Should health care operate more like public schools?

In the New Yorker, Atul Gawande implies that the problem with our health care system is that it isn’t like our K-12 education system:

During the next two centuries, we relied on government to establish a system of compulsory public education, infrastructure for everything from running water to the electric grid, and old-age pensions, along with tax systems to pay for it all. As in other countries, these programs were designed to be universal. For the most part, we didn’t divide families between those who qualified and those who didn’t, between participants and patrons. This inclusiveness is likely a major reason that these policies have garnered such enduring support.

So let’s imagine a world in which the health care system is like our system of public education:

(1) There are local “health care districts” administered by elected politicians.

(2) The HC districts establishes a “local clinic” in each neighborhood.  You’re asssigned to your local clinic and required by law to submit to care.

(3) You’re allowed to “apply” for access to clinics outside your neighborhood, if those clinics “have space.”

(4) Most of the best doctors choose to work at the clinics in the wealthier, whiter neighborhoods.

(5) Therefore, the clinics in the wealthier, whiter neighborhoods provide better care.  They are also full-up with wealthy, white patients.  They’re required by law to turn away the poor, brown folks from other neighborhoods who try to gain access to their doctors.

(6) Each clinic is given an “allocation” of doctor positions, so that the ratio of doctors-to-patients is the same across all clinics.  Salaries, however, are determined by seniority.  The doctors in the upscale clinics make more money, because they typically stick around longer, because the upscale clinics are quite nice places to work.  So the upscale clinics actually have larger budgets for doctor salaries, despite the fact that their patient base is healthier.  It’s redistribution in reverse!

(7) It’s virtually impossible to fire a doctor.  Because they’re doctors!  You can’t fire someone who is a doctor.  He/she needs to be protected.

To his credit, Gawande identifies the root of all our health-care problems: the moment when the federal government made employer-provided health insurance tax deductible.  This whole mess springs from that decision.

But please don’t use K12 education as the model for reforming health care.

 

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McCain takes brave stand on health insurance reform… again

The media is applauding John McCain for his “maverick moment” in killing Trumpcare.

I’m no huge fan of John McCain, but I want to note that this is not the first time that McCain has taken a brave stand on health insurance.  Back in 2008, when he was running for President, he proposed eliminating the tax deduction for employer-provided health plans.

Economists agree that the tax deduction is a major reason that our health care system is so screwed up:

  1. It’s a huge government give-away, and it disproportionately benefits people who make a lot of money (since their health plans are typically more costly). #welfarefortherich
  2. By linking employment and health insurance, it creates uncertainty and anxiety for anyone who is sick and/or unemployed.  (And then the economy gets gummed up with people who are afraid of leaving their jobs because of concerns about health insurance.)
  3.  It encourages the over-consumption of health care by putting one more entity between the consumer and the entity that is paying for that health care. (consumer -> employer -> insurance company -> provider group -> health care provider)

I’m unaware of any other Presidential candidate – from either party – who’s been willing to take that brave stand.  What did McCain get for his bravery back in 2008?  Barack Obama hammered him with fear-mongering ads that called the plan “radical.”

“I don’t care about health insurance….[I] really care about health CARE.”

Russ Roberts makes the distinction in a conversation with political scientist John Teles.

But I would take it even further.  I don’t care about health insurance.  I don’t care about health care.  What I do care about is health.

Our public policies (and private actions) are often oriented around procuring insurance and care, rather than achieving and maintaining health itself.  How would the world be different if we all pursued health first, and health insurance and health care were only a means to that end?

Gateway drug to heroin? Percocet and oxycontin

From NPR: Doctors over-prescribe opioids like Percocet and OxyContin.  Patients get addicted.  Regulations restrict access to prescription drugs.  Addicts turn to heroin. Heroin deaths increase.

Again, it’s not clear what the greater health menace is – legal drugs or illegal drugs.

But thank goodness this all started with “a doctor who meant well”…