06 March 2007

Universal Health rundown

Scalpel has made it clear that he would prefer the federal government stay more or less out of the uninsured crisis, as he feels that, given adequate resources, local authorities can handle it better. (please correct if I misstate your thoughts, Scalpel.) Michael Negron over at TPMCafe has an interesting rundown on the various proposals which have been floated to address the situation. Here's one which ought to please the other irascible Texan:

Another approach, outlined by Henry Aaron and Stuart Butler, is the creation of a structured national program of state experimentation with approaches towards expanding insurance coverage. This program could be enacted through federal-state “covenants” that condition federal funds upon the adoption of congressionally-specific policy constraints and approaches aimed at a set of defined goals. The “policy toolbox” of presumptively approved insurance solutions would enable advocates of different approaches, typically divided by partisanship or ideology, to buy into the program in hopes of building a broader consensus in favor of their views. The toolbox may also have the virtue of expanding coverage while simultaneously shifting the political playing field to the states, as advocates lobby state governments to adopt one approach or another. This approach may require preemption of state benefit mandates by federal regulation to permit. Like the individual mandate, this approach could expand health insurance coverage across the country while leaving costs rooted in administrative overhead and quality and efficiency of care unattended.
Personally, I am not a fan of the 'local experimentation' model. The reason is highlighted by the disagreement between Scalpel and myself: his community apparently has great resources set up for for indigent/uninsured, while those in my community are inadequate for the need. If local communities are allowed to tinker with the options, it's guaranteed that some communities will screw it up and those people will suffer, and I feel that health care is important enough that it shouldn't vary by the accident of where you happen to live. It is true that a locally varying solution would be better than a universal solution that sucks, and I am really afraid of some half-assed please-nobody compromise will come out of this whole debate. I also admit that I have not yet read the full text of the Aaron-Butler proposal and I am feeling a bit too hypoxic and dehydrated after Karate to give it careful thought just now.


  1. It's not necessarily that states could (or would) handle it better. As you said, some would, some wouldn't. I just don't agree that guaranteed provision of healthcare to all citizens is a federal responsibility.

    We are a nation of states, and not all states are equally prosperous or adept. Our roads are not equal, our schools are not equal, our individual circumstances (such as the numbers of illegal aliens, unemployment, college education, teen pregnancy, and the like) are not equal. Why should we be subjected to a one-size-fits-all national healthcare financing system?

    Huge federal nanny programs lead to complacency, dependence, and ultimately poverty. We can do better.

  2. My take, btw, is that it doesn't matter who is paying. Our healthcare crisis will not be solvable by any solution until the realization sets into the American consciousness that not everyone is entitled to the same level of healthcare, and that a lower level of care is often sufficient. Heck, I hate paying the exorbitant cost of my family's healthcare too, and I'm a "rich doctor." Going to the dentist is a huge financial hit, but we haven't heard many arguing for universal dental coverage.

    You want to tax everyone $500? Then you can give $500 worth of healthcare to all. That's less than one ER visit for a sprained ankle, the Radiologist's fee for reading a CT scan, or a few months of Lipitor. Forget about the MRI, PET scan, endoscopic pill camera, or TEE.

    Would it ever be OK to do a transthoracic ECHO in a "poor patient" instead of a TEE, even though the TEE would give better info? How about serial examinations instead of a CT scan? A trial of Zantac instead of an EGD? Amputation instead of fem pop? Pain meds instead of knee replacement? Diet and exercise instead of bariatric surgery?

    These are the sorts of things that are on the horizon, if not now then eventually. Prices (and expectations) have to come down. We overtest, overtreat, and skip over many simple inexpensive therapies, and that is what is straining our healthcare wallets.

  3. While you are at it why not b/l orchiectomy for prostate cancer? The cheapest quickest cure for prostate cancer by far...

  4. Nah, watchful waiting is cheaper. But if that's the only treatment someone could afford, then why not? They might even offer it in shadowfax's single payer plan for "free."

    Would they offer radical prostatectomy? Maybe to selected cases on a waiting list basis, after one has obtained the proper clearance.

  5. scalpel:

    taxing everybody $500 gives $2500 of care to all, because only one in five is uninsured. you are correct, of course, that the issue of universal coverage is different to that of rising health costs; however, a monopoly purchaser is better able to negotiate with pharma, with doctors, with other suppliers about reducing these. in Australia (the other health system that I am familiar with), the government negotiates prices with pharmaceutical companies; if agreement cannot be reached, the drug is not listed in the formulary and the great majority of doctors don't prescribe it. OTOH, the government has decreed (not negotiated) doctors' reimbursement (like Medicare reimbursements) and so now 25% of general practitioners and about 80% of specialists will charge a fee above the reimbursement, which comes out of the patient's pocket. Where the government and doctors have negotiated (primarily radiology and pathology), rates of "bulk billing" (ie not charging a surcharge) are much much higher.

    what does this mean for the US? you're right that states are not equally prosperous. for things that are supplied nationally (drugs, stents, supplies) national price negotiation is appropriate. however, for things that are supplied locally (primarily services) local supply and negotiation is appropriate.


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