The US healthcare debate is both facsinating and frustrating. Facsinating to a political or economic junkie who gets to hear so many differnt ideas about how to pay for, manage and deliver affordable yet high quality healthcare services to a growing population of three hundred million scattered across fifty plus jusrisdictions with diverse geographical and social needs. Fitting all the disparate interests and needs into a single solution seems at best a fools errand.
But it is quit frustrating to actual people; patients, caregivers, providers and others who intimately live with the US healthcare system everyday. Part of the frustration is the lackadasical attitude with which Republican politicians and policy drivers across the land appears to treat the real issue of life and death that is healthcare. Not suprising though, given Repulican's tradditional lack of empathy -- individual Republicans seems to only grow empathy when an issue directly affects their initimate famiiy member such as their children. Patient's and their caregiver wonder, constantly, if new policy changes will upend their lives and make access to basic treatment even more difficult and suddenly restrict their options even further. Like it or not, access to healthcare in America is still based on who you are and on what zipcode you live in.
So what is healthcare? Ask a patient, a patient with chronic disease. Most will tell you it has to do with the assurance that you will live to see the next day, and that tomorrow may turn out better than today. It will include whole body, inclduing mental, dental, optical and nutritional. What about how to pay for it --- Almost everybody wants to pay for good healthcare, within their ability to pay of course. To most people, including most American's healthcare must include ability to access it, and ability to afford it it. Thinks of air -- something most of us can both access and afford.
So the question for policy makers and politicains is how do we create a system, a healthcare system that affords the populace whole body helthcare while guranteeing universal access and universal affordability withut banckrupting the nation. How do we incentivice innovative healthcare solutions, including life enhancing and life extending solutions as well as improving delivery systems --- all while keeping the costs down?
Herein lies the paradox of American healthcare system. One one side is the tug for universal access and univeral affordability, and on the other is continuous innovation and system sustainability. Within each subset there are also conflict. Will universal affordability hamper universal access, and how will sustainability impact continuous innovation.
The last major overhaul to the US healthcare system, the Affordable Care Act made a stab at answering some of these interwoven and complex questions. It mandates access to the healthcare system (requiring everyone get's health insurance and asking that insurers accepts everyone regardless of health status). The one problem about mandate and insurance is that they are contradictory. If everyone is required to get something like healthcare, what is the point of insurance -- in the legal sense of something you get to mitigate risks.
Let me explain. In the case of Auto Insurance, a market makes sense because different people buy different types of automobile. Some own multiple vehicles and others own just one. Also, different people can choose to mitigate different levels of risk, based on their history and othegr personal traits --- a wealthy person can choose to have higher liability deductibles than a poorer person. In the case of healthcare, the conditions that may strike are not always predictable. Everyone is essentially in the same healthcare boat! Certain age group or biological groups may be more prone to certain conditions that others, e.g men above 50 years old are more likely to suffer from prostrate cancer than teenage woman, and women older than 13 are more likely to become pregnant than boys. So in the aggregate, insuring against these conditions may not make a lot of sense. How can you prevent prostrate or breast cancer, realistically? or better yet, how can you prevent a predisposition to breast cancer! Indeed, there are promises that genetic engineering may one day help us avoid or eliminate many a chronic disease, but the realization of that promise is still many years away. So the best approach remains to afford everyone access to medical care that can help mitigate or treat these conditions, if and when they do occure. Of course, not everyone will end up suffering every disease, but everyone is ultimately prone to them.
But then if universal access leads to system bankruptcy, no one then will have access. And that is the key risk of single-payer. There are many ways to mitigate this risk. There are already signals that this could happen, just take a look at Medicaid and even many comercial insurance programs and how they ration access to specific therapies and physicians. Also pay attention to the endemic inefficiencies in the current practices of the government substitute --- the insurance companies. So we are already seeing what could go wrong with a single, single payer system, particularly one where all medical administration is centrally arbitrated and where all of a patient's options are made for them by some government agent ---see public schools as an example.
The physicians become agents of the state and thus more difficult to hold accountable and an arbitraty group of beauracrats determine who dies or lives.
But it doesn't have to be that way. The US medicare system offers a path forward in many respects, albeit imperfectly. A single payer system could be setup to reward efficiency and quality without sacrificing access and affordability. A progressive tax funded healthcare system where the government's role is limited to payment, regulations and oversight could provide a framework for highly innovative delivery system with excellent care and even more efficiency.
Imagine changing the mandate of health insurance companies to health management systems. And imagine changing episodical payment to whole health based payment. Allow patient's shop around for the best health management provider. The health management providers will play the role insurance companies now play, paying hospitals and clinical providers, while competing for patients dollars from the Federal or State governments. Federal agencies will provide oversight and measure performances based on Federal requirements. Clinical providers (hospitals, physicians and others) will compete for the business of the health management groups. Having the health management group between the government and the physicians and patients may help immunes the system from the temptations of monopolies, the zeal of beuraucrats to act like gods, and the impulse of care management groups to try to cut corners.
So, how do you pay for a single payer system. Many politicians and self-styled analyst have raised the spectre of national bankruptcy when talking about single payer, but their claim is so far from reality. The US can afford it. First let's look at th numbers.
Today, the just over three trillion dollars US healthcare market is funded 33% by the government (Federal, State and local), 33% by indivduals (premiums, out of pocket, etc) and 33% by others. So the issue here is to transfer the remaining 67% that is not currently paied for by the government into government control. This of course will be done by transfering same amount from the current payers to the government coffers! You ask for a merginal tax increase from individuals and corporation to make up the 67%. They already spend it, you are just re-organizing how the money is collected and disbursed. Not a simple task, but quite doable. That will maintain financial equilibrium between current cost and current deliverables.
And that's is when the innovation starts. For one you can optimize the existing system by reducing various operational and process inefficiencies by going to a sinle operational and process standard across the board, not at the clinical level. The standards can be continuously improved and various operational and process innovations incentivised as new standards are developed to take advantage of new knowldege and breakthrough in technology and organizational beahvior.
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