Promoted for discussion by Brendan
This is inspired by this diary by All-Time QB about Britain’s NHS, and by our need to address the issue of healthcare. I am a bit leery of saying we should copy Country X’s system, but our system is clearly dysfunctional and some expanded form of nationalized healthcare is in our future. So, what problems need to be addressed, how might we structure a system to address those problems, and how can we do it without complete destruction of the market forces that support both innovation and supply?
The problems: Health insurance costs exceed housing costs and continue to climb, making insurance impractical for many families and diluting the underwriting base. Doctors and hospitals are forced to expend greater amounts on administration, cutting into their profits, which in turn sends them looking for more ways to increase their incomes. Doctors suggest unnecessary tests both to increase their own profit and to avoid litigation. Patients are trained to believe that doctor visits and pills and tests are necessary components of “good health” despite the lack of definite proof that many such things actually make a difference. This all combines into a self-reinforcing spiral of increasing costs.
So, how might we structure a system to address these issues?
(1) Move catastrophic care to the federal level. These are the most costly items which distort marketplace actions the most. The federal government has the largest underwriting base available. Things the government would cover would include only:
Accidents, injuries, acute conditions: The things that happen that we don’t expect: car wrecks, falls, heart attacks, strokes, kidney stones, etc The kind of thing one goes to the emergency room for.
Diseases that threaten life or livelihood: Cancer, diabetes, some communicable diseases, some non-communicable diseases, premature failure of organs, etc. Costs for care would have to be balanced against efficacy and lifespan. Can we spend half a million tax dollars on cancer treatments for an 85 year old? These sound like tough choices, but they are no tougher than we have today under lifetime insurance caps.
Required immunizations: Why not. More economical when purchased by the government for the entire population, provides a more reliable market for manufacturers and the incentive for discovery of new vaccines. Builds and maintains an immunological infrastructure that can be considered part of our civil defense system (bird flu, tuberculosis, other communicable and rapidly spreading diseases, including those that may increase in frequency as global climate change progresses).
(2) Decide whether drug costs should be subsidized for whom and negotiate lower prices from the manufacturers. Does Granny really need to take twenty pills a day? Unless we force price negotiations or other restrictions, we will never address that question. Doctors prescribe freely because someone is picking up the tab. Sorry, gramps, but if you want your Viagra, you need to pay for that on your own ;}
(3) Develop local clinic systems so that emergency rooms return to being emergency rooms. Accept the fact that until premiums and/or costs for routine care return to some “normal” level, government will have to subsidize this for the portion of the populace too poor or not civic-minded enough to purchase insurance.
(4) Release more commonly-used drugs as over-the-counter and empower pharmacists (and citizens) to diagnose symptoms and determine appropriate medication. If this scares you, recall that common drugs like Motrin, Sudafed, Actifed, etc. were prescription-only drugs until fairly recently, and we seem to have survived just fine allowing the masses to purchase them on their own. Sometimes, we really don’t need a doctor to tell us what’s wrong and what to do about it. Databases of clinical data can diagnose and prescribe just as well as a MDs memory cells can.
(5) Let the insurers and the market figure out how best to handle what’s left. (The really nice part about having so many smart folks on this blog is that I say that and most of you know exactly what that entails, because this diary is far too long already . . . )
__________________________
don't ask me, I'm just improvising
Political Compass Score: Econ L/R -0.12 Social Lib/Auth -1.33
I like a lot of these common-sense ideas
Especially this:
I really like this idea. You are spot on here. People have a lot more information at hand now than they used to-- so I think that people could take responsiblity for a great deal more of their own medication than they are currently permitted to do. When I went to the doctor for my first appointment for my back, he did not even look at my back, yet he prescribed me a steroid. I could easily have figured out an appropriate medication for my problem by going on WebMD or the like, but under our system I am not permitted to do so. Going to the doctor simply to get a prescription is not only expensive; it's not convenient or quick either, and that's if you can even get an appointment squeezed in between all the other patients (most of whom will just get a cursory examination leading to a prescription also).
I also agree that attitudes need to change about squeezing that last few months of painful existence from terminally ill patients, when the cost of that care is hundreds of thousands or even millions of dollars per patient in some cases. I think that people currently believe that they should be entitled to the full array of the newest and most advanced treatment for any condition, no matter how old they are, no matter how dim their prospects, no matter how unlikely the success of the treatment, and no matter the cost. I believe that a national healthcare system must maintain a patient's right to open up their own checkbook and pay for whatever treatment they desire; but any national healthcare program will need to set common-sense limits on the extent of coverage.
__________________________skymutt: wise and powerful... enlightened...
I don't know
that one gives me serious pause.
What are the most commonly used prescription drugs? I'd guess (and maybe I'm way off) that it's antibiotics. Overuse of antibiotics can have extremely serious negative effects not only for the person but everyone around them (the development of antibiotic resistant strains of infection).
Another common prescription would most likely be painkillers, which are often opiates and hence physically addicting. That requires some care in making widely available.
Other prescriptions would seem to be specialty purpose drugs for which you most likely do need a doctor to figure out it is what you need.
How about an alternative- require the first time you need a given drug that you go to the doctor to confirm the case, but then allow people to pick up refills basically on their own (with the presumption that they will recognize the same thing is wrong with them, or have a chronic recurring illness) with some guidelines to prevent opiate and anitbiotic abuse (say only a certain amount within a given timeframe unless the doctor certifies a new level).
__________________________I came. I saw. I posted.
Veni, Vidi, Bitchy.
How about some sort of registry at the pharmacy level?
Kind of like what they do for the ephedra-based medicines, to prevent meth manufacturers from stocking up. There's no reason why overpurchasing can't be stopped at the pharmacy level. And meanwhile, there's very little stopping patients from doctor-shopping and getting too much medication currently.
Drugs prone to abuse, such as strong painkillers, would require prescriptions still.
We'll have to work on the details, but we all seem to agree that the need for some prescriptions can be eliminated. A lot of doctor visits are simply for the purpose of obtaining a prescription. Something should be done to eliminate this costly waste.
__________________________skymutt: wise and powerful... enlightened...
The concern over antibiotics is valid
But I would counter that even with doctors controlling the supply, we overprescribed and needlessly used antibiotics and have already created superbugs, all with doctors being the gatekeepers. So in theory, they should have stopped this, but in reality, they did not. (The latest being the studies finding that use of antibiotics and tubes for children's ear infections was pointless, ineffective, and had very little affect other than to make erythromycin, a formerly very effective drug, useless.)
Having said that, however, I think we are at a point now where the remaining effective antibiotics must be rigorously controlled, and our only hope of that is via the prescription process. Not that I think it's going to work, however. But the odds are slightly better than if we made antibiotics OTC at this point.
__________________________don't ask me, I'm just improvising
Political Compass Score: Econ L/R -0.12 Social Lib/Auth -1.33
True
I just suspect it would be even worse if people were diagnosing for themselves. Anecdotal but I know a fair number of people who think that antibiotics are the answer to everything.
__________________________I came. I saw. I posted.
Veni, Vidi, Bitchy.
Agree on catastrophic care
The way it is paid for now hurts businesses, insurers, individuals, and taxpayers. Put all the hurt on the taxpayers and provide catastrophic coverage for anyone.
In theory this will quickly lower premiums for everyone.
If you can also incentivize preventative care and healthy living then I think you've got a good national health plan. People can purchase insurance as they see fit to cover less serious or elective care.
One tweak: I would mandate that children have comprehensive coverage, so that there is no reason for parents to avoid treatment for their children due to cost. We already have programs that subsidize that for low-income families, but we might want to consider expanding them.
I should mention here that Obama's plan does essentially shift the cost of catastrophic cases onto government through "reinsurance" -- an idea he borrowed from Kerry.
__________________________Come, my friends. 'Tis not too late to seek a newer world -- Tennyson
Children's coverage
I think you have to be very careful here, as this is one area that skews actions and costs significantly. Emergency rooms are clogged with children with colds and flu -- "just in case" it might be something worse, and for which there is really very little a doctor can do except treat the symptoms (fever, congestion, body aches), most of which can be handled with OTC drugs. And, actually, treating routine childhood illnesses has been a huge contributor to the overuse and misuse of antibiotics: parents insisting upon a prescription. How many time have you seen a doctor do an actual culture to determine if it's viral or bacterial?
Parents, understandably, are very concerned about their children's illnesses. But I would still put children and adults in the same category.
__________________________don't ask me, I'm just improvising
Political Compass Score: Econ L/R -0.12 Social Lib/Auth -1.33
Maybe so
but I could see handling the antibiotic issue with simple guidelines and other than that I'm willing to risk people over-treating children to minimize under-treatment.
(Edit: deleted further response, not sure it made sense on second thought.)
__________________________Come, my friends. 'Tis not too late to seek a newer world -- Tennyson
NHS vs US System
Did you know that England has also a private health system.
It is like Public Schools. Many complain of their local public schools but they can opt to enroll their children in private schools. But if they ran out of money they can still go back to a public school.
So with England. At least there is an NHS. Any shortcomings--there is still a private system for backup.
Besides---if you compare to NHS vs private insurance, I am sure you will get more services with NHS without the headache than a private insurance who will make you sweat first before authorizing the treatment or even not pay at all and would even increase your insurances when you become too sick.
Balancing cost and care
The idea of a backup NHS is comforting, but as All-Time QB mentions in his diary, England is facing rationing and cost issues and their program will ultimately have to change to remain viable.
The challenge for us it to learn from every other country's experiences and craft a system that is more effective and financially sustainable.
Today private insurance acts as they do (mostly ;} ) because of the extreme costs they are paying for a small section of their insured. If I and most of us cost them $400 a year, but you cost them $1 million for your cancer treatments, then the rest of us bear your cost burden. If we remove that $1 million, private insurance should readjust. That's a simplistic and short answer but I hope it suffices ;}
__________________________don't ask me, I'm just improvising
Political Compass Score: Econ L/R -0.12 Social Lib/Auth -1.33
What are you saying?
That rationing of expensive $1 million cancer treatments is necessary so we can both pay little and private insurance companies can still make record profits?
__________________________Sic semper tyrannis
No
I'm saying that the extremely expensive items get paid for by the taxpayers -- the largest underwriting base possible.
Private insurance companies could still function in the range that includes much more realistic numbers. The best analogy is automobile insurers -- they manage liabilities generally up to what, $500,000? depending upon the policy, and they seem to be able to do this without charging the average family an exorbitant amount every month.
I mean, we aren't hearing a hue and cry to eliminate the automobile insurers, are we? So insurance can and does function in our society. We just need to fix this particular version.
Rationing may still happen. It happens today in every nationalized medical system. It happens in our system today, even though we don't call it that.
__________________________don't ask me, I'm just improvising
Political Compass Score: Econ L/R -0.12 Social Lib/Auth -1.33
health care
as always I defer to Ezra Klein in matters of health care, he is an expert in my opinion ( he blogs at The American Prospect) He thinks France actually has the best system . Having worked in health care in Britain and in the USA I see the shortcomings of both systems.
Its a complicated issue in USA because of liability issues. Basically anyone going to ER with a bad headache ( yes its happened to me and I KNEW it was a migraine ) gets the full battery of tests CT scans etc. ( 1200 dollar at least ) because if something is missed , thats a lawsuit, its not the same in Britain . This is the reason for so much testing and its the reason for so many C sections for example , because its easier to get the baby out rather than have even a hint of fetal distress that could be parlayed into a lawsuit . This is not to say we cannot fix the problems , we could have a simple checklist , where the doctor is not held liable if he follows ABCD etc.... its the only way to go really .....
__________________________The drug issue is another thing, not allowing Medicare to bargain drugs down was the dumbest thing , the biggest customer is not allowed to ask for a discount ????
Market forces will just not work in the field of health care,,, I see it every day in my town ,,, if you get shot , or get cancer you go to the City hosptial ,, best experts in both fields are there! You may wait a long time to get the little niceties of care and you may not get the " have a nice day " but hey , your life may just be saved that day !
As far as private insurers go ... what do they really do ? They try to deny you care ... do we need them to operate a good system ? NO we do not need them , we need doctors , nurses , hospitals , hospice care, drug companies , we need a reimbursement system ( like Medicare ) to take care of the billing ... .see ? no private insurance needed .....
sligowoman
Liability is a huge part of it
I would agree that some sort of reform is needed, but I would add that doctors and the medical field in general have access to government today to address these issues and they could affect change separately from new healthcare legislation.
I would expect that any serious deliberations on anything I've said here would have to include the litigation aspect as well. I agree that we tend to see doctors and hospitals as rich targets and people choose to bring suit where none is warranted. We could perhaps learn more about this from the limits on liability imposed by other countries.
I think for now, we have to accept that private insurers will be a part of whatever is decided. First, because they do provide basic, well, insurance, and insurance does serve a function (house, car, flood, storm, etc). And second, because they are a huge employer, and no government official wants to be the one who eliminates hundreds of thousands of jobs with the stroke of a pen.
__________________________don't ask me, I'm just improvising
Political Compass Score: Econ L/R -0.12 Social Lib/Auth -1.33
Single payer insurance is good too vs NHS
Single Payer or Medicare for all is good too. Hospitals and doctors are private but there is only one insurance--that is Medicare.
The administrative cost of Medicare is so much lower than private health insurances. Furthermore, it will also help the administrative costs of private doctors, they dont have to hire lots of people to make sense of all the rules and billing of a variety of insurers.
As opposed to NHS where hospitals, doctors are NHS run.
No comments from our economists :-(
That must mean either (1) these ideas really suck and they don't want to hurt my feelings, or (2) they're busy.
__________________________don't ask me, I'm just improvising
Political Compass Score: Econ L/R -0.12 Social Lib/Auth -1.33
Either (2) or else
(3) they didn't read the thread. Maybe it needs a more provocative title =)
I'm no economist but the ideas seem quite solid to me. And it's not like the economists are shy about saying if they think something doesn't make sense =P
__________________________Come, my friends. 'Tis not too late to seek a newer world -- Tennyson
purpleface -- somewhat off-topic, I am planning
to add a page for "in-depth" pieces so they don't scroll off the front page so quickly, to let people discuss something over the course of a week or longer. I don't know when I'll get to that but I thought I'd mention it.
I basically see SC becoming three sites in one: (1) SC Daily, which will have open threads and pieces on day-to-day politics and issues; (2) SC Analysis, which will have longer pieces looking at big-picture questions, maybe also some collaborative projects; (3) SC Debate, which will serve as a central hub for formal debates.
Anyway, we're talking about how to overhaul things, so we'll see what happens. I don't have a timeline or anything. But when that happens it will hopefully become easier to bring people in and also easier to slot content into the appropriate place so it gets widely discussed.
__________________________Come, my friends. 'Tis not too late to seek a newer world -- Tennyson
Sounds great, Brendan! (nt)
don't ask me, I'm just improvising
Political Compass Score: Econ L/R -0.12 Social Lib/Auth -1.33
I still prefer universal health care NHS style
If you think NHS is rationing care, then US private health insurances do it 1000 x more.
It is expensive so it makes sense to ration in a way that those who needed more care gets it first. Just like when you go to an emergency room.
A person having a heart attack will be treated first compared to a person with flu.
And people can buy extra health insurance to pay for those that NHS wont pay.
But people should have basic health services. However when you want to have a liposuction, facial lift, or experimental treatment then NHS does not need to pay it.