Despite all that I’ve written about healthcare reform I think it’s been some time (more than six years!) since I actually put down in black and white what sort of healthcare system I think we should have. That’s an essential question since our present system is so enormously out of whack that a little tinkering around the edges will not accomplish what we need to do and need to do soon. This is an opinion piece so I’m not going to source it. If you want to look at some facts, I’ll give you just two references: Gerald Anderson and Uwe Reinhardt’s paper, It’s the Prices, Stupid and usgovernmentspending.com. Those two should be enough to convince you that here in the United States we’re paying enormously more for what we’re receiving in healthcare than any other country in the world and that our current path is not sustainable, not merely in the long term but just in the next few years.
In order to say anything sensible about what should be I think you need to state your objectives first so here goes. I think that a good healthcare system would enable people to get some reasonable level of healthcare, that the system should produce a good general level of public health, that providers should earn a decent wage, and that from an economic standpoint the healthcare sector should not be a drag on other sectors of the economy or abroad.
In theory and at some point in time (i.e. the 1960s) we probably could have achieved those objectives with a reasonably free market solution. Conditions were substantially different then than they are now and IMO from a structural standpoint better. A market solution would be something along the lines that have been proposed by some Republicans and libertarians recently: high deductible health savings accounts, means-based subsidies, and so on. IMO the time has long passed when such a solution would be effective in a manner consistent with good public health (if it ever would have been).
Despite my general predispositions towards market solutions I believe that the situation in healthcare is along the lines of the old joke: you can’t get there from here. If anything my views have hardened since I wrote about this six years ago. I think we need to take private insurance companies and employers out of the picture with a single payer system (or, at the very least, private insurance companies should play a very different role as they do in Germany or France), I think there should be no for-profit co-ops or health maintenance organizations, I think that specialists should be salaried employees of hospitals and that hospitals should be run by the government (federal or state) and that their salaries should be set by law, that GPs can remain private but should be paid based on a capitation, and that there should be some restrictions on what the government single payer will pay for. I also recognize that practically everybody would despise the system I’m proposing.
If you’ve got a better idea that would allow patients to get all of the healthcare they want, insurance companies, hospitals and other healthcare providers, and all other parties involved to make as much money as they want, won’t drive the states and federal government bankrupt, won’t cause us to borrow to pay its operating expenses, and will produce a decent level of public health, I’m all ears. I don’t see it.