Osler's Razor

Personally, I think that health care reform should be focused as much on reducing the need for health care as providing expanded coverage. Things like subsidizing fitness and wellness programs, increased funding for education, and reducing the availability of unhealthy foods and products that decrease health is the first place to start. That said, I think the biggest step to increase overall health is government subsidization of basic preventive medicine, either through a single payer system or a government insurance program.
 

What was the myth?

One concern I have is the idea that government healthcare would provide "competition" with private healthcare insuerers. How does the fact that nothing requires the government to run in the black impact the new "competitive" market? If you and I are selling the same widget but I HAVE to make a profit and you can hemorrhage money without blinking, how do I stay in business?
 

Impose reforms and let charities, religious groups, etc. do their jobs. Sure, there will still be people who can't get coverage, but its too idealistic and unrealistic to think some government plan will solve the problem.
 

Option 2 presumes that centralized medical records is a solution to a problem, or that it would affect efficiency to a visible degree - enough to change the affordability of health care to some one. No basis in fact.

I'd ask first, what is the root cause of unavailable to too expensive health care for Americans? What is the biggest expense driver? Betcha it isn't medical records!

A fact based analysis would help folks decide which side of the "debate" to fall on; right now it looks like unsubstantiated assertion on both sides.
 

The only one that makes sense if what you want is decent health care for all Americans (that won't send them into individual bankruptcy) is #4.

However, if what you want is extraordinary care for the wealthiest, you probably want #1.

If you want low taxes, you probably want #2.
 

Centralized records are something that will help the system be more efficient but I don't think that needs to be a cornerstone of the bigger reform that is needed. It is just something that is logical and should happen.

I lean toward option 3 as a person who purchases health insurance in the open market. I have no faith in Humana, Aetna, BCBS, etc...

If we get sick; not the standard flu, broken arm, etc... but SICK; cancer, stroke, heart attack I dare say that they will drop our insurance or make it so cost prohibitive that we can not pay for insurance. Take our money and run!

The fact that health insurance company's are concerned with THEIR bottom line means they do not have our best interest at heart; unless we are shareholders!
 

The problem with health care is a decoupling of the relationship between patients and health care providers. Insurance companies act as an intermediary between the two and skew the effect of supply and demand on pricing. So does pharmaceutical advertising.

For example, most patients are going to ask for whatever treatment they can get for free and more of what is partially covered than they would otherwise. That's prudent from their perspective, why take chances with your health? But it increases insurance costs. Doctors are complicit because a) they get paid more and b) some are scared of being sued if they miss something.

Re: pharmaceuticals, there is a similar effect as advertising creates demand by consumers and drug reps give incentives to doctors, often for new drugs that are very similar, but less tested, than older drugs.

The solution is to restore a more direct relationship between health care providers and their customers and educate consumers about pharmaceutical advertising (which is still relatively new).

I would do this by letting plaintiff's lawyers sue the hell out of doctors who pad their expenses with unnecessary treatments, roll back tort reform on med-mal, and let them go after pharmaceutical companies for their advertising and sales practices. We also need to allow competition between insurance companies across state lines and suits for price-fixing and other anti-competitive practices. Centralized medical records provides only a minor improvement to economic efficiency while creating a huge risk of abuse or loss of privacy.

I think insurance companies should be forced to compete, dr's should be held accountable for running up their costs, pharma should be held accountable for their advertising claims and their marketing practices. The best way to do that in my mind is to let plaintiff's lawyer's loose on behalf of consumers who are being victimized.
 

Joe - very well put
 

I favor a combination of 3 and 4: a public option plus single-payer, but with strict limits.

In other words, have the government create two plans -- one publicly-funded and universal, the other funded by premiums of people who sign up (the public option plan).

The public option competes with private insurers. That's why you do it, not an undesirable side effect. If private insurers can't offer something better than a government-run plan can provide, they lose. Unfair, you say? Tough. Keeping insurers in business should not be a policy consideration (unless that contributes to the public good). Once launched, the public option runs on revenue, just like the post office. It can't "hemorrhage money without blinking," it just doesn't have to show a profit. Why should I have to pay more for health care so that some shareholders make a profit?

Everyone in the country is automatically a member of the universal plan; No need to sign up, no need to send out membership IDs, no need to spend money administering a huge list. But it only provides "basic" health care. So what is "basic"? Whatever we, collectively, are willing to pay for through taxes.

Estimate the cost and benefit (both private and public) of various treatments, especially preventative care, and put them in a list sorted by the ratio of cost to public benefit, then by cost to private benefit. From existing studies, I know there's going to be part of this list where the public benefit exceeds the cost -- vaccinations for certain diseases, for instance.

Decide (through the political process) to fund $X in universal care in a given year. Start at the top of the list (most "cost-effective" treatment), project the likely demand for that treatment, and multiply by the cost. Subtract that from the $X. Keep going until you reach an item that would leave you with negative dollars. Every treatment up to that point is "basic" care.

The universal plan makes both public and private health insurance cheaper, since they don't have to pay for "basic" care. Of course, we still pay through taxes, but the cost is distributed in a progressive fashion. Meanwhile, the public option lowers the aggregate cost of health care by reducing the amount of money spent on administration and private profits.
 

I agree with Joe...address the real problems...don't add problems by bringing in some government system
 

Wow, Evan, that sounds pretty interesting . . .and I agree with Justin, too.

One irony that has struck me lately is that it's assumed--expected--that the federal government will of course come up with a vaccine for H1N1; that the Government is the entity ENTIRELY responsible for dealing with it. We have no problems trusting the federal government with that part of the health-care spectrum. We expect it, just as we expect that FEMA will come in immediately when a hurricane strikes.

So why are people so suspicious of a public health insurance option?
 

I'm gonna point out that even in Universal systems (I lived in a communist country for a time) there are still large numbers of the population that go without insurance.

Furthermore, in the socialized countries that are typically held up as models, we find very homogeneous populations thus making it cheaper to administer proper care. The french have less heart ailments, the Japanese, less cancer, the canadians, less obesity issues etc etc.
Becuase of America's development as a "melting pot" you can't get far due to the lack of economies of scale. Hence, any publicly funded option will ulitmately be too cost prohibitive.

Also, don't forget that the ones who are without insurance are typically your highest cost patients due to problems health problems associated with socioeconomic status. Thus, to make any system work, you have to force the healthy (i.e. wealthier people who take care of themselves, and most likely already have insurance) into the system.

the answer to the question is probably closest to #2. We have to make the changes to the system to increase efficiency and thus lower costs for both the government and insurance companies but that alone will not solve any real problems.

My favorite approach would funnel the money to public hospitals (like Dallas' Parkland) that are generally free to those that can't pay. Build hundreds of state of the art hospitals across the country in the neediest areas and attack the issues from those centers of care. This also creates jobs in poor areas and brings in quality doctors since many are "teaching hospitals." By the way, Parkland does a great job with preventative medicine and doesn't limit itself to emergency care.

The other component would be to give tax breaks/credits for low income people to purchase insurance from private insurers. You work, you pay taxes, you can now afford health insurance. You don't work, you don't pay taxes, you can try the free hospital if you have an emergency.

As I said before, you will never be able to help everyone and insure everyone, but I think that this approach would help the neediest and allow many more to get insurance.
 

This is the best discussion I have seen yet of the health care issue. Too bad it is on this low-traffic blog! Which, hy the way, seems to be run by a community of fascinating weirdos. I have to assume that "Professor Osler" is a fictional character?
 

All of these comments have been very thoughtful. But at the end of the day there are still a whole lot of people who are healthy (not obese, diabetic, etc..), who exercise, eat reasonably well who are fearful that what insurance they can or can't afford won't do the trick. They are willing to pay but would like the assurance that IF they really need medical help they will have coverage they can afford without the fear of being priced out or dropped.

These are reasons we need reform.

Swissgirl - I like your comments about H1N1 and FEMA
 

the H1N1 and FEMA analogies don't hold...first, I don't know that we trust the government in those cases all that much anyways...second, even if we do, those are temporary solutions to temporary problems
 

There is a fifth option that I'm surprised no one is talking about. Of course we'd do everything we can to streamline, modernize, and improve our current system. But instead of implementing a "public option" in direct competition with private insurers, we create a low-cost, subsidized option and only open it up to the low to middle income folks who can't afford insurance without help. Think Medicaid, but with people paying what they can afford to.

The problem isn't that we don't have enough insurers in the market and need more "competition" from the gov't. The real issue is that we don't have good low-cost options available. Obviously, a gov't option will be designed to undercut private insurers, and you have to recognize how this hurts those of us who already have private insurance. A low-cost gov't option open to all consumers would do more harm to existing coverage levels than it would to help insure more people. Ultimately, all it will do is create lowest common denominator coverage under a price ceiling. However, a low-cost option only open to the people who really need it increases coverage, brings new customers to the market, and does nothing to harm the existing market and our current coverages. Don't forget that only 1/2 to 2/3s of oft-quoted the 46 million uninsured in this country lack insurance because they can't afford it. The remainder pay out of pocket out of choice, or are here illegally and wouldn't be covered under a public option anyway.

In short, I think in healthcare we can have our cake and eat it too, so long as we exercise later as Justin recommends.
 

Anon: Osler is real. You can look up his faculty profile at baylor law school.

I think the preventative medicine and "basic" plans are an interesting idea, except that we already have them. Anybody who wants to can engage in exercise and healthy eating and low income and elderly and disabled folks and most kids qualify for government provided or subsidized health care already. If they choose not to use it, then what? You gonna make 'em? I'd rather not have the government tell me when I need to report to have my lifestyle examined and my body prodded. Lol.
 

And, frankly, we would prefer not to prod Joe's body.