Universal Health Care Ideas
(Note: This was written in 2008, before the recent changes
and laws, and although I am not in favor of government health
care, the ideas suggested here assume it will happen in any case.)
Universal health care could be a problem for our economy.
It also creates some agonizing moral dilemmas (consider the eye
treatment ruling below). But despite my opposition to it, I can
see that it's a real possibility in the near future. With that
in mind, here are some ideas on how to make it work better, and
allow more freedom of choice.
The Blindness of QUALYs
Deciding who can get what health care would be a tricky proposition
for any of us, but some might argue that the bureaucrats in the
National Institute for Clinical Excellence (NICE) do a pretty
good job. These are the people responsible for evaluating and
approving treatments for the National Health Services administration
in Britain (their universal health care system). So far, life
expectancy in Britain is roughly the same as in the United States,
and the government spends less on health care for its citizens
while covering ALL of them.
However, making such decisions does lead to some interesting
situations. For example, NICE recommended in 2002 that a certain
course of treatment for macular degeneration be used only in
the eye less affected. The other eye was presumably to be allowed
to go blind. How did they arrive at this decision? By using QUALYs.
QUALYs are Quality-Adjusted Life Years. Under this way of
measuring the value of treatments, a surgery that gives you an
average of ten years of life is better than one that gives you
five. Furthermore, if you might be saved by a treatment but be
in a coma for six years, but another man might be saved and healthy
for six years by some other treatment, the latter will be approved.
In the case of the eye treatment, the score for QUALYs is high
for the first eye, since seeing presumably greatly increases
the quality of life over blindness, but seeing with the second
eye doesn't boost the quality of life nearly as much.
There is a certain logic here. Without going into the complexities
of the system, you can understand the basic idea. It is that
not just life matters, but quality of life. That's something
most of us can agree with. Of course, it leads to some uncomfortable
conclusions. Someone who already has a debilitating disease or
handicap, for example, presumably scores lower in QUALYs when
considered for a life-prolonging heart operation, and therefore
might be passed over in favor of a healthier person who would
benefit more according to the QUALYs equation.
The bottom line is that there a limit to what any country
can afford to spend on a health care plan. If we are honest enough
to recognize this, we will make decisions that can certainly
be uncomfortable at the least, and sometimes downright offensive.
Suppose for example, a million dollars can prevent ten thousand
people from getting a deadly disease, or could be used to treat
and possibly cure twenty people who already have the disease.
Do we let the twenty die?
It is easy to say that we should both cure the twenty and
run the prevention program, and this may even be possible. We
certainly can even pay for both eyes to be treated in the case
of macular degeneration. But we really can't do everything, and
honesty compels us to admit that perhaps going blind in one eye
isn't nearly so tragic as losing sight in both, and if treating
just one eye for one patient saves enough money to treat another
patient's heart problem with a new procedure that saves his life,
No matter what kind of utopian theorizing we do, the tough
choices will have to be made at some point if we nationalize
health care. We will have to put a value on life, or at least
on various qualities of life. We will have to put a value on
one eye versus two, or on eyesight versus limbs that can be either
saved or amputated. Unlike a market system (which we've never
really had), where medical providers compete to provide better
treatments for your diabetes, this will be, in part, a system
where your diabetes competes with somebody's migraine headaches
With this in mind, I hope that at least we can allow a market
system of health care to exist alongside a national plan. It
would be nice to be able to pay to have the other eye fixed as
well. I don't think that we are such an envious people that we
would vote against such a dual-system just because the rich will
obviously get better care. Their healthiness doesn't hurt the
rest of us, and we all could at least have the hope that we could
raise the money for whatever additional health care we need.
In addition to the obviously difficult decisions that will
be made, there will also be the problem of demand in general.
Anything that is free will be in higher demand, of course. I
have a few teeth that I might have a dentist look at right now
if the examination and treatment was free. There are many times
when people delay treatment or find alternatives because of the
expense. In fact, without looking at the statistics, I can virtually
guarantee that people who pay directly for their health care
have less of it than those who have insurance.
With free universal health care, there will be a big increase
in demand. A cut that might be bandaged will be more likely to
be stitched if the service is free. A sniffle or headache that
would be endured might mean a trip to the free hospital. Unfortunately,
this would use funds that might otherwise pay for research or
treatment for life-threatening diseases. Hmm... More tough decisions.
One thing that would help alleviate this problem of excessive
demand is to design a system that isn't free. The problem we
face after all, isn't that we have to pay for health care. We
find a way to pay for groceries, clothing and cable television
without government help. The issue is the high price and unpredictability
of health care costs. The problem isn't an occasional surprise,
but the fact that a few weeks in a hospital can eat up the assets
you have built up over a lifetime.
Why not address the larger issue, rather than encourage people's
unwillingness to budget for unexpected, but affordable expenses?
One way to do this would be to have national health insurance
rather than have the government take over the whole system. Have
a $1,000 annual deductible. The person who can't afford $84 per
month for health care usually has a budgeting problem, not a
problem of over-priced care, and in any case, a hospital could
take payments from patients, as they currently do.
Then have each person pay 20% of the costs beyond that deductible,
up to say $5,000 (which would be $1,000 for the insured person).
This real cost will keep people from running to the doctor or
hospital for every imagined illness. It will also encourage them
to look for cheaper effective treatments.
Don't pay for prescription drugs either, at least not until
the cost goes beyond that $1,000 annual deductible. Even then
the patient should pay his or her 20%. There are bigger expenses
in life that people find a way to pay for (even poor Americans
spend thousands annually to buy groceries and household goods).
This would keep the system from being abused too badly. If people
really are too poor to afford even this, address that problem
through general welfare programs, rather than paying for prescriptions
for tens of millions who can easily afford them on their own.
Many of us are not thrilled with the idea of a national health
care system. But if it is going to happen, at least make it sustainable
and leave us more options. That is what the system outlined above
would hopefully do.