Look at it this way: governments serve people in varying ways with varying success rates. Our taxes build bridges and sewage plants, lay sewers and highways, and many etc.’s. We ignore these background details. I’m not aware of graft and corruption, although I ran into an example as a youth [another time; enough to prove it exists.]
America and Australia are frontier nations; we expanded into a large area populated, if at all, by stone age peoples. That experience dulled our consciences but also molded our expectations. All of South America, Central America, and Canada are on the same list, and we’re all different. So calling ourselves Americans emphasizes those differences. Not that they are good or bad – they define us, full stop.
Our medical industry involves insurers and providers,with varying mixes. On the one hand are medical insurance companies; in the middle are HMOs which act as both insurer and provider; and on the other side there are doctors and hospitals, clinics, etc. who provide care but on a cash basis.
The rest of the free world has decided to bureaucratize provision of health care, and let the tax system handle the cash elements. Everyone pays some sort of tax, and everyone gets care.
Here in America we have a phobia against bureaucratizing medicine. All we need to do about that is invert the incentive structure.
What’s wrong with our current incentives? Insurance companies have no incentive to court you if you’re going to cost them money. After one year, if you’re expensive, you wind up “in a pool” with other expensive people, and your premium reflects the expected cost of your pool. This lets the insurance companies focus on you one year at a time. Every birthday you become an official stranger.
The nut to crack is how to make you more attractive, not less, as time goes by. Here’s one idea.
Look at all medical payouts to doctors, dentists, chiropractors, hospitals, nurses, surgeons, clinics, – – – look at all medical payouts as a POOL. The total POOL in the rest of the free world is, call it, TEN. Per citizen and after correcting for cost differences in different economies, we pay somewhere between THIRTEEN and FIFTEEN.
So – rearrange the Medicare income tax and the Medicaid state expenditures and the amounts that major employers spend on health insurance so that all of it winds up in a “Medical Account” or POOL. Then encourage every employer of actuaries who estimate your probable health cost for the coming year to send their crew to a month-long vacation somewhere boring. Let them confer and bring their laptops, databases, etc. Have them draw up a table each year which has a thousand (pick your own number – mine is just to enable a discussion) diagnoses.
What goes into a diagnosis? – age, gender, prior history, DNA, height, weight, and all of those odd things doctors have written about you over the course of your life. When the table is complete, you John Doe wind up as Diagnosis 739; mine as Joe Blow is 148. Do we care what that number is? Of course not.
And when we show up at an Urgent Care, or our doctor’s office, or a hospital ER, or need an ambulance ride, one of two things happens, both good. A – we already have an insurer who gets the money associated with our diagnosis, like 148 for me, and pull out a one-year policy cost. They pay the bills. They sweat about keeping us so healthy that they are money ahead at the end of the year. OR B – we don’t yet have an insurer, and either (B1) name one, or (B2) draw one out of a hat. In either case, said insurer gets access to your Diagnosis’s predicted annual cost, and you get care.
Our POOL isn’t going to be the whole FIFTEEN – but a lot of the cash we spend to reach FIFTEEN is likely to fade away. We build palacial doctor’s offices and hospitals to attract patients. We pay huge fees to the best doctors. Those elements of the FIFTEEN pie aren’t going to decline soon, but the idea is to avoid excesses. The rest of the free world does so by telling them, “WE get all the patients, and WE employ you to treat them, and HERE is what you’ll get paid.”
No Americal likes that kind of bureaucracy mucking up a merit-based system, so our FIFTEEN isn’t going to get all that much closer to TEN – so for now let’s accept the idea that we haven’t solved the whole problem.
But look at the new picture. For one, insurers are going to compete for the highest-cost Diagnoses. The ability to manage that huge sum will mean that the sickest will get the most attention, rich or poor or indifferent. They will mean a big cash outlay from the POOL, even if they happen to be indigent.
For another thing, gym memberships will be open to all. Just show up, and your insurer will happily dump five bucks into the gym’s account. Because (those actuaries again, the folks who estimate cost and return) understand that you’re likely to cost them six dollars less in care for each visit to the gym. Will gym memberships be free? Likely not – but they’ll compete hard for your subsidized patronage. The insurer is happy, the gym is happy, and you’re healthier. No plan is foolproof, but something like this is bound to occur.
Whose taxes build up the POOL? Employer medicare expands to what a current employer now pays for your medical coverage. The medical insurers won’t starve – instead, they will receive your Diagnosis from the POOL. Their sales staff will find other things to sell, but disruption will occur, which also means that opposition to such a huge change will be loud and aggressive. So, tough. Go forward.
Copays? White collar workers’ medicare taxes might have two tiers – low meaning copays exist, and high meaning they don’t. Low-wage workers’ copays will be nominal. Necessary (another discussion) but small.
Freelance doctors (cosmetic, special sports treatments, you-name-it) will have a market presence. Their compensation won’t be “out-of-system” because the insurer-provider combination will disappear. Too many horror stories come from folks today with low cost HMO coverage (yet another discussion.)
All doctors and all hospitals will get a fee-for-result (fee-for-service in specific cases) and the Beverly Hills MD’s will be able to tack on their own fees, and insurers will doubtless allow clients to pay extra up-front for that, because “it’s a free country.”
The thing to do is to meld market participants with government funding, such that there are no government employees making any critical decisions. My apologies to folks who are civil servants.
Most of you work hard and do a specialized job. But pulling medical care away from private hands and turning it over to new hires wearing federal and state hats is just not going to sell well.
Laws do not have to create bureaucracies, and the ones that already constitute the private market have task masters driving toward an efficient outcome.
Oh, and Another Thing 