At Democracy Marcia Angell has produced a post on health care reform with which I agree more than I do with most of what’s written. Here’s an example:
Many liberals nevertheless saw Obamacare as a step in the right direction. But others (I was one of them) saw it as a step in the wrong direction, because it provided the illusion of a fix to our dysfunctional health-care system, and might thereby delay a real solution. Although that illusion appears to finally be collapsing.
I would go farther. It’s not just that it “might” delay “a real solution”. It inevitably would delay such a solution.
We do not engage in continuous fine-tuning of policies in this country, particularly health care policies. The process is so painful major reforms occur only take place once a generation at the very fastest.
The fatal flaw in Obamacare is that it is inherently unsustainable. (Unfortunately, the Republicans are right that it is unraveling, but wrong about the reason, and certainly wrong that the solution is more market competition.) Obama made the mistake of trying to increase access to better health insurance without fundamentally altering the features of our health system that made it so expensive, inflationary, and inadequate in the first place. Thus he continued to rely on investor-owned insurance companies and even guaranteed them millions more customers, while he also relied on revenue-seeking providers, including hospital conglomerates (even if technically nonprofit), out-patient facilities, drug companies, and medical specialists paid to provide ever more and ever pricier tests and procedures.
Where we differ is that I see improved care as the objective rather than coverage and, consequently, I think the sine qua non of health care reform is cost control. Presently, the cost of care doubles roughly every 12 years. Only education experiences comparable growth. Regardless of who pays no system that doubles every 12 years can be affordable. Simple as that.
How to accomplish that? Your guess is as good as mine. I do think that the fee for services model presently in use is incompatible with better access to care for everybody. Part of our problem is that we’re always fighting the last war. The solutions being proposed today might have worked a generation ago but won’t now. So, for example, I think that in 1965 a VA-style system might have addressed the problems that Medicare and Medicaid were intended to address: better access to affordable care for the elderly and poor. And in 1992 a single-payer system might have provided the necessary reforms if accompanied by a commitment to cost control.