Health Care Reform

So, there's a pretty good chance that Congress will approve some kind of health care reform this year. The House and Senate have each passed their own versions of the bill, both, to my surprise, with a public insurance option.

I read an article about the bills in the Times yesterday, and, frankly, it's dismaying, because they're leaving the present mess standing and requiring health insurance for all. (You can read that article here; for a comparison of the bills, click the multimedia sidebar.)

If you think I'm joking about the present mess, I am not. The New Republic ran a spectacular graphic the other day showing how many businesses, government entities, and other organizations are involved. Take a look; it's here.

Opposition and fear are starting to build. The governors quite rightly fear unfunded mandates. Businesses look at the requirements for providing insurance to their employees, and you just know that many businesses will either not grow or will lay people off as they hit or try to stay under the size limits where it's required that they provide insurance.

Here's the deal: we don't need health insurance. What we need is health care. The present system, which combines employer-sponsored health insurance, socialized medicine for the poor, those over 65, veterans, and the disabled, and a patchwork of individual policies and state-sponsored programs, is insanely inefficient, inequitable, and expensive.

Any single-payer or integrated system would be better. I'm a Kaiser Permanente member and have been for 19 years now. Kaiser owns its own buildings, hospitals, and anicillary facilities; sporadic attempts at outsourcing, like giving maternal care to Alta Bates, worked badly and just lasted a few years. There's some specialization, in that, for example, in Northern California, brain tumors are treated at the Redwood City hospital and much orthopedic surgery is done at Vallejo. It's an excellent model; referrals take place seamlessly; test results are available at the touch of a keyboard; if you need X-rays, they send you downstairs and the photos are taken. Doctors are on salary instead of being paid per patient or per procedure. There are no incentives at all to provide too much care, as there are for other doctors.

The funny thing is that 25 years ago when I moved to the Bay Area, Kaiser was looked on with some suspicion. For one thing, it was the working class person's health care. The plan originated with the visionary Henry Kaiser, who wanted his workers to have decent health care available. And the membership has always had high percentages of minority and working class people.

For another, it had a reputation for not working very well, for being too controlling, for not referring, for being incompetent.

Things have changed a lot since the 1980s. Kaiser has improved enormously, while the fee-for-service system has gone insane and gotten crazy expensive.

It's time for the US to look at single payer or an integrated, socialized system. The transition would be mighty painful, but it would free up an awful lot of money in these ways:

• Predictable financing, through taxes on all individuals and businesses
• Ability to control costs in a rational and consistent way
• Coverage for all
• Simplified billing and administrative systems

Alternatively, the government could mandate that all insurance companies must provide policies to anyone who applies, at a predictable, government-determined rate, and that those policies provide nationally-consistent coverage.

I don't think the political will exists to do either of these things, and so we will wind up with a continuation of the current Frankenstein-monster system.

Now, if you think my ideas are just! terrible! and would rob people of their choices, think again: as Paul Krugman pointed out the other day, the private health-insurance system (employer-paid and individual plans) pays 34% of U.S. health care costs, while various government-sponsored programs pay for 46%. "Most of the rest is out-of-pocket spending," he says.

So, given that we're already more than half way to socialized medicine, let's go all the way while we have the chance.

Update: rootlesscosmo suggests a couple about the current situation. Click here to read an editorial by Arnold Relman. The other link is, alas, broken.