February 6 , 2006
Now I'm really worried
If I wasn't worried enough already. What with war, terrorism, the price of oil, avian flu, bad air, bad food, bad water, global warming, danger everywhere. What next? This is it: a headline in the Wall Street Journal, “Bottled Water and Tooth Decay: Kids May Not Be Getting Enough Fluoride.” Uncle! I give up!! Drink the good water and rot your teeth. Sheesh. Slow news day for sure.
But what really got me worried are the recent exertions to resurrect the Healthcare Crisis. Again. Some may think phoenix, I think Dracula. But an election is coming. The pols just can't resist. So get ready to relive the perpetual crisis that was, after all, created by the same politicians who are now hell bent on solving it. Again.
Even the Brits are piling on. The January 28 issue of The Economist has nothing less than a Special Report on “ America 's Healthcare Crisis”. The headlines roll on: “Desperate measures.” And most amusingly, “The world's biggest and most expensive health-care system is beginning to fall apart. Can George Bush mend it?” Huh?
I search for answers but not from “W” or the gov'ment or The Economist for that matter.
Like the good wonk that I secretly am, I trotted out my Health Affairs from December, 2005. In there is a plethora of articles trotting out once again the ancient, tried and failed, discussed but thankfully never tried, and shall we say new but not very interesting constructs that the politicians can hang some real stuff on. It's an election year. And I'm worried.
And what to my wondering eyes should appear, but my old buddy Victor Fuchs, leading off the issue with—what else?—the answer. Some of you may recall that it was none other than the same Professor Fuchs that uttered one of my all time favorite admonitions about healthcare spending in the self same Health Affairs a few years back: …there is only one reliable way to slow spending growth: slow the growth of services to patients…the most important strategy for slowing that growth must be to slow the development and diffusion of new technology (Victor R. Fuchs Health Affairs. Vol..18, No.1,Jan/Feb., 1999, pages 15,16).
Oh, my! Slow growth in healthcare spending by simply denying access to new and better care. Brilliant!! Who knew? I'm all for transparency, and this view is an oft overlooked policy truth in our country and indeed the world.
His current article entitled “Health Care Reform: Why? What? When?” written along with Ezekiel Emanuel is an updated if well worn set of recommendations.
To answer the question about why we need healthcare reform, the good Professors from Stanford recite the litany of sins of the system: no universal insurance, rising spending on services, rising spending on administration, medical errors, rising tides, global warming…Ok, not the last two. For almost two pages they moan about employer-based insurance and long for the days of government sponsored (and regulated) corporate monopoly (Old AT&T, Ma Bell, you know), and the 1950's when unions were really, really good and actually looked after their members. And the government regulated them too. Life was so simple. No globalization. The world was easy to understand. Them and us. Good and evil. Etc.
The employer based system of insurance has developed some serious flaws over the years to be sure. And by most accounts many employers would like to opt out of the system all together. Health Savings Accounts for current employees—defined contribution—is one method. Making sure the retirees and everyone else gets onto the government system is the other. They are moving. Are we?
Other whys include: means tested insurance, lack of information technology, lack of quality control, and the lack of cost-benefit trade-off decision making at the point of service.
Much of the rest of the article is a good description of various alternative solutions for financing healthcare. These include:
- Incremental change
- Individual mandates with subsidies
- Single payer
- Universal health care vouchers
I recommend reading the entire article for a pretty good comparison of the pros and cons of the various approaches from the American socialist perspective.
The authors favor a comprehensive, universal voucher system. The reason primarily is they feel this approach would combine publicly funded social insurance for basic care with important elements of choice and competition. Sounds good so far.
They plan to pay for this new entitlement with an “earmarked” value added tax (VAT). Oops. This type of program would ultimately replace employer-based insurance, Medicaid, and Medicare. Not. The federal government would “select” plans that could be purchased with the voucher and they would determine “basic benefits”. Ouch. The system would require creating new Boards, regional management committees, and a new Institute for Technology and Outcomes Assessment. This makes me itch all over. I wonder if allergies are covered.
This is an attempt to balance the conflicting cultural mandates of freedom and fairness. Freedom is definable. Fairness is not except at extremes. Back door socialism barely disguised.
Is there anything to like here? Yes, the idea of voucher is good. Freedom of choice is good. Getting rid of ineffective government programs and approaches is good, though not likely to happen in anyone's lifetime. But I'd leave off new taxes and all the other government control and intervention.
The government would do well to split the finance and delivery functions of healthcare and put a wall between them. The government could provide financial instruments like vouchers to those who couldn't afford other methods of obtaining insurance. The government should exit the delivery of healthcare business. And they should stay out of mandating benefits and saying who can provide a policy and who can't. Let the market decide. The loss of innovation is too great a price. Let the private insurance industry and other financial institutions bring new and innovative healthcare finance products to market. Getting rid of the state-based system of insurance would help.
Professor Fuchs, et al., have made another pass at the problem. I hope they keep missing. If anyone, especially politicians take this seriously, I'm worried. It's an election year.
Robert B. Teague is a pulmonologist and business consultant who is based in Houston, Texas. E-mail him.
Read other blogs in this series.
