Needed in America: a huge healthcare experiment

[Thomas Eakins, The Agnew Clinic, 1889]

So the House Republicans are having a really hard time coming up with a healthcare plan that all Republicans are willing to support. Apparently during their seven years of saying no to the ACA, it never occurred to them that they might one day be in a position to propose something better. They just never saw this coming.

Oh, they'll pass something all right. Maybe even tomorrow. The ACA, they have always maintained, is a bad plan. They are probably right: under President Obama, American  healthcare went from worse to bad. Under any proposals the Republicans have made so far, it will go from bad to worse.

If only our lawmakers read books. Eight years ago T.R. Reid, in The Healing of America, explained why our healthcare system doesn't work. He even used entertaining anecdotes and simple language that members of Congress could grasp, if they'd take the time to read it. It's unlikely that our current president would be able to focus long enough to understand it, but he could be overruled by a conscientious Congress (is that an oxymoron?).

What we Americans need is not a tweaking or even an overhaul of our healthcare system. We need a radically new-to-America approach. 

Pundits on the left argue in favor of a single-payer system. It works quite well in many Western European countries: everyone has healthcare; total costs are about half of what Americans pay; Western Europeans live longer than we do; and they tend to like their healthcare systems.

Pundits on the right argue in favor of a free-market system. No developed country has tried such an approach for at least 50 years, so they can't argue from real-world examples. They ardently believe, however, that competition would keep prices down, increase personal responsibility, and provide better care--and who's to say they're wrong?

Why don't we put it to the test? Let's have two healthcare systems. Let each state decide, by popular vote, which they want:

A. A single-payer system, financed primarily by state taxes, assuring all residents of basic, emergency, and catastrophic medical and dental care at low or no cost. Each state can decide what to do about deductibles and co-pays. Private insurance companies are welcome to offer supplementary policies for amenities such as private hospital rooms, cosmetic surgery, and excellent hospital food (joking! I don't actually believe that any U.S. healthcare system can manage good food, though a friend assures me that Swiss hospitals can, and do). States are permitted to negotiate prices with all providers, and may set caps on prices if they wish.

B. A free-market system, financed by private insurance policies purchased by individuals or corporations (to use as an employment benefit). Insurance is never required, and insurance companies are free to offer whatever benefits they choose and charge whatever they wish. States opting into this system may choose (or not) to subsidize insurance for people with low incomes. The only federal requirement is full, upfront, publicly posted disclosure of all prices--insurance, office visits, tests, procedures, hospital stays, equipment, pharmaceuticals--so consumers can easily choose among providers and provisions: otherwise the system would not be free-market.

What happens if a resident of one state goes to a different state for medical care? The person's insurance--whether publicly or privately financed--pays whatever they would pay in the person's home state, not exceeding the actual cost of the care.

After a few years of this, Americans might have a pretty clear idea of which system costs less, which one provides a  higher quality of care, which one covers a greater percentage of residents, which one operates more smoothly, which one has higher approval ratings, and so on.

I think the single-payer system is likely to work better, but maybe not. European healthcare systems work better than ours, according to Bradley and Taylor in The American Health Care Paradox, because Europeans spend a lot more on other social services than we do. By focusing on fixing problems rather than preventing them, Americans are no doubt capable of producing a single-payer system that doesn't work. Maybe, on the other hand, full disclosure of prices coupled with our entrepreneurial spirit would actually come up with something good. We'll never know unless we try.

If given the choice, would you prefer single-payer or free-market? Why?

Why single-payer healthcare funding may not work in America

Of course Obamacare is failing.

Not quite as badly as No-Obamacare was failing, so I'm still glad it exists. It's a necessary stopgap until we find a system that actually works.

But you know what? Single-payer healthcare will fail just as badly.

In 2015, U.S. spending is projected to hit $10,000.

Yes, I know that single-payer healthcare systems succeed in other developed nations. I also know that competitive insurance-based healthcare systems succeed elsewhere. But neither system will succeed in the United States, because the U.S. is the only nation on earth that refuses to keep healthcare spending from spiraling out of control. If the cost remains the same, it doesn't matter who's paying. In the long run, we all are.

Many Americans believe that a free market would drive spending down, but the American healthcare mishmash (both before and after Obamacare) is definitely not a free market. Just try finding out what a procedure is going to cost so you can choose the least expensive provider. Even the providers have no idea until they've already signed you up and run your insurance numbers. If you're computer literate and have lots of time and patience, it's possible to get approximate prices for prescription drugs, but what can consumers do about profiteers like the infamous Martin Shrekli?

And anyway, when you're being rushed to Emergency is no time to comparative shop.

Many in the general public scream "Rationing!" whenever any limitation to healthcare is suggested, no matter how sensible it may be (refusing to fund drugs with no proven benefits, for example, or allowing futile, often painful, but expensive procedures for people in the last stages of dying). It's frustrating when we grow up and realize that we can't all have everything we want, but it's rational to make sure that, when something (like money for healthcare) is in short supply, it's apportioned wisely for the common good. Americans are not rational about rationing.

Congress, as the right arm of lobbyists, has no interest in keeping healthcare affordable. They would not pass either George W. Bush's Medicare prescription drug plan or Barack Obama's Affordable Care Act until all threat of price caps was removed. Medicare is not even allowed to negotiate drug prices.

Well, folks,

• if consumers are unable to do comparative shopping;
• if we all believe we have a divine right to any healthcare that's available, no matter how expensive or ineffective it may be;
• if we will not allow our healthcare payers to set price ceilings or negotiate lower prices;
• and if our lawmakers continue to favor the lobbies who fund them rather than the people who elect them;

of course our healthcare system will fail.

It will fail millions of people who cannot afford the treatment they need. It will fail millions who pay high prices for treatment they don't need. It is failing all of us, since we pay twice as much for healthcare as we would pay in other developed countries.

Until we find an effective way to limit healthcare spending, American healthcare will continue to fail--whether it is funded by private individuals, by competing insurance companies, or by a single payer.