Thinking Big -- And Thinking Realistically
My thanks to Jon for writing such a wonderful book and for raising such an important set of issues with his initial post. As Jon would be the first to admit, Sick is not a policy book; it's a deeply textured story about the crumbling of America's employment-based framework of health financing (a central element of what I've called the "Great Risk Shift") and the go-it-alone world of fragmented risk that's inexorably taking its place. But the central point of Jon's book does have substantial policy implications, and I want to trace them out briefly in responding to Jon's important query.
The essence of Sick -- and yes, you still need to read it -- is an animating argument as simple as it is profound: The problem of health insecurity is not a problem experienced only by those on the fringes of American society; it is a problem increasingly affecting all Americans, both directly and indirectly. And the implication of this core argument is equally simple and profound: Any real solution will have to address the problems faced by us all -- rapidly rising costs, widespread gaps in coverage for the insured as well as the uninsured, health care that's not producing a healthy society as well as it could. We can no longer content ourselves with yet another round of gap-filling half-measures aimed at correcting the most egregious failures of our rickety financing structure.
So far, so good. But what does this mean in policy terms? Ay, there's the rub.
The fact is, as Jon says, the United States has debated this issue before -- many times before, in fact. And the resolution of these debates has always been gap-filling half-measures.
Even Medicare, the only true national health program in the United States -- and, in my view, the most viable model for expanding health insurance today -- largely fits the mold. When it became clear that America's expanding framework of private insurance couldn't serve the aged, the conclusion that was drawn wasn't that private insurance failed to provide a secure basis for spreading risk and financing care on relatively similar terms for all Americans. It was that the aged needed a special exemption from America's predominantly private system. This helped America's elderly immensely; it also helped secure the dominance of private employment-based coverage for decades after.
Now, when it's clear that private employment-based coverage is failing much of the rest of the population, too, many are calling for an even balder rescue package: huge new subsidies for private insurers, mandates on individuals to enroll in costly insurance that may not even cover their needs, and a new framework for obtaining coverage that will allow private insurance to thrive even as employers' commitment to financing insurance withers.
Jon rightly implies that this is the wrong approach on both substantive and political grounds. Where I think he goes too far is in suggesting that, in thinking about alternatives, political and fiscal considerations should not be a major concern, or that reaping the gains of public insurance necessarily requires moving toward "Medicare for All" or some other universal public framework in a single fell swoop.
First, while policy advocates and designers should not be trying to nail down every political compromise that politicians will eventually have to make for a policy vision to become law -- this, I think, was a major defect of the Clinton health plan in the early 1990s-- neither should they ignore the two big constraints on fundamental reform: namely, the impact on government budgets of transferring financing from the private to the public sectors, and the potentially ignitable fears of Americans with relatively good private coverage that reform will harm their existing protections and/or require that they pay much more. Moreover, these two considerations both push in the same direction: create a large public insurance plan, but keep a good deal of health financing in the private sector in the short to medium term. That's the essential structure of my "Health Care for America" proposal, which allows employers to continue to provide private coverage, but creates strong incentives for them to enroll their workers in a Medicare-like plan. But there are multiple ways in which the objective of a large, but not immediately universal, public plan could be achieved.
Second, many of the gains of public insurance -- most notably, the huge cost-control advantages, but also the ability to develop stronger systems for quality control -- could be achieved without moving to "Medicare for All" overnight. By creating a large public insurance plan that bargains for lower prices and monitors and improves quality, a "Medicare for Many" plan would demonstrate over time the strengths of the public sector, creating additional reasons for employers to enroll their workers in public insurance. Here, I agree with John Edwards's emphasis on competition between the public and private sectors. That competition, however, has to be fair, and Edwards's proposal (which remains vague in key areas) lacks strong guarantees that it would be fair. There is little question that public insurance will mop the floor with private insurance unless one hand is tied behind its back at the outset.
Thus, I find myself agreeing with Jon at the end of my disagreement. There does need to be a great deal of pressure on politicians to embrace the benefits of broadly pooled risk through cost-effective public insurance. But that pressure should be for a set of principles -- a large public insurance plan with guarantees of cost control and quality improvement, fair competition between public and private insurance, and an abiding commitment to risk sharing. It shouldn't consist of manning the baricades with the slogan, "Single payer, or nothing!" Because, I fear, nothing may be what we end up getting.
We don't need to start with Plan B. But we may want to start with Plan A-.
Thanks to both Jacob Hacker and Jonathan Cohn for posting on this blog.They are both making major contributions to the health care reform debate in different ways.
I,for one, am a physician forcaster who agrees with Dr. Elias Zerhouni,head of the prestigious NIH,who said last summer that "a treatment based U.S. Health Care system is not economically sustainable.
He is correct!
You are kidding yourself if you think it we can afford our current level of expenditures especially as 77 million boomers age.
So let's get behind both individual and institutional prevention as our ONLY way out of this mess.
Here is my own Health Care Plan from 1995
(slightly revised after Katrina)
GROW UP AMERICA-A HEALTH CARE PLAN FOR ALL AMERICAN CITIZENS
-Stop prolonging death. It’s both expensive and dehumanizing at best, greedy and cruel at worst.
-Empower US citizens to assume increased individual responsibility for health and convince medical consumers that it is in their best interests not to assume the role of helpless, dependent victims/patients.
-Yet also recognize that we have medicalized America’s social problems. So we must provide healthy and safe jobs for all able citizens thereby reducing poverty and all its subsequent health impacts (possibly 1/3rd of Health Care Costs)
-Provide healthy environments including healthy air, water, soil and food.
-Rebuild America’s public health infrastructure to ensure we provide appropriate macro and individual interventions to especially low income citizens such as childhood and adult immunizations and response to man-made and natural catastrophes.
-Face the reality that a very large percentage of illnesses, injuries and hospitalizations are entirely preventable. Subsequently, the elimination of tobacco, alcohol, drug, medication and dietary abuse alone could immediately reduce medical costs by a factor of at least fifty percent.
-Incent and train physicians to maintain the health of patients and populations. Radical changes in provider re-imbursement and medical education strategies are necessary
-Recognize that early childhood preventive medical education can profoundly affect lifelong health behaviors.
*proposed in June of 1995
Revised January 2006/2007
Of course as a physician I am for treating the ill but much illness can indeed be avoided. More than most of us are willing to recognize.
Be Well,
Dr.Rick Lippin
Southampton,Pa
for more go to my blog
April 10, 2007 3:38 PM | Reply | Permalink
I've posted a proposal for a single-payer system that I think could actually pass through Congress. Rather than take up a lot of space here I invite the reader to check it out: http://tinyurl.com/2kct3z
Here's a synopsis:
A Proposal for a Single Payer Partnership, funded equally by employer and employee, modeled after self-insured industries, administered by insurance companies selected through competitive bidding in the respective States.
April 10, 2007 4:04 PM | Reply | Permalink
I think a fundamental problem with our current health care crisis is that the mandates of health care providers and private insurance companies are completely at odds.
Insurers are in business ostensibly to provide coverage, but primarily to make a profit for shareholders.
When a private insurer prices coverage out of reach of large swaths of the population, or denies coverage either outright, or for specific procedures, they satisfy their mandate.
We need to get providers out of the competitive trap of "big medicine" that big dollars for specialized care push them toward, and back into the small preventative health care business that keeps everybody healthier, and on a first name basis with their family doctor, nurse or other health care professional.
April 10, 2007 4:22 PM | Reply | Permalink
"There is little question that public insurance will mop the floor with private insurance unless one hand is tied behind its back at the outset."
Really?
Let's review the innovative ways that private insurance has attempted to control costs:
- in network/out of network providers (closed and open networks), preferred providers, two/three/four tiered formularies, utilization review, capitation, pay-for-performance incentives, consumer directed health care plans, etc. i could name another 20 if i took the time...
the insurance industry has come up with a number of novel mechanisms to try and manage the amount of care, and provide options to do so.
the most effective of these (capitation, utilization review) were employed in the 90's, when costs were successfully contained, but societal intolerance/pressure forced insurance companies to discontinue their use.
The one hammer single-payer/government health care does offer is dictating prices (negotiation is a misnomer). Could that be better? Perhaps. But the private sector has offered a number of solutions that are more novel (and likely better in the long-run) than price controls.
To say there is "little question" that public insurance would be better, demonstrates your own ignorance on this wildly complex issue.
April 10, 2007 4:29 PM | Reply | Permalink
I'm not a doctor, economist or actuary, but it seems a very effective early step to take would be to somehow control the psychotic money games played by the health industry. They rival the oil industry for reasonable explanations of their pricing structures.
April 10, 2007 4:31 PM | Reply | Permalink
I think that there are two ways out.
1. Every American should have the same health insurance (and for that matter the same retirement package) as Congress, for the same rates. Too costly, you say? Well, how about going the other way - Congress has to use the same system for the same costs as the rest of us.
2. Somewhat more seriously - how about extending Medicare a bit at a time? The first year, go to age 60, a couple of years later to 55 and so forth. At the same time, start Medicare from birth up - say up to age 5 the first year, then to 10 a couple of years late. In a few years - maybe a decade - these will meet in the middle.
Now, current Medicare has one good feature and one bad. The good one: people can buy Medigap insurance that supplements Medicare. The bad one: it doesn't cost enough. That is, tax money supplements Medicare insurance payments. But, as the system extends to more and more people, you could move gradually towards a fully (or more fully) funded system. Perhaps some tax support could be kept, especially for those unable to afford premiums.
Oh yes, fold part D into regular Medicare, treating drugs just like any other medical care.
Oh yes second, put Congresspeople into the new system immediately.
April 10, 2007 4:35 PM | Reply | Permalink
Dr. Lippin,
I began reading your entry from the top down and your first statement almost sent my mental gears into full reverse. Then I stopped myself, went to the bottom of your post and started reading from the bottom up. I found myself agreeing with nearly everything you propose.
I worked for a number of years as a clinical IT professional in a hospital system. I gained familiarity with the HMO model and process, the "Charge Master" billing model, computerized DRG optimization, and cost/benefit patient treatment and materials management. It was a real eye-opener. Everything was designed to maximize profitability. Hedge fund managers have nothing on not-for-profit hospital administrators and healthcare insurers when it comes to figuring all the angles.
Like you, I am firmly convinced that the current healthcare model is not sustainable and that preventive healthcare is a much better approach than after the fact sickcare.
Everyone has their opinion. My opinion is that economies of scale in purchasing (not just drugs - everything) when combined with single-payer insurance offers the least risk and the greatest benefit for the majority of Americans.
I also think that healthcare carries a large burden of costs that should be attributed to other segments of society.
Unlike others, I do not think that a reduction in the cost of day-to-day healthcare would place innovation at risk. I believe it might actually increase real scientific and medical innovation as the current tendency to rely on patent litigation, IP portfolio "management" and direct to consumer marketing (as is presently the case with pharma) became less profitable.
In short, I like what you say. I wish you (and all of us) success in your efforts.
April 10, 2007 4:43 PM | Reply | Permalink
First, and in my opinion the most important, question:
Is medical care primarily a private buisness or a public service?
All other questions and possible answers flow from the answer to that question.
"Governments are instituted among men, deriving their just powers from the consent of the governed."
Thomas Jefferson
April 10, 2007 4:52 PM | Reply | Permalink
It shouldn't consist of manning the baricades with the slogan, "Single payer, or nothing!" Because, I fear, nothing may be what we end up getting.
Yeah. Like that's really going to happen. Worst case is we get the individual mandates to buy something like the Medicare Drug plan with fees non-negotiable and government as a force for good gets another blackeye.
As bad as things are don't forget that the current healthcare crisis presents what is a once or, at most, twice in a generation opportunity to do something really great and worthwhile. Work out the best and most sensible plan we can afford and sell it -- not to Congress -- to the American people.
April 10, 2007 4:53 PM | Reply | Permalink
"We, the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."
April 10, 2007 4:56 PM | Reply | Permalink
I really do wish you would spell out briefly just what you expect the real problems are here (maybe you did it elsewhere -- but I'd like to see them in the very post in which you make these claims).
I don't see what the fundamental problem is in "the impact on government budgets of transferring financing from the private to the public sectors". Presumably, some of this took place when Medicare originally was introduced. Why is it suddenly an intractable problem when it is extended to everybody? In the end, most people are of course ALREADY paying a huge amount of money, either directly or through their employers, to cover their insurance. What is the great practical problem in transferring those very payments into Medicare for All? The point is, the money is really already there, simply being paid to private insurance instead of into a public fund of some kind.
Likewise, I'd like to have a further explanation of the concern over "the potentially ignitable fears of Americans with relatively good private coverage that reform will harm their existing protections and/or require that they pay much more." In the end, the effectiveness and quality of Medicare itself is a pretty good rebuttal to those kinds of fears, I should think. There aren't many seniors who bitterly complain about the poor service they receive under Medicare; virtually all of them indeed looked forward to reaching an age when they could be covered under Medicare insurance.
Of course, insurance companies will do everything possible to stoke people's fears via advertisements, etc. But how much credibility do you really think they are going to have at this stage? This isn't the early nineties -- people are much more fed up with their insurance coverage than they were over a decade ago, and are in little mood to listen to what they will know to be propaganda from insurance companies.
April 10, 2007 5:01 PM | Reply | Permalink
The passage in the boy's column about people opposing government based coverage because they might have to pay more for already good coverage was painful as it was laughable: am going on 65 but with younger wife and two young kids I will soon be paying $23,000 a year for coverage now costing me $15,000. Few more years and we will be paying $40,000.
All the worries about money when Blue Shield in California collects $6 billion a year in premiums and spends 15% of that on exec salaries and overhead and CEO gets end of year million "performance bonus" for denying people treatment. A sick and insane and cruel system and we have to tippy toe around the greed and hypocrisy of it all.
April 10, 2007 5:06 PM | Reply | Permalink
Any "solution" that involves private health insurance is NOT a solution. The Calif plan to force those already not insured (i.e. too poor to have any) will simply expand the number of claims refused by insurers - and thus their profits.
It isn't rocket science. At the very least our nation MUST provide FREE HEALTH CARE to all persons under 18 years of age. Not free insurance, or insurance of any kind, but free health care.
April 10, 2007 5:08 PM | Reply | Permalink
The only way that we will obtain a fair health system is if that system is truly universal. No exceptions. That means Congress, govt. employees, everyone receives the same package. Private insurance should remain strictly as a supplemental to public insurance. For example, eye exams would be covered by public insurance, but eyeglasses would require modest supplemental insurance (i.e., $10 per month).
I would like to see a straight increase in the Federal income tax to support the program. That way, someone who isn't earning enough to pay much in taxes will not be deprived of health care;nor will that individual be subjected to the indignity of our public aid programs and the inherent prejudice against someone who needs public assistance. We not only need to eliminate income inequality--we need to eliminate the stigma attached to public assistance programs.
I know far too many people who have lost their jobs working for medium or large corporations who are now struggling to make a living as entrepreneurs because they are over 50 and considered "too old" and too expensive for the corporations they used to work for. These are the people who can't afford to have corporations pay for insurance because they are the corporation. They are well-educated, creative, productive people who need a chance to succeed in their new careers. Part of that success will come from not being saddled with expensive private insurance programs.
April 10, 2007 5:09 PM | Reply | Permalink
I think we should stick to the most cogent question, "what do we know that every other industrialized country doesn't"?
April 10, 2007 5:20 PM | Reply | Permalink
One thing I've never understood (not snarking here - really asking): what is meant by "political realities" in this context?
The public overwhelmingly supports some kind of universal coverage. I haven't seen polling on any specific plan in a while but what I recall seeing in the past is that people generally tend to favor European-style plans over insurance bailouts.
Now, a Democratic congress is in power (both houses) that was elected on a platform that prominently featured universal health coverage as a key plank.
Yet still it seems there is some sort of "political reality" preventing true universal, publicly-funded coverage.
What is this political reality? Again, I'm not implying that it doesn't exist. I'm just curious as to what people are referring to when they refer to that. What, specifically, is the barrier?
I hear a lot of lefists (of which I am one) talk about how the Democrats are in the pocket of big insurance or whatever. And that may be the case, but I've never met anyone who can actually explain how that works, and how, specifically, the insurance lobby is preventing the Democrats from doing what they said they would do, and what their constituency massively supports. Personally it sounds like leftist poppycock to me (and I say that in the spirit of love, fellow lefties, I truly do.)
So really, what gives?
APS
"If you're going to be crazy, you have to get paid for it or else you're going to be locked up."
- The Good Doctor
April 10, 2007 5:20 PM | Reply | Permalink
To clarify, I accept that the fiscal concerns are serious. But that's not what I'm asking about. What I'm asking is, if we had a way to pay for it, it seems that folks are saying there is still some political opposition to that. I'm interested in knowing the source of that political opposition.
APS
If you're going to be crazy, you have to get paid for it or else you're going to be locked up.
- The Good Doctor
April 10, 2007 5:22 PM | Reply | Permalink
Specifically I would like to see a detailed key-point comparison between the US' and Germany's health care systems.
sPh
April 10, 2007 5:31 PM | Reply | Permalink
As I just commented in response to Mr. Cohn's post, I think we need first to get the basics straight. Behind the single payer model is not the simple proposition that the health insurer market be totally eliminated, but simply that health insurers and health care providers are different markets. The single payer model, conceptually, simply puts a firewall between them. Not a single private sector institution need be eliminated to do that, though it may be useful over time to eliminate the entirer insurer market as unnecessary.
Single payer thus IS the incremental solution, and we'd see that if we get past the strawman that it requires eliminating all health insurance companies. It doesn't. It could, eventually, get to that, but all it need do initially is provide a different source of income to both insurers and providers - the single payer. Those who currently pay either insurers or providers (i.e., individuals or employers) would instead support the costs of the single payer through tax revenues, and eventually, even that may not be necessary.
Health insurers now are oligopolies, and as such are not subject to competitive forces. A single payer would force them to be competitive, with each other, in ways that the current situation can't force upon them. Providers, on the other hand, would have to compete not for insurer funding, but for patients, and that would be on the basis of such factors as quality of care, and is should be, if _promoting the general welfare_ is even remotely a part of the standard for competition. Not all competition need be financial; I would suggest that the best competitions have nothing at all to do with money.
Dr. Lippin - I agree with you about prevention. But to force it on individuals without a single payer in place would amount to an unfunded mandate on that level. As an uninsured individual, I have no choice but to take preventative measures, to minimize my risk. I would behave no worse had we a single payer system - indeed, would be able to do things I currently can't afford to do.
April 10, 2007 5:32 PM | Reply | Permalink
I pretty much agree with your sentiments.
I think that when people talk about "political realities" here, what they really mean are corporations and their lobbyists.
Now, last I heard, corporations don't actually vote. In the end, politicians owe their jobs ONLY to people who vote -- money for campaigns coming from corporations means nothing if it doesn't translate into votes of actual people.
But if the people are well and truly fed up, they are NOT going to be persuaded by big money in campaigns. (If you need to, look at Freakonomics on this point.)
Politicians need to take the argument directly to the people, and over the heads of lobbyists. I had always thought that was what a progressive might seek to do.
April 10, 2007 5:33 PM | Reply | Permalink
I am a little unclear on how you avoid the adverse selection problem (e.g. the current situation in California with the ex-Blues) under that model. Enlightenment would be appreciated.
sPh
April 10, 2007 5:35 PM | Reply | Permalink
Well, that's the answer I always get. But it's really a non-answer. It doesn't describe any specific mechanism by which these plans are being blocked. That's what I'm interested in.
Perhaps I am really supposed to believe that US Congressmen are, as a class, so totally dependent upon PAC donations from insurers that they can't introduce a serious reform package and get it passed? Maybe that's true, but if it is, somebody ought to be able to demonstrate, specifically, how that's true.
If it's NOT true, something else is at work. What?
"If you're going to be crazy, you have to get paid for it or else you're going to be locked up."
- The Good Doctor
April 10, 2007 5:53 PM | Reply | Permalink
I'm not familiar with the "California situation" - please do comment further, but let me try to respond in the interim.
Adverse selection is a problem with asymmetry of information being used for competitive advantage. Once there is a single payer which provides universal coverage, the problem takes on a different nature than it now has, first for the hopefully obvious reason, but second because the single payer can define a new basis for compensating insurers (I'm assuming that we're talking about the case where insurers still exist as private entities). If the single payer's new standard for compensation doesn't prove attractive for insurers who are taking advantage of adverse selection, those insurers would have to decide to find another business, and turn over their insured base to the single payer directly, or to another insurer who can support them.
Put another way, adverse selection is now an issue for both insurers and individuals who are insured. The problem for the insured goes away immediately with a single payer. It would still be a problem for the insurers, but I don't view that as a bad thing, since my eventual goal would be to see them go out of business anyway. They could also be forced by payment policy to merge with others, in the hope that larger insured bases would mitigate the effects of insuring high risk individuals.
A single payer would hopefully have access to the same risk information that the insurance industry does, but more importantly, a single payer would have enormous leverage. Simply put, to an insurer: take what we offer, or go out of business. If we offer a flat rate for number of insured, you take it, or you have no customers. Individual and individual employers don't have that kind of leverage, even when such things as legislation are used to try to force insurers to accept high-risk customers.
I hope this is responsive - I could maybe comment further if you can prompt me a bit more.
April 10, 2007 5:54 PM | Reply | Permalink
One other comment if you'll allow me, sPh.
I like the idea of using eminent domain to nationalize the health insurance industry (and others, like energy). A single payer plan might overnight make private health insurance unattractive as a business model, but that would serve to make the fair value of insurers go down, dramatically, I would expect. Insurers might clamor to be bought out via eminent domain. And the advantage otherwise to the approach is that those who currently work in the industry would not lose their jobs - they just become public sector employees instead of private. The entire infrastructure could stay in place otherwise.
The only parties that would suffer in this would be shareholders expecting insurance companies to profit. And there may be various ways to keep them happy also, e.g., exchanging shares in private insurers for public bonds of various sorts, e.g., possibly as the mechanisms for the eminent domain buyouts.
Sooner or later, insurers are going to start losing money anyway. Are we going to fail to add 2+2 and bail them out when they ask for it, or something else of the sort for silly ideological reasons, or move in a better direction and realize that their function is part of the public trust in the first place, and buy them out, starting now (or soon)?
April 10, 2007 6:20 PM | Reply | Permalink
Yes, I think something else is at work. People are afraid of a word: socialism.
Single-payer represents the more general fears of socialism in the American psyche. That's partly good, because it is socialism. The error in the perception is
to conclude that socialism is itself necessarily bad.
Socialism does not equate to authoritarianism or totalitarianism or an absense of democracy in ideological terms, in my view. In my industry, for example (computer software), there is a monopoly - Microsoft. A monopoly is a private source of anti-democracy, and thus in effect, at least economic authoritarianism or totalitarianism. The so-called open-source movement has created a democratic alternative, and particular artifacts like the Linux operating system.
I've been asked if Linux is communism. Maybe so, but the Christian churches of the 1st century were communists in whatever sense that might be true. The point is that socialism is not simply something to be feared on broad ideological ground, and in fact, oligopoly and monopoly capitalism are bigger threats, right under our noses.
Purchasing power is not voting in a democratic sense - it's plutocracy if anything. Monopolies and oligopolies are not democratically accountable, even to their oft-captive markets. That's basic economics. We miss it. And in the face of this kind of mass ignorance, even a little socialism might go a long way...
April 10, 2007 6:31 PM | Reply | Permalink
Unlike others, I do not think that a reduction in the cost of day-to-day healthcare would place innovation at risk. I believe it might actually increase real scientific and medical innovation as the current tendency to rely on patent litigation, IP portfolio "management" and direct to consumer marketing (as is presently the case with pharma) became less profitable.
Absolutely. Most basic research is *still* performed by academics at publicly funded institutions.
Profits don't necessarily drive innovation, particularly in health care. People who care about science and people's health drive innovation in health care.
If you're interested in profits, you tend to focus on blockbuster drugs rather than monitoring and prevention, which is where health care should be focused.
April 10, 2007 6:36 PM | Reply | Permalink
The way I see it, health care isn't a utility, BUT health insurance is and should be treated as such.
Like all utilities AND all insurance schemes, the larger the pool, the lower the per capita cost.
The way to do healthcare insurance then, is a universal single payer system to drive down the per unit cost.
The way to do universal single payer coverage, is to follow the existing model of the Telephone monopoly/oligopoly, circa pre-1980.
Under that regime we had universal single payer-ish phone service provided by private oligopoly that was highly regulated.
For its time it was the most advanced system in the world and many people I know, even today, wish for it to return.
If you had a problem with your phone, you made one phone call and they took care of it.
This would tie up the Republicans in fits on the one hand and lesson the institutional resistance on the other.
This would undermine Republicans demanding private insurance companies. If they complain about monopolies, then we can point out all the other monopolies that they happily support.
Simply pick one or a few big health insurers and force others to merge with them. This will solve any takeings issues that stock holders would experience. The stockholders would realize some gains through the process of mergers. Executives could not claim that it was not in the interest of their stockholders. The big boys would get bigger, but they would be regulated.
The cost savings from a single payer oligopoly will pay for the cost of all the mergers.
Later on down the line we can either nationalize the entity or make it not-for profit or non-profit or consumer owned or a co-opt.
This way carves out a route of least resistence to a single payer universal system: Stockholders can't object, executives can't object.
Its easy to point at Medicare and say make it universal, but a wall of resistance will always come from stakeholders in the status quo. This approach just buys out their interest and thereby eliminates the source of resistence to change. Its all about pushing as many interest into alignment.
Democrats get what we want, universal health coverage, single payer utility. Stockholders get what they want: the vaulted control premium. Executives get what they want, bonus for negotiating the sale of their company. Republicans can't bitch because its still private, not government run.
The nice benefit for consumers is that they will also be able to sue the entity because its still private.
The regulatory board could be chaired by representatives over every primary interest group, from patients, to doctors, to nurses, to pharm industry, to unions, to academia, and management etc...
The policies generated then would likely be sound.
Maybe things are more complicated than this, still, I'd like to see more critics of this sort of approach.
He that hath a trade, hath an estate - from Poor Richards Almanac - Benjamin Franklin
April 10, 2007 7:19 PM | Reply | Permalink
Thanks Michael Harold-
We all would do well to re-visit Ivan Illich's "Limits to Medicine.Medical Nemesis:The Expropriation of Health.(1974)
Illich, a former priest, was prescient when he said "the major threat to health in the world is modern medicine"
Now we have Nortin Hadler writing "The Last Well Person"(2004) which is equally powerful in its indictment of contemporary medicine for its failure to demonstrate efficacy.
"First do know harm". We need to question the whole medical enterprise not just dance around who is going to pay? and how?
But if you want my pragmatic side I am for single-payer with much more emphasis on prevention
Who could trust anything employers promise or provide (especially multinationals) in 2007 given their recent history?
Dr. Rick Lippin
Southampton, Pa
http://medicalcrises.blogspot.com
April 10, 2007 7:34 PM | Reply | Permalink
Ask a Primary Care Doctor whose patient population is mostly covered by Medicare about the benefits of a single payer system. His response is likely to be sarcastic and his voice is likely to start loud and get louder. Nothing nice will be said. They can't imagine a more awful, bureaucratic, demeaning system of nonpayment on the face of the earth. A single payer system like Medicare is a disaster waiting to happen.
The key to improved medical care is well, improved medical care. Yes, prevention is critical. Ready and routine access to primary medical professionals is critical to reduce expensive interventionist strategies. Universal coverage is critical. But the advantages of a single payor system are illusory.
The system is broken; not just in mechanisms for coverage, but in mechanisms for delivery and for compensation. It's absurd to have health care professionals jumping through hoops filling out forms which if not "coded" correctly means lost revenue (The joys of Medicare).
The key is in compensation based on outcomes. Morbidity and mortality. You want innovation that really benefits the patient? Tie compensation to outcomes, and pointless expensive procedures will disappear quickly and the most effective systems possible will be developed and put in place.
All this talk of single payor etc is just BS. I seriously doubt that the effective delivery healthcare is going to happen in this country in my lifetime. Too many well-entrenched monetary interests.
April 10, 2007 7:41 PM | Reply | Permalink
PS
Maybe I should reverse the order of my points in my plan?
And start with early childhood education and end with death and dying since the latter point scares away people from reading all of my plan?
What do you think?
Thanks
Dr. Rick Lippin
Southampton, Pa
http://medicalcrises.blogspot.com
April 10, 2007 7:45 PM | Reply | Permalink
johnOneOne
Pragmatically speaking I'm for single payer-period! but with much more prevention emphasized.
Why anyone would trust corporate america(especially multinationals) with almost anything-let alone health care- in 2007 is beyond my wildest imaginations given their recent track record.
Dr. Rick Lippin
Southampton, Pa
http://medicalcrises.blogspot.com
April 10, 2007 7:53 PM | Reply | Permalink
deleted
April 10, 2007 8:18 PM | Reply | Permalink
No real argument from me...
I've more just been trying to make the point that single-payer isn't just the extreme case in implementation and thus political terms. It embodies the extreme case of there being no health insurer industry at all, but allows that to be reached in baby steps. It could thus, literally, be put in place almost overnight, and refined until there were no private health insurers left.
Of course, again, the problem is the politics. That's my real target here.
The term "Orwellian" is in vogue these days; amazingly, it gets used by the right to describe the left. Orwell was a socialist. His target wasn't socialism, it was authoritarianism and totalitarianism, who had co-opted the term "socialism" for their purposes. That's the historical truth behind the idea of NewSpeak. But he made another very big point that I don't hear getting mentioned these days, and it relates to this very discussion.
If one can succeed in removing a useful word from the vocabulary, the idea(s) that word most truthfully and simply represent will become unthinkable. Unthinkable.
And that has happened in this country. Good ideas need only get the label "socialism", and otherwise very intelligent people become incapable of processing them (or coming up with them to begin with) in rational terms.
There are EASY solutions to some of our nation's problems - but the easy solutions involve things are appropriately labelled socialism, and as soon as one gets the thought to attach the label, there goes the good idea itself.
Orwell was right. We need to get past this fear of one word - socialism - or we'll never solve problems like health care costs and oil prices and such.
April 10, 2007 8:19 PM | Reply | Permalink