I was thinking about the health care morass on an airplane the other day; thinkin hard enough to jot down some notes. My thoughts aren’t all good, but this is important stuff and needs to be fixed. I heard back from my Congressman, Parker Griffith, who is a retired medical doctor. He used a Hippocratic Oath analogy: “first we need to do no harm to our current system.” I didn't swallow that cod liver oil. His is a misguided anthropomorphism – our health care system is not a human being. If you break it completely it may actually help you to rebuild it better than it was. Besides, there’s no reason to think that doctors and hospitals will stop treating sick people during a transition from one payment system to another. What else they gonna do?
We need meaningful reform. We need it on moral grounds, to help people who don’t get care for routine and treatable ailments. We need it on financial grounds, to make our businesses stronger and independent of the yoke of health insurance. We need it on equitable grounds, to stop the arbitrary nature of who has coverage and who doesn’t, just depending on which way the labor market winds are blowing. We need individual coverage that can negotiate the same rates that groups can. No more small group "death spirals".
We need to align the monetary goals of providers with healthy consumers. We need to flip the pay-per-treatment or “fee for service” system on its head. A pay-per-patient system is possible and being tried in certain places. I worry that that method incentivizes not performing needed treatments, at least in the short run. Maybe there could be monetary penalties if a treatment was skimped – this is basically the old HMO model and didn’t work out well in the US(although similar models work in other countries). The salient differences should be explored and overcome.
Or pay doctors via a salary, with bonuses for healthy patients. This seems pretty reasonable, but has a couple of pitfalls to guard against. For one, “the talent” will no longer be automatically getting paid for their high skills. Management will be seeing the cash flow (both on the insurance company side and on the hospital administration side), and they’ll rake off as big a share as they are allowed to. So it needs regulating, which is unsavory, but sane. Absolute control of the monetary pipeline leads to money-drunk plumbers -- I may have mixed my metaphors there, but unfortunately we need watchers when money is involved. And people to watch the watchers.
Health itself is not and healt care also is not and will not be, egalitarian. Maybe there is some solace for the less-well-heeled in that. That is, that everyone can fall ill or get injured, and all of us get old. Waiting for routine and typical care as a method of cost control is unacceptable. That is, back door rationing of health care through curtailed availability cannot be a solution. Apparently that is a diminishing state of affairs in Canada and the United Kingdom at this point. Their waits are often no more than ours for the same specialists. Have you tried to get an appointment with a dermatologist? Your best hope is for a cancellation to open something up -- or to look up a good poultice on the Interweb.
Extraordinary care remains another matter. Extremely expensive and experimental treatments have to be uncovered (except as part of research studies, but that's a special case). But the bar needs to be high and the decisions open and transparent. I'm sorry, it's not worth 2 million dollars to extend anyone individual's life by 6 months -- not to society (i.e. the rest of us). If there is a rich benefactor, okay, it's their money. But when it's our money, we can extend a lot of other people's lives a lot more than 6 months with $2MM.
Risk takers are a tough area for me. I haven't got that figured out. In some cases of course their health care is cheap -- if they fall while rock climbing and die, well, it's their funeral. If they only break their back, though, then it's everyone's bank account. I think in those cases they need to cough up some personal funds to help with coverage -- but which things are risky? Smoking? Of course (if you weren't already addicted in 1965). Failing to exercise? Eh. Over-exercising? Hmmm. Maybe we better hope this one comes out in the wash, that it evens out over the pool of citizenry.
Penultimately, I want to address what the correlation between health insurance and business should be: none. There's no rational connection. Health insurance should be more like the fire department; businesses can pay their share through taxes. Different businesses shouldn't pay different amounts per employee depending on the type of business they are, how big they are, etc. In the U.S., employer paid health insurance started as a differentiating fringe benefit. It's no longer effective in that role, except to stifle small businesses, consultants and entrepreneurs. And it allows large business management (and their customers) to squeeze the employees through passing on ever higher health insurance costs to the employees through higher co-pays and decreased coverages.
And finally, I find myself agreeing with some European voices that I respect, that treating the health misfortunes of others should not be a ticket to riches for anyone. It's just plain wrong.