OK, here is my long-promised attempt to summarize the health care policy options of the two candidates. Below I will list my "executive summary" but I've prepared a longer review of the issues so follow this link to read the full account.
This may well be (I think is) the single most complex policy issue of them all. There is no simple, easy solution that I think we would be happy with.
That said, something needs to be done - for various reasons the current system is inadequate.
Both candidates have some good ideas as to lowering overall costs, improving health care overall nationally, and getting more Americans covered by insurance.
Where they particularly differ is in their approach to increasing the number of Americans covered by insurance, and in what portion of the overall health care system would be paid for and managed by the government.
Obama would still leave current options basically in place but would open up the government run insurance company to all Americans (currently just for federal employees).
McCain would basically work through the states on programs (currently operating fairly effectively in several) that would insure all Americans eventually, and would give people who are applying as individuals for insurance a tax credit/rebate to help pay for premiums.
McCain’s program is more decentralized (coordinating with the states) and likely would take some time to work out, but in its essentials I think would ultimately work.
Obama’s program I think sets some important standards and gives new options for getting insurance, but I believe will lead us in the direction where the government pays for and directly controls more and more of the overall health care system, which I think would have very negative consequences down the road.
My overall opinion: both have some good ideas, but I fear any policy that significantly expands the direct government involvement in determining and paying for health care benefits.
Update: It may be that the current expenditures being decided on to stabilize the financial system make it impossible to have a very large increase in expenditures on health care, which would impact plans for both candidates, but more so for Obama since his proposals are much more costly.
12 comments:
I am from Canada and have several close family members still there and have seen some of the results of government being too involved in the health-care industry, so anyone who suggests anything that even hints of socialized medicine scares me to death.
brilliant, teej!! thanks for this!
I have to say that anyone who encourages greater levels of insurance scares me as well, at least unless they are willing to change the way we do insurance. I would love for everyone to have catastrophic insurance, but the way we do insurance now is ridiculous. Instead of covering against the risks of terrible things happening, insurance has become nothing more than a health maintenance plan, where insurance pays for every little thing.
One thing that no one ever considers is that insurance causes people to use more health care than they would otherwise, and while that might be an improvement for some people, it dramatically increases the demand for health care, which drives up health care costs. Yes, I did just say that the existence of insurance (whether provided by the government or private companies) increases the cost of health care. Greater levels of health insurance would only make that worse.
Another thing to consider is that the risk of adverse health consequences from interactions with the health care system is real. I don't blame doctors, and I think med-mal suits are a bane on our society, but that's a different story. The point is that if we eliminate health insurance, we would decrease interractions with the health care system, which would decrease the total number of adverse health consequences. If that weren't enough benefit, it would also mean fewer med-mal cases.
I am not currently planning on voting for either major candidate, but if one of them would say that they were interested in increasing the opportunities for Medical Savings Accounts, and removing all state and federal mandates on insurance coverage, that might be enough for me to vote for them.
Some good points, Jeremy, but let me give counterpoints in reverse order.
First, although adverse outcomes have always been and will always be a part of the equation, they are more rare than they've ever been and can be decreased further. I mention this principally because if you look at the overall system, people with regular interaction with the "medical system" on balance end up with many more positives than negatives. I tell people all the time when we are making medical decisions that there are consequences to inaction as well as action. Point being, I would not argue that insurance encouraging more doctor visits, etc. is a net medical negative. I could give many examples of this point.
Now in terms of cost, sure it can add to the total costs, and we need to look at the reasons why and address it (it may not seem this way from the 'outside' but there is great interest among docs and others in health care to avoid unnecessary cost both to individuals and to the overall "system." But there are many reasons why health care is too expensive in the US, and I don't think insurance per se is the problem. Consider, for example, the typical Canada/Europe model. People don't pay ANYTHING for going to the doctor, and they do indeed go quite often, and yet their per capita costs are significantly lower than the US system. In other words, it's not the number of visits/interactions that makes our system expensive.
Americans expectations from their health care system, and the fact that we don't like to be told no, and that we love new technology (which is often beneficial, but that doesn't lessen the high cost of these new meds and technologies, etc.), are perhaps underlying reasons for the high cost of our system. In any case, I think we have to look elsewhere for the reasons for high costs in our system...it's not because insurance lowers barriers to getting medical care.
Finally on the point of medical savings accounts, I agree I love that program and think it has great potential. Those programs have improved with time and both candidates speak favorably of them - I'm sure both will include this in the mix.
TJ,
My point about adverse health consequences from interracting with the health care profession was only to point out that, if you go to the doctor for every little thing, the law of averages will eventually catch up with you - if you go to the doctor for only those things that are necessary, you are less likely to have a serious problem.
As for the issue of insurance and cost, I am sorry to say that insurance is THE reason why health care costs are so high. Your arguments are the common ones, but they are flawed in a couple of ways.
The reason insurance causes costs to rise is that when someone else is paying most of the cost, we buy more of it. That's probably a near-universal truth. As people begin to use more health care, the market (such as it is) responds, and diverts more resources from other industries into the health care system. Buying those resources away from the next-best option costs more money, so the cost of health care services rises. The more insurance we have, the more we use services, and the more the cost rises.
Your argument about Canada and other places where there is socialized medicine is flawed because the government in those countries sets a ceiling on the total amount of health care that can be provided, so they don't have the escalation of costs that comes from having to buy resources from other indutries. They set that limit because they have to pay for the system, and so instead of money rationing health care services, the government puts you on a list. My aunt desperately needed hip replacement, and had to wait 16 months. That sort of wait would never happen in the U.S., nor would the type of wait that happens in Canada and England, where people needing treatment for cancer die while on the waiting list. Again, so long as we are committed to a free market (and I am, for sure), insurance causes the cost of health care to rise, and the more insurance, the greater the increase.
Your argument regarding Americans loving new technology is absolutely correct, but you missed the fact that it is insurance that allows them to demand the new, expensive treatments.
Think of it this way: if there is a new treatment that costs thousands of dollars, and is only an incremental improvement, someone who has to pay the whole amount will likely say no. However, the person who has insurance, and makes a co-payment of only $20 or $50 will certainly say yes. It is only an incremental improvement, which is not worth thousands of dollars, but it is certainly worth a minimal $20. If we all paid more for our health care, we'd make decisions that more accurately reflected the reality of the costs and benefits of new technology.
Just a brief reply. You make some good points about market forces and how they may apply here - I can verify that happens when someone says 'no' to an MRI rather than 'yes' if they have to pay a lot for it themselves. And so you are right that insurance adds that element of cost. And that the Canada/Europe models attenuates this effect by simply saying "no" to people more often.
I just want to point out that there is a counterbalancing element in the equation. For example, the person who said 'no' to the MRI because of the cost did not get better, and turned out to have a mass in the spine, which because of the delay in diagnosis (let's not even talk about the lawsuit there in the US!) went from needing a simple surgery to a very complex one and left him partially paralyzed, etc. My point just being that people getting regular medical attention and tests finding problems earlier and emphasizing prevention, etc. can add an element of cost savings.
Still, in the end, I'm sure the costs are higher. But are you telling me you think you're going to convince Americans at this point to not have health insurance that pays many of the costs? And in terms of "catastrophic insurance" where do you draw the line? It doesn't take much sometimes for health issues to load on or cripple a person or family financially.
I think Americans have decided that they are entitled to health care (thanks to Obama and liberals everywhere), so I don't think I'm going to convince them that they shouldn't have insurance. The problem is that because of community ratings and state-level mandates (not to mention the Patients' Bill of Rights from a few years ago - what a mess that thing is), those of us who would like to buy just catastrophic, and then cover our health maintenance costs with a MSA find it hard to do so. More to the point, there is no reason why health insurance ought to be provided by employers, and if we got rid of the tax benefit to employers, then people would get paid more, but they would be responsible for getting their own insurance, and they would be much more aware of the cost of their insurance, so they would be more inclined to consider all of the costs and benefits. If that were to happen, and I think that is part of McCain's plan, then I think you would see a lot of people switching to catastrophic plus MSA's, and those who insist on luxury plans would have to pay the full cost, instead of making the rest of us pay for their excessive use of health care services.
I actually did most of my research in grad school on health care economics, so I have heard the arguments regarding those who say no to care when they really need it, and then the costs are much higher later on. Part of that argument relies on the cost of health care being so high, but as I've pointed out, that is in large part due to the widespread presence of insurance. Add to that the fact that there is a government-provided "safety net," and a lot of those people say no because they know if something major happens, they won't bear any cost.
However, I think the best argument is simple statistics: most people don't have a mass in their spine, but we inevitably do MRI's on them, anyway, just in case, and most people don't say no because their insurance will cover it. If we went with no insurance, and (taking the most extreme position) no one got MRI's, there would be a few who would have greater costs later, but there is no reason to suspect that those increased costs would outweigh the savings on not having done all those MRI's. Add to that the fact that I trust doctors to know those who REALLY need an MRI, and their additional emphasis of the need would convince some who would otherwise say no to say yes, so we would probably reduce dramatically the number of those who would have greater costs later on.
Right. We are saying largely the same thing although I'm more accepting of the fact that I don't know of an existing example in the world today of high quality health care being provided by a market-based system such as you describe. Could it happen? Maybe, and I'm intrigued by your suggestions. And for an "average income" American maybe this works. Do you think it works for all, even the poor? What if anything would you do for them? And say we don't "require" catastrophic insurance - what happens to those folks who don't buy that catastrophic, when it hits the fan, as it were? I ask these in part because if we don't have effective answers, I don't think we stand much chance of moving things back to market-based system. Because although in the long run market-based solutions tend to come up with the best solutions, they also rely on "natural consequences" to change behavior, and that means people who make 'bad decisions' (whether or not they could have foreseen it) take the consequences. That leaves a lot of 'market detritus' if you will, which our society is not very accepting of. So if we want to move towards market-based solutions, we need to understand this and consider answers to it.
Also, I will tell you that docs, even very good docs, simply are not capable of always getting it right on who needs that MRI. If we could do that, we wouldn't need the MRI (you get my drift). And then you have to fit into the mix malpractice lawsuits - as long as docs feel heavy pressure to check that MRI "just in case" for this reason, they will pass some of that heavy pressure on to the patient, and if that patient is paying the 2-grand for the MRI themselves, well that gets back to my original point about health care costs potentially crippling some families financially.
I should say that I do agree with you that overall costs would be lower without insurance, but if we say we are not going to have insurance of the kind we have now, it raises some tough questions that I still haven't heard great answers to from a market-based perspective.
I think there would be a pretty painful transition, because we have trained people to rely on the government taking care of them when they make bad choices, like not buying catastrophic insurance. I think that a lot of doctors would help where they could, especially if they weren't encumbered by insurance and government rules. I also think that private charity would pick up much of the slack, although it would do it in a way that was much more centered on the individual, and much more likely to make sure that the individual was edified by the process (learning from mistakes, etc.), rather than just seeing whether the items on a checklist were met, and then cutting a check.
I have a libertarian friend who often says that the arguments over the status quo versus a perfect free market are interesting as a theoretical debate, but useless in terms of practical change, because we're never going to get to a free market. I don't know that I am willing to give up on it yet, because I think it is morally and economically superior, but his point is that even if we can't get to a perfect free market, we can at least avoid moving away from it and towards greater socialism. I think the trend towards wanting to insure everyone is a trend towards socialism, and that we should, instead, remove insurance mandates, remove the tax provisions that essentially assure that employers will be the ones providing the insurance (including getting to tell you what you have to choose from), and cut back a little on the health care safety net. If we could do that, we would start to ease the high demand for health care services (most of which is not essential), and we would see costs begin to decline, so that those who are really struggling might stand a chance of getting health care when they really need it.
It's interesting because I think we are largely kindred spirits in believing that effective markets with competition can solve many seemingly insoluble problems, and as you so well suggest, we have to get away from the seductive mindset that government is the locus of all solutions.
But the practical matter of living in the society we do, with a majority of the people ingrained with the idea that truly free markets are always bad, and government (all three branches) must be looked to for the solutions to all worldy suffering, is challenging to say the least.
I admit I don't know for sure that we can "shape" complex markets without the law of unintended consequences kicking us in the rear some more. However, obviously from my original post I am open to a pragmatic approach wherein I hope we can create a system still largely private and with fairly robust competition/markets as a way to avoid the socialized medicine that you rightly fear.
Correcting Joe Biden and Obama ads: copy and paste this to your browser - article demonstrating the lies and deceptions in the VP debate about McCain's healthcare proposals: http://article.nationalreview.com/?q=NTRmYzJkMmZkN2U2MDY4NmIwZTdlZTk5YzY5NTU1OTc=&w=MA==
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