Wednesday, September 19, 2007
To a Republican:
You may be surprised but you and I are not far apart on this.
I too like the idea of a healthcare safety net, though it needs to extend beyond the poor because the costs of catastrophic care are so high that one nees to be very rich or have unusually great insurance to survive such a challenge.
I also think there is danger in a socialized system that leaves the decision as to what is elective and what is not elective to a political process.
All that said, we come back to a very hard issue. Is it possible in modern emdicine to have a free market. Let me point out that NO civilized country, including the US, today has a free market. You and I would not want the health care in third world nations that come closest to a free market.
So, how could one develop a free market? I really do not know but a few rules seem clear:
1. health care should never be tied to employment. This was a major blunder of WWII. It makes no more sense than tying housing, food, or education to employment.
2. Where a free market can exist, it should be created. The obvious example is th new effort by capitalists to recreate the old time GP now as "doc in a box" clinics in malls and drug stores. This saves hug amounts of money over the big clinic or ER model and seems idelaly suited toi a free market.
3. A safety net must prevent health care form being the cause of bankruptcy AND seperate the issue of long term care from the current rules that require impoverishment to receive etc.
4. recognize some parts of medicine as natural monopolies that need to be socialized or regulated.
5. create the competition, as much as possible, at the vendor level rather than the insurance level. Insurance is a poor level to create a free market because there is too much of a conflict of interest in the insurer. One result of this is an estimate that a third of the health care dollar in the US goes to administrative overhead.
6. We need to distinguish, as we do not now, between insurance and pre-paid health care. A large part of medical need is very predictable. Insurance ofr this makes no more sense than using insurance, rather than a service contract, to fund car maintenance or housing repairs. I would limit insurance to catastrophic issues and develop a service mechanism to deal with predictable health care. The service component might be able to function competitively.
That would be a start. The result would be individual or societal decisions, rather than corporate, as to a lot of the health care $.
My suspicion is that such a system would focus on childhood health care where prevention is essential. We might underwrite basic healthcare for kids in a number of ways but since much of that would be by the doc-in-a-box market, free market forces should work well as long as we provide an incentive to the parents to shop by having appropriate copays.
A the other end, such a system would likely socialize a lot of in hospital care simply because this level has become so expensive that it is a natural monopoly. I see little evidence that private monopolies (e.g. the old Ma Bell) are more efficient or less efficient than socialized entities (e.g. Seattle Light}.
Posted by SM Schwartz at 11:31 AM