Monday, April 2, 2012

Obamacare Alternatives


I am hardly wedded to Obamacare, although it certainly seemed better to me then the current alternative. We do agree on the issues, and I'll wager that we can also agree that the goal of any system is to provide the best care to the most people at the least cost. The alternatives, in my highly prejudicial order of preference are (drum roll please...).

1) A nationalized system-this is the UK model. The chief advantage is an ironclad lid on cost. The UK provides pretty good care by the usual broad measures, such as infant mortality, life expectancy etc. The Brits are not crazy about it. I am strongly opposed as a direct result of my experience within the US version of same, which is the VA health care system. I was an advanced trainee at a flagship VA in Boston.  Patients there were treated with an indifference bordering on contempt. Doctors were answerable only to the bureaucracy. Necessary care was denied routinely for the flimsiest of reasons, and the vets were lied to to justify it. By the time I finished I became an expert at getting my patients out of the VA and into one of the fancy teaching hospitals downtown. When your bete noir writes about the virtues of the VA system, my response is, "Come get your health care there. I want to see how long you would put up with it."

2) Single payer-this is the Canadian model, given reasonable marks by those who participate in it. The system delivers high quality care by any measure and frees docs from the torment of engaging in mortal combat with payers on a daily basis. Care is rationed as a function of the total amount of money put into the system (somewhere around $4000 per capita compared to nearly double that in the US). Medicine is an elite profession there just like here, but docs make a middle class living. No orthopedic surgeons making a million a year. There are waits for some kinds of treatment, so if you have a teenage soccer player who needs a timely ACL repair to get back on the field (as 3 of my daughter's high school teammates did) you may have to pay for that out of pocket. I am strongly enamored of such a system, especially since it means that you would take me out to dinner on a regular basis, since I would no longer be able to afford it.

3) Mixed models-the best example seems to be Switzerland, which requires everyone to buy health insurance (there's  that nasty mandate again ) from a consortium of private insurers.Per capital expenditure is significantly higher ($4800) than everywhere but here. Patients have skin in the game through a series of deductibles that vary with the fanciness of the policy they buy, just like car insurance here. Insurers are only allowed to make a profit on more lavish plans. Participants are required to pay up to 8% of their income for insurance, after which the government subsidizes the cost. Indices of health care are among the highest in the world, and Swiss doctors always know exactly what time it is.

4) The Ryan Wyden alternative, or vouchers with premium support. This plan, which is actually just a vague idea at present may have some merit, but the chief criticism launched against it is that it shifts costs on to patients and does little to control total expenditures. I am intrgued but skeptical.

Finally, you are right that the independent payment advisory board (IPAB) brings with it great potiential for unintented consequences. But letting insurance companies screw patients out of care they paid for is not an acceptable alternative.


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