The Big Plan

I have been anticipating laying out "the big plan" for a better health care system since I started this blog, and I've started this particular column several times this week. Over those several false starts, I discovered that my ideas really weren't that revolutionary at all. The more I dig, I'm realizing that stealing bits and pieces of other countries' health care policy really isn't the final solution. At the same time, I feel a need to explain where I wished health reform would have gone first in 1992 and then in 2010. Then I can explore moving past those not-so-new ideas.

The Big Plan - 2009-2011 version.

1. A publicly funded and administered safety net that everyone pays into based on income, and all can access.
2. A private system for those who have paid their share but want access to services the public system does not offer.

Our present school system is a perfect example of this idea. We all pay taxes, we can all go to a public school. We can choose private if we want something different. The British medical system is designed this way but in reality the proportion using public care is higher than I envision in the United States. The VA system now is functioning much in this fashion, with most savvy vets using their benefits for many basic functions and hospitalizations but turning to private doctors when they don't get satisfaction.

I advocate for the least number of middle men between the public's money and the actual delivery of care. A specific health system tax (like our Medicare taxes now) and public health services best achieve this goal, and also represent the simplest way to deliver care to the entire populace. The most legitimate criticism, in my mind, is that these kind of systems are notoriously inefficient. The other is that we can't afford the tax burden of paying for such a system. The latter claim is shaky at best, for all other first-world systems of this sort actually operate at significantly lower per capita cost, often with greater access to both providers and technology.

I believe(d) that because this basic plan already existed in other sectors of American life, that we as citizens would be willing to give it a try in health care too. I was wrong. There were voices during the debate pushing for just this kind of model. But at the height of the Tea Party's influence, the phrase "Evil Socialist," as stupid as it was as an argument, did have significant political power. So we got what I'd argue is the worst kind of hybrid system, a publically mandated use of private providers. Not publically supported, which is dicey but has proven to work in some areas, but publically mandated. For a free market to work, you must have choices, including the reasonable ability to opt out completely. That way a business offering terrible product can simply fail. (Similarly, if you are going to apply free market ideas to social problems, you must be ok with people dying as a result of market competition. Many capitalists believe this but know it won't fly well to say it out loud.)

Two weeks into my "save the world" binge, and I've already realized this kind of political dialogue isn't where we're going to find the solution. First we must reconcile the fact that our economy (the basic framework in which we deal with fellow humans) is at this time competition and scarcity based on all but the smallest scales. Not only is this at odds with an industry that is about helping others, it doesn't work well in that context, and makes false assumptions about the endeavour in general.

Proper health care isn't a scarcity. Because the #1 determinant of patient satisfaction (manifest most basely as avoiding lawsuits), outcomes, and professional satisfaction, is that quality of the patient-provider communication. This resource is not quantifiable, and therefore not easily priced. It is not a zero-sum transaction and in fact often follows positive feedback increase.

This is where I'm going next...thinking about an actual paradigm shift.