First of all, let me say that we do need to look at our health care system and start fixing things.
However, the options that are being called for right now aren’t the way to do it.
How do I know this? Because we’ve been trying it in some places, and it has this nasty habit of having unintended consequences.
Consider Barbara Wagner, who’s covered under Oregon’s public health options. And who was denied life-prolonging medication in favor of vastly cheaper comfort care, including ‘physician aid in dying.’ I understand that they only have so many dollars. And I understand that this means they have to make some difficult choices. But gradually shifting everybody onto that system will stretch those dollars further and further.
But, the proponents point out, it won’t force everybody onto that system. Why am I spreading fishy messages? Do I need to be reported to Big Brother the government?
Allow me to explain. Establishing a truly competitive public option – i.e., a public option that actually covers everything the private ones do, like I keep hearing battle cries for – will result in shifting to a single payer system. Why? Because the government isn’t trying to make a profit. Hell, the government can operate at a loss and nobody bats an eye. Therefore, they can charge less. That’s where economics kick in, especially considering that they’re not just charging their customers. They’re charging everybody.
Let’s say that they push their current system of reform through. They’re going to have to pay for it somehow – the only way to do it is going to be through taxes, since they want an option that allows people who don’t have money to get health care. So they’ll probably tax on employer-based health care. If not, then on employers themselves and on the wealthy (sorry for the redundancy there – remember folks, rich people tend to have employees).
Let’s say that I’m paying more for my employer based healthcare, courtesy of the new taxes. It’s a simple economic decision – I’m reasonably healthy (believe it or not). I have a handful of prescriptions, most of which are available as generics. I could use dental coverage (no word that I’m aware of on whether or not that would be covered, but it’s not covered in my current plan). My main concern, in terms of insurance, would be that my company might drop my coverage if they decide I’m too expensive. So, what should I do? Continue paying for coverage that I don’t need to use, and that might not be there when I need it? Or stop paying for it, and go to the federal system? Even if you’re only taxing the rich, why should I be paying for health care when I could be getting it for free?
It’s simple economics – for me, and the vast majority of profitable insurance customers, the federal system would be the way to go. From there, the insurance companies can’t stay in business. They’re forced to drop more customers, or to go out of business entirely, and their customers end up on the federal system. The burden on the federal system increases, along with either the price that people have to pay to prop it up, or the pressure to pull costs down.
Now, reducing costs is a great idea. Our payment and information systems, as they stand, are horribly inefficient and need an overhaul. Go ahead and do that, it’s only sensible. Try not to think about the fact that when you say “inefficient and burdened with excessive bureaucracy,” most people think about the federal government, not their health insurance.
But after you do that, you’re running out of ways to reduce costs. So, let’s say that we eliminate the inefficiencies, and leave ourselves with simple cost of services provided. You’re still going to need to pull that down further, which leaves you with only two options.
When you have to pay less, you have two choices. You pay less for the same amount of service, or you pay for fewer services.
If you pay for fewer services, there’s no way around it other than rationing health care. Your dental insurer already does this, by applying lifetime maximums on your benefits. Your health insurer might well be doing it too, officially or otherwise. But we’ve got people swearing up, down, and sideways that they’re not going to do that in the government. So what’s the other option? Cut the reimbursement rates. Which means that people are going to have to either pay out-of-pocket to make up the difference, or that you’re going to have to mandate reductions in price. Establish a government price tag for services – you can’t charge more, or you’ll be punished in one way or another.
By establishing price limits, you’re going to reduce the number of providers willing to stick with it. What’s worse, you’re going to eliminate the good providers, not the poor ones. A good doctor, whose skills go for higher prices on the market, is going to question why he should stay in the public system when he’s not getting paid any better than the sixth-rate schmoozer who barely made his way through med school and drinks on his lunch break even when he’s on call and might have to operate any minute. Those providers will be encouraged to go elsewhere – either outside of the country entirely, to the places where there is a market-based medical economy, or to drop the public patients and begin providing their services purely to those who can afford them personally. And then we’re back in the position of the rich getting the best care, and the poor getting substandard care… or, at least, getting a level of standard care that’s lower than what it should be.
No, not every good provider is going to quit working in the system, but more and more of them will.
Now, I said at the beginning of this that I think reform is necessary, but here I am coming out pretty firmly against the public system. So, what would I recommend?
First off, improve those systems I mentioned. Get us up to snuff on records and improve the bureaucracy. That’ll reduce health care costs across the board.
Then? Fix the tort system, as it currently stands. Right now, some doctors are estimating 20-25% of health care services they recommend are ‘defensive medicine’ – they know what the problem is, but they need more tests and specialists in order to minimize the risk of losing a lawsuit. The estimates I’ve seen indicate anywhere between $41 billion and $178 billion in savings from simply reforming the tort system, and that’s just in the medical savings. When you add the overhead costs associated with all of it, and the price of defending against lawsuits, and the numbers go up even higher.
How do I recommend fixing the tort system? I’ll admit, I’m not an expert here, so I’m not sure. But one system that does occur to me is putting the malpractice system in the hands of medical experts, rather than a dozen randomly chosen laypeople who’ve been trained by the media to view pharmaceutical companies, insurance companies, and doctors as the bad guys (think about it – when was the last time you saw an episode of… oh, anything… where the bad guy was a blue-collar worker milking money out of his insurance company by faking an injury? Now, when was the last time the bad guy was an insurance company that didn’t cover the medicine the gunman, or his wife, needed to survive?)
Another way to do it would actually be to nationalize the licensing. As it stands, I could have a license to practice medicine in Wisconsin that gets revoked for gross negligence, go to Oregon, and get a new license, then start practicing as though nothing had happened. Indeed, thanks to privacy laws, it might even be virtually impossible for folks to know that I killed a patient by sending them home with a roll of Tums when any intern would have known they were having an actual heart attack. If you put the malpractice system in the hands of medical experts, and then put in threshholds where a certain level of incompetence means they take your scalpel away and won’t give it back, you’ll maintain punishments for malpractice, but reduce the lottery system of malpractice payments, where some people end up paying for the privilege of calling themselves part of a class action lawsuit and others retire because the jury felt that the company should have tested to see if their medicine would have a disastrous effect on people with a rare genetic quirk.
Further, the government could offer to pay for people who honestly can’t pay. Allow an emergency backup for when you’ve got needed medical treatment that you can’t cover, and insurance pools for people who are ‘uninsurable’ by the private system’s standards. But don’t offer this system to absolutely everybody, only to the people who need it.
Oh, Barbara Wagner? In case you didn’t read that link up above, she got her medicine. Not from the state system, but from the ‘evil’ pharmaceutical company, who gave her the fabulously expensive medication for free when they were asked to. Just like most pharmaceutical companies will cut deals with people who can’t afford their medicine – these companies give away a lot of meds at reduced or eliminated price (I should know – I’ve got friends who benefit greatly from those plans).