One Terrible Plan for Universal Health Care - and the Seeds of Something Better

Before proposing a basic layout for improvements on the health care system, first we need to ask ourselves "What isn't working in the system we have now?" Though there are many many possible issues, this is what I'd consider the Big 3.

1. According to multiple measures, our health outcomes are not good. Life expectancy in the U.S. is 78.3 years, ranked 36th by the U.N. (#1 Japan is 82.6) Infant mortality is 7 per 1000 live births, 34th. (#1 Singapore is 2.6) We've all seen these statistics before. They're not subtle.

2. Our costs are extremely high ($8,400 per capita, 17.9% of GDP in 2010), in fact the highest in the world. Japan was spending below $3000 in 2007 when the U.S. was spending over $7000. (While kicking our rears in measurable results.)

3. A large proportion of the population has minimal access to health care. (I was very careful in the wording of this statement, I'll return to why.) 50 million people, or 16.7% of the population, are completely uninsured. 27 million of those are working and 10 million are children.

It may seem like a tautology, but I would argue that the #1 priority of a health care system is to improve the health care of those who use it. We would be having a very different conversation in the United States if we were both #1 in health metrics and spending. But we're not. The old saying goes that the system is perfectly designed to get the results it produces. Our system must be designed to produce in the area we are #1 - spending. That is, our system is designed to move massive amounts of money around and it succeeds marvelously. I'll let that simmer a bit. Remember the "pot of gold" from an earlier entry.

Back to my careful wording in #3. When I say that "a large proportion of the population has minimal access," I specifically mean not zero. There is a safety net in place already in the United States, EMTALA. Since 1986, all persons are entitled to evalutation and stabilization in any Emergency Room of a hospital that accepts money from Medicare or Medicaid, regardless of age, race, religion, nationality, ethnicity, residence, citizenship, or legal status. "Stable" is broadly defined such that simple triage does not fulfill a hospital's obligation.

Thanks to EMTALA, we have de facto Universal Health Care now.

This isn't some convoluted technicality. Americans are currently using Emergency Rooms as de facto public health care, in enormous volume. Everyone involved agrees that this is both extremely costly and delivers low quality care (except in the true emergencies that the departments are designed for.) Unless we are going to repeal EMTALA (no politician would dare have that vote on their resume), we are stuck with Universal Health Care.

To be clear, we all are paying out the nose for this horrid form of Universal Care through cost shifting. Hospitals overcharge for virtually every service, in part to compensate for losses caring for the uninsured as required by EMTALA. The cost savings at standalone radiology and surgery centers comes mainly from cherry-picking the high revenue services and avoiding care for those without coverage. But this in turn forces hospitals to overcharge for their services even more. This cycle is at the center of our crisis as a whole, and absolutely affects even those of us with "good insurance."

We have to build a better safety net. Even we (proverbially individualistic and selfish) Americans won't stomach going completely bare. Next post is about what that might look like. The following is my personal framework, but if you're reading this, I welcome other's input before I write that entry.

1. A bare-bones public plan that all citizens pay in on a sliding scale, and covers everyone.
2. A private system of supplemental coverage and services.