Solving the Healthcare Mess

Anyone who has had even passing experience, recently, with the delivery of health care and the insurance financing arrangements that attend it comes away yearning for improvement; there must be something that can be done. The current political debate about what steps our society can take have raised the issue to fever pitch, but no convincing solution, at anything close to affordable cost, seems to be seriously on the table. I’m not optimistic that the present political environment will yield good results. What follows is my attempt to sort out some of the more important issues…if only for myself…so the conversation I have with myself and with others is not so frustratingly muddled. For ease of reference, I’ve identified themes as (D) Democrat, (R) Republican, or (N) Neither.

Let’s start with the philosophy of where major societal solutions should come from. Acknowledging the over-generalization, one (D) approach is to rely on a wise and benevolent government to provide, or at least catalyze, the solution. The other key philosophical approach (R) is to rely on private solutions, harnessing the aggregate wisdom of millions of participants’ self-interest. Philosophically, that latter approach appeals most strongly to me. We rely on private solutions (and tolerate major societal disparities) on such basic human needs as food, clothing, shelter, transportation. In our system, no-one expects the government to provide food, or housing, or an automobile comparable to what the wealthy can afford. In fact, extreme examples of consumption in these realms are usually matters of admiration, a plateau of size, quality, speed, or fashion that most are willing to strive for, without the expectation of any particular help from the government. But none of these examples are pure. Government subsidies (e.g. food-stamps or heavily subsidized public transportation) are often at work to establish a floor level above which private consumption can reach virtually unlimited heights.

Maybe a better example would be education, for there too, as in health care, society, itself, has a substantial interest in every member of that society having access to good quantity and quality. But while government, thru tax revenues, provides a comprehensive system of education at all levels, private alternatives abound and, especially at the primary and secondary levels, are generally considered superior (often very much so) to their public alternatives. If it didn’t generally deliver excellence, private education’s consumers would look elsewhere and it wouldn’t survive. Public education, even where it delivers horrible results, manages to survive because of its governmental aegis. It is often barely tolerated only by those who can’t afford to escape it. If society has an interest in broadly available, high quality health care, I’d argue that it has an even greater interest in high quality, broadly available education for its members. Education primarily benefits society through those who have their productive lives mostly ahead of them; health care is mostly spent on those who have already made the bulk of the contributions of which they are capable. So, if health care needs fixing, maybe education needs it even more; and the education “public option” (D) has not made a great case for its providing the solution to either.

Still, a private health care situation can’t make a great case either. If it were really able to provide the solution, why hasn’t the market place already done so? I think I know a number of reasons, all of which, I believe, can be managed, in time. But, still, some governmental support (direct subsidy and/or tax allowance)(D) may be necessary to “jump start” a better plan.

  • Refocus attention on good health outcomes, not on transactions/procedures, regardless of their impact on actual results. Here are some actual ways to do that.
  • Change our mentality about the role of health insurance. It is the problem, not the solution. Today, some tend to think of that coverage as needing to provide access to the ultimate in procedures, or treatments, or medications, regardless of cost, from the first dollar. When we insure our homes, we don’t expect that coverage to apply to the replacement of burnt-out light bulbs, but some seem to behave as if health insurance should cover small things, as if by right. I happily acknowledge the benefit of this stunning example from David Goldhill’s excellent article in The Atlantic, Sept, 2009. I owe much of my current thinking about how to solve our health care problems to his wise analysis. So, instead of thinking of health insurance as a “first dollar” proposition, view it as catastrophe level coverage that would provide extreme care, rarely, to keep anyone from having to exhaust their other resources to meet extreme needs. Because of the very high deductibles and very substantial “co-pays” that this would involve, this catastrophe level coverage could be very inexpensive (if other features apply…read on). To make this “core” insurance coverage especially cheap, we could mandate that everyoneacquire it (D), broadening the pool of premium payers and reducing the liability risks of the insurers. This would mean including in the mandate especially the young and healthy. For those very poor for whom even this cheap coverage would be difficult to afford, we could provide some government subsidy (D).
  • Since the threshholds of actual coverage would be very high in this regime, individuals would have substantial incentive to carefully evaluate the cost/benefit calculus of their healthcare use (R)…as they do in every other realm of their economic activity. That consumer consciousness would go a long way to discipline the delivery system on quality and cost, forcing providers and the insurers themselves to provide good value for money.
  • To make sure people don’t just ignore their health situation until extreme care becomes necessary, the mandated core insurance could cover a comprehensive physical examination at appropriate age intervals, with “discounted” costs for therapies that are identified and promptly pursued as a result of such periodic examinations.
  • Expand HSA’s (Health Savings Accounts) by making the deductible contribution larger and making the HSA funds eligible for payment of premiums for coverage in addition to the mandatory core. But, as a counterpoint, and as a way to make this tax-neutral, eliminate (gradually) the non-taxability of employer provided health insurance. This is an idea whose time has passed (a large industrial employer-based solution, inaugurated when wage controls precluded cash wage increases; the times, they have a changed!)
  • Enable a nation-wide health insurance market (R), to provide access to very large policy-holder bases (reduces premium costs and liability risks).
  • Cap malpractice awards (R). Some argue that this is a very small problem in the overall tally of costs. Even if true, I’m not sure why it’s being small should permit us to not solve a problem that many believe exists. More important than the direct malpractice recovery costs, however, are the impacts on practitioners’ insurance costs (passed on to health care consumers) and the mentality of practicing “defensive medicine”.
  • Finally, and this is the big one: gradually eliminate Medicare (N). Start by raising the eligibility age from the current 65, by 2 years, every 4 years. In 40 years, the threshhold elibility age would then be 85; then, 40 years from now, bring the program to a complete close. Anyone today older than 40 would get some, diminishing Medicare benefit. Anyone today 40 years old or younger would be on notice that they will have to fend for themselves…even in their very old age. But with decades of opportunity to accumulate reserves in HSA accounts and with their mandatory core, catastrophic insurance policies in place, everyone (younger, or older, than 40, today) will probably be in a much better place to wisely manage… and pay for… their health care needs than most other aspects of a comfortable life in old age. And, in the meantime, society as whole will have saved an enormous cost.
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