Building An Escape Hatch Into Single Payer Healthcare
Several of my recent columns in Forbes and Bio-IT World have critiqued the mess we've made of the healthcare system in this country. Readers took me to task. Don't just criticize, how about offering some concrete alternatives that make economic sense and are politically feasible! While there is every reason to believe that these conflicting requirements produce a null set, let's give it a try and you be the judge.
Contrary to all other proposals, the only approach that has any chance of working requires that defenders of the free market acknowledge reality. In the words of the tall thin man in the black top hat, "A house divided against itself cannot stand." Attempts to maintain a system half-free and half-socialist in which vote-hungry politicians and profit-seeking corporations battle to allocate resources are inherently doomed.
The die was cast the day the Medicare Act was first passed in 1964, exactly as its opponents predicted. While we have put it off longer than any other advanced democracy, a move from our current catastrophe to a single payer system is inevitable. All democracies do this on their way to bankrupting themselves and there is no reason to believe we are going to be any different.
So, let's get it over with and cut a deal to save what's worth saving. Give the Progressives what they want and make universal healthcare a unitary government service, provided free of charge to all comers, on one condition. That they agree to legislatively authorize a parallel nationwide healthcare free market enterprise zone.
The purpose of this escape hatch is twofold. The first is to keep medical innovation alive, for it will surely die if there is not a competitive market somewhere that rewards inventors and entrepreneurs for the outsized risks they take. The second is to provide an alternative for people who would prefer not to leave the country to get care that a public system cannot or will not provide, as do citizens from every other country that has socialized medicine.
Universal free healthcare would function much like public schools without the neighborhood variation. Everyone would complain but no one would be denied access. The system should be paid for out of general tax revenues subject to whatever annual budget Congress allocates given its other spending priorities. Medicare and Medicaid must cease to exist as separate programs. Everything would operate on a pay as you go basis using current cash accounting with no illusions about "trust funds." Patients in the public system will only get what Congress can afford to buy for them.
Doctors who contract to work in the public system would be offered free medical education and upon graduation would receive civil service wages, knowing that they would only have to work civil service hours. The public service would be exempt from malpractice lawsuits; aggrieved patients would apply to a specially appointed federal board to receive compensation for pain and suffering. Primary care physicians would dominate the system and the number of specialists would be both strictly limited and geographically assigned to assure interstate equality. Every element of the system would be scientifically planned under the control of a cabinet level healthcare czar.
Sure, there would be some drawbacks. Over time native born public service doctors could probably be expected to have the same intelligence, work ethic, and attention to detail as the people who deliver your mail or punch your ticket on the Metroliner. And they might even unionize. But this will not matter because everything doctors do will be prescribed by standardized procedures worked out by experts at the National Institutes of Health. To freshen up the gene pool and make up for inevitable doctor shortages, immigrant doctors and nurses from third world countries would be promised citizenship on condition that they serve ten years in the public service.
Access to medical products and services would be allocated according to federally mandated best practices and all patients would be subject to waiting lists except for Congressmen and their families. (You asked for realism, right?) No new medications, devices, or therapies could be introduced into the public system without passing rigorous cost effectiveness testing and all vendors would have to agree to sell their wares to the government on a cost plus basis. Profiteering would not be allowed.
People suffering from lifestyle related illnesses caused by things like drinking, smoking, obesity, and sloth would be treated without discrimination, though they may find their access to alcohol, tobacco, and junk food increasingly limited as new public health laws are introduced to control costs. Because it is a violation of human rights to hold individuals responsible for their own self-destructive behavior, businesses that knowingly serve high risk people in contravention to regulations would be fined.
Got what you asked for? Make the best of it until you drain the treasury dry. Now here is the flip side of the deal.
In return for making the lifelong dreams of Progressives come true, a new private healthcare industry would be legislatively enabled that would serve cash and private insurance patients only. It would operate under distinct federal free enterprise zone rules that would supersede state laws. Private doctors and hospitals would be legally free to serve whichever patients they choose, charge whatever they like, and deny service to anyone for any reason, including inability to pay. As a condition of service some providers may require patients to sign truly enforceable informed consent forms that would shield them from malpractice suits, directing all disputes to private adjudication.
All state and federal health insurance regulations would be abolished excepting those regulating fraud. Insurers could sell policies across state lines to whomever they choose at whatever price they want making as much profit as they can with deductibles as high as they please. Insurance would be underwritten, reviving a concept that was abandoned when the words "health insurance" came to mean "free stuff." Insurance applicants could be rejected for any reason or be charged higher prices or have their coverage restricted if they were at higher risk. Like any insurance, once a customer is accepted coverage would be bound by contract. (This is a free enterprise zone, not anarchy.)
Doctors, hospitals, and Wal-Mart doc-in-a-box centers would have the option of dispensing any medication or treatment they believe is in a patient's best interest whether it is FDA approved or not. The only requirement is that patients be informed. Hospitals could choose to hire only licensed practitioners or not, and may specialize in particular procedures, or offer general services according to whatever business model they wish to pursue.
Two systems living side by side. One run by the government paid for with taxes and available to all. One run by the market and paid for by willing customers who can afford it. Like public and private high schools these two systems would serve the needs of different constituencies. One system would be a monopoly that designs, allocates, and rations healthcare politically. The other would be a competitive system that balances supply and demand by price.
There are no workable solutions that blend these two approaches, making it folly to try. The only arguments Progressives can muster to oppose a two-system solution are the same arguments that erected the Berlin Wall. The only arguments libertarians can make to stop the rise of single payer healthcare is the futile belief that their fellow Americans will wake up and rediscover the long since abandoned values of individual freedom and personal responsibility.
