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June 17, 2005

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Abby

I am in no way an expert on these issues, but I did notice that you had much better data on the Medicare and Medicaid populations than you do for private plans.

I think that I would be better served by a good single payer system. I have a chronic condition that was mis-diagnosed when I was in college. In college I was restricted to using a university health service (similar to student health service--only larger). I was not happy with the quality of care offered.

I would have liked to be able to go to proper specialists, but I couldn't. I make sure to follow the medical literature on my condition, and I'd like to be able to fire any doctor who doesn't. With single payer I would have a greater choice of doctors. (The only doctor I've met that I thought was really competent didn't take any insurance. So, I prefer a PPO model where I can get 70% coverage to an HMO where I'm stuck with the crappy Kaiser doctors.)

If I got sick outside of my regional coverage area, I wouldn't have to worry about whether it was covered. And I wouldn't have to worry about doctors leaving my plan or a particular plan being dropped by my employer.

TomH

OK, I've read John's post. Here are my thoughts.

I think John is exploring a new angle of the universal care debate, one that I really haven't seen debated before. Usually, when an analysis drills down to the delivery level, it's to examine how a particular model will save money. That's critically important, but frustrating. The rejection of the Clinton plan, in part, because of the canard that it would have limited consumer choice, marked the beginning of a consumer revolution that rejected all limits on choice, thus virtually all cost-control mechanisms. So discussions of how we'll reshape the delivery system under a particular universal health care system to control costs probably miss the point, which is that the American public may not allow costs to be controlled under any model. (which is why I think it makes sense to target administration and marketing costs, since those may be the only excess costs truly on the table.)

So perhaps it makes more sense to create a universal health care model that does what John suggests, which is to 1) reduce overuse of health care services; 2) reduce misuse; 3) increase utilization of underused services. The public might respond less suspiciously to a proposal that made this a high priority. And it would ultimately save money. The overused services are very expensive. The underused services are cheap and needed to control chronic conditions, which are much more expensive at the back end.

I'm intrigued by the questions John raises, but not so sure about his answers. In part, that's because I don't know what plan he supports, just that it involves competition between health plans. But if we look at our choice as an election, in which we're choosing between some form of managed competition and some form of single-payer based on which would do a better job of improving quality of care, it's not at all clear who I should vote for.

The starting point is our current system, which is highly decentralized - that's what created the preconditions for geographical disparities in the first place. Have private insurers incorporated Wennberg's findings into their rates and benefit structures? Have they demanded that providers create shared decision-making structures so that patients can exercise more control over the decision whether to undergo surgery or to stick with a more conservative plan of treatment? They have not. In fact, it's not clear what private insurers have done to improve quality of care in the United States. That doesn't mean that health plans are bad and should be abolished. Hey, maybe it's the employers' fault for not demanding high-quality care. But it means that John is pinning a lot of hopes on a market sector that has no track record for doing what he wants. Well, except for Kaiser Permanente. If John's proposal involves forcing all insurers to turn into integrated staff-model group practices, count me in.

One last thought on Jack Wennberg. Like John (and Governor Pataki), he's concerned about "finding mechanisms to clear regional markets of excess capacity." Here's his plan: "If Medicare was willing and able to take steps to select providers on the basis of quality and efficiency - and other payers were willing to play by similar rules - this would serve as a life or death wakeup call to the provider community, one which would presumably result in accelerated change throughout U.S. health care markets."

Got that? Wennberg wants the Federal government to decisively intervene in our high-functioning market economy to solve an intractable quality of care problem. And he wants this intervention to be carried out through a single-payer system, which is to say, Medicare.

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