lousy payer. It would be easily tarred by opponents as big and scary and wasteful and requiring Canadian-style waiting lists, and too expensive. So it's dead, alas, because single-payer is definitely the best way to go, if only in theory.

I feel like I'm in a strange time warp to 1993. Heady times. I hope someone can muster the political courage to get soemthing on the table passed, if only as an experiment


  1. Single-payor dynamism? Been reading NHS Blog Doctor? Once the government is in total control of the system, it's doomed.

    As my latest example I offer not the Post Office but the Department of Education, and all the efficiencies their single-payor system has brought to the American Educational System. There's no dynamism in that system, it is expensive and wasteful beyond belief, it is NOT producing a better end product than even 10 years ago. Finally, if you run into conflict with the system you lump it. The system always wins, the system exists for the system, not for its constituents.

    And that's the best we could hope for with Single Payor.


  2. Medicare for all -- that is what was on offer in Austria (where I was born, grew up, and worked for a few years), Germany, Luxembourg, and every other European country I worked in.

    I ended up getting private add-on insurance, for about the same money I pay here (Seattle area) for a no-copay no-deductible no-nothing PPO plan.

    Oh, and you may not have heard what Germans and Austrians said about the healthcare on offer when I worked there -- "too little to live, too much to die." Sort of like EMTALA-mandated ER care, methinks ....



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