Health Care

I’m really cautious about wading into this one; I don’t have any good answers. Maybe there are no good answers, just less bad ones. I do think we have to do something to fix the health care system in this country. Aside from those who make some serious profits from the industry (like lawyers, insurers and drug companies), no group is happy with it. Doctors dislike the oversight from the insurers, the patients dislike the impersonal nature of the business, and employers dislike the rising costs. From a strictly efficiency standpoint, Americans in aggregate get less health care (measured in medical results, not in medical procedures) per dollar spent than just about any other industrialized country, even those with socialized systems. As a small example, just wander the often empty halls of most hospitals and look at machines lying idle.

If one has money or good insurance, the U.S. system can be the best in the world. We have developed amazing new (and often expensive) technologies that can more or less fix a wide range of ills. That’s good, because the American lifestyle produces a lot of ills. It is probable that much of this new technology would not have been developed under a socialized system, as it takes large amounts of money to do new development and a socialized system doesn’t have much incentive to develop it.

Everyone has heard about the large numbers of uninsured Americans, now at roughly 20% of the population. And many others have pretty scrimpy insurance. There are any number of stories about how uninsureds don’t get early and relatively cheap treatment, until their condition requires a very expensive trip to the emergency room. Many evenings, the hospitals in my area play a revolving “shut down the emergency room” game due to the high number of walk-ins who have no other place to go.

The hard-hearted conservatives would say that’s tough luck, they should work at getting a better job, and besides it’s God’s will. The jelly-minded liberals would say that everyone is entitled to the same medical care, no matter how dissolute a life they’ve led. Hillary tried to fix the whole thing in one motion, which was way over-reaching, and got shot down. There were really two basic things that needed to get fixed. First, somehow provide some medical services to those who can’t afford them, especially for children. Second, provide for insurance transferability when changing jobs.

The only idea I have (and given with some reluctance) for fixing the uninsured problem is that the government establish subsidized clinics where anyone could receive basic medical care. The staff might be government employees or contractors, but would be protected from malpractice suits. Due to costs, the staff would probably include only a few full-strength doctors, with other lessor practitioners being more common. This arrangement would mimic the military clinics that serve dependents, hopefully with different priorities and more money. These clinics would not have access to some of the more expensive technologies, especially those whose benefits were uncertain. Oregon has been playing around with a rationing system that, as distasteful as it may be, may be the only reasonable way to limit costs. Given that about 30% of all health care expenses are incurred in a person’s last year of life, you have to question how much benefit all that money is buying. The quality of the service at these clinics might be described as just adequate, and would be lower relative to what would be available in private service. Yes, a two-tier system. I don’t see how to avoid it. For most health care needs, availability is more important that high quality.

To fix the second problem, the government should pass legislation, beyond Cobra, that would allow for transferability of insurance, or maybe the government becomes the insurer of last resort. The basic problem is often when there’s an existing condition, the new insurance company won’t touch it, forcing the employee to stay at the old job or to risk losing insurance all together. A family with children is especially at risk. With a large number of layoffs, this becomes a major problem with the classic family structure where just the dad works and has 2.1 kids.

None of these options is pretty. I have not yet heard a pretty option. I do think we have to do something to better service a larger percentage of our citizens. The lack of money is one problem, and maybe if we roll Medicaid and Medicare into one comprehensive program, the additional expense won’t be too great.

I’ve seen Canada’s system at close hand, and I guess it works ok, but I don’t think it practical or even desirable in the US. Medical professionals are leaving there and coming to the US, and some Canadian patients are doing the same. One curious benefit of the system is that employers don’t have to fund their employees’ insurance (at least not directly), so hiring entry-level workers is easier to do.

December 28, 2002

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