Health Policy - New York State

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June 24, 2005


John Fembup

Solid thinking.

"a one-time jump in transfers from the rest of the economy to healthcare that would accompany a political move to universal coverage would not, by itself, change the system structures that create these dynamics . . . Any universal coverage system must directly face up to how the core costs will be controlled."

That's precisely why I say, until I see persuasive arguments that health care costs can be contained, I have absolutely no faith in "solutions" that rest on some kind of insurance mechanism.

That's my story, and I'm stickin to it.


My remarks aren't tempered by any real-world experience in the healthcare biz. So take them for what they're worth, which is not much.

A general question, why does France seem to do so much better with less? I don't know, and I'd really like to.


1.) The administrative aspects. This is a one-off deal, but I think it might be enough to bring everyone into the system at current spending levels.

2.) Freeing people from employer-based coverage might allow people to be more entrepreneurial and could spur economic growth. (Strictly speaking, that's an argument for universal coverage, not single payer, but if we could get the economy to grow faster then the proportion of our economy taken up by health care won't go up so much even as health spending rises absolutely.)

3.) Rational pricing on pharmaceuticals. Yeah, these are price controls, but I don't think it will kill all innovation. The government could, for example, pay a reasonable and customary rate for medical services received during the course of research. This would cut down the cost of doing clinical trials and could make up for some of the loss in revenue to drug Pharma and others.

4.) If the government insures you over your whole life time, it will have an incentive to give you good preventative care---not a panacea, but not negligible either.

5.) The government will have an incentive to clean up the health care environment. I know that this sounds coercive and big brotherish, but I don't mean for it to be. If the government has to pay for the asthma care of kids in polluted areas, there will be a greater incentive to get the polluters to pay for the cost of that care or simply to clean up their mess.

6.) I think it could be easier to get things like electronic medical records and other IT innovations which could allow for co-ordinated care implemented. It would be a lot easier to collect naturalistic data. (Some of the best studies on schizophrenia treatment come from Denmark, and patients who were discharged from the military, because it's relatively easy to follow their course of treatment.)

7.) I think that there would be a greater emphasis on research into cures and vaccines. If there were a fairly expensive treatment that cured your diabetes, it would still be worth it for the gov. to shell out, since the gov. would otherwise be paying for your pills for the rest of your life. A private insurer knows that you probably won't be with the same plan in a few years and isn't therefore incentivized properly.

Now maybe that should be combined with some sort of HSA, although I think that, if it is, there ought to be some sort of redistribution towards those at the bottom.


you're all very learned on this topic, and certainly more intellectual then i. however i've existed and occasionally triumphed as a solo fp in small town with a large multi-specialty( think churn those patients till we've rung every last dollar out of them), a hospital employee group( think, who cares if we see any patients, we're making 300k a piece), and a federally funded "migrant" health center that now runs its own health plan and competes with me for insured patients. so here are my well cogitated thoughts on insuring all:
1) no change will make any difference as long as there is not real tort reform. the cost of defensive medicine is incalculable. as i watch the work of recent grads (5-6 years) it's quite clear that they don't even why they're doing some of the things they do routinely. even in my generation, there is tremendous pressure to do things that cover you in the future. as a former police officer, i well remember the lessons of cya, taught from the very first day of tha academy. medicine doesn't do it very well. because, i think, they're afraid to call it what it is. and it's very expensive
2)any real universal and/or single payer will eventually cap fees. there is no other way to control costs. the problem is that you have new grads coming out of training owing 250k in loans. where are they to make the money to pay off that debt?
3) while i'm not troubled by the idea of universal coverage, i am troubled by the single payer concept. because we all know the government would be the payer. we have a national healthcare system in place. it's called the va. you see almost constant roll backs from the commitments made to vets, in an effort to control costs. who really thinks that the same government that brought us the postal service, would manage healthcare at some mystical higher level then it runs anything else. name one government program that really works. medicaid? medicare?
frankly, i think the wheels are falling off, and our political system lacks the flexibilty and the integrity to deal with the problem.
i have 15 years to go, but my wife makes a nice income. like so many others, it wouldn't take much to chuck it.

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