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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, well...

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 or influenza.

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.

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Universal Health Care