I was going to list Mr. Obama’s proposals one by one and then discuss what is right and what is wrong with each.  I have decided that it would take me too long and no sane person would read it all.  So, instead I will present a brief list of things I question about Mr. Obama’s plan, a list of the areas where I think Mr. Obama is on the right track, and my list of things I think we should consider to improve our healthcare delivery system.

Where Mr. Obama has it WRONG:

First and foremost, I disagree with the basic premise of the OBAMA PLAN that Healthcare is a basic right.  Mr. Obama’s entire argument for Universal Healthcare is based on this assumption.  Mr. Obama claims that since healthcare is a right, it should be provided for all people.  In his view, the way to do this is to place the burden for providing healthcare on a government agency funded by taxpayer dollars.  His assumption is wrong.  Healthcare is not a basic human right.   Is it a basic right to have three meals a day and shelter over your head?  Is it a basic right to have clothing?  Is it a basic right to have a job?  How about a television? Ensuring that all citizens are healthy is a lofty and well meaning goal.  Asking you, no, requiring you, to pay for treatment for your neighbor who drinks a quart of gin and smokes three packs a day is not the way to achieve that goal.  Second, placing all healthcare in the hands of a government agency will only guarantee mediocre care or worse.  Just look at what sick Canadians do.  They come across the border to get good care here if they can afford it.

Where Mr. Obama has it RIGHT:

An ounce of PREVENTION is worth a pound of cure.  Mr. Obama is right when he says that we need to spend more money and effort in preventing ill health.  He is also right to emphasize using current technology to manage healthcare records.  And, I think he is on the right track to suggest that health insurance should be portable, allowed to move with the person regardless of where he or she works.  None of these recommendations requires universal healthcare or a government managed system to be implemented.

Here is the list of Healthcare issues and my take on each:

1. Cost – 

I agree that healthcare costs have risen more than they should, effectively pricing many companies and individuals out of the market.  Some of this is due to Medicare and Medicaid paying below market prices for services therefore pushing the costs to the private sector to pay.  Some is caused by providing emergency room care for those who are not covered by insurance plans.  Some is caused by an adversarial relationship between providers of worker’s compensation and regular health insurance.  This drives up legal and administrative costs.  Part is due to a legal system that has no limit on its rewards for successful lawsuits and the pressure that puts on Physicians and Hospital liability insurance costs.  Some is due to Hospitals keeping up with the competition by buying all the latest technology.  Much is due to a less healthy population.  We are fatter, more sedentary.  The list goes on but none of the reasons suggest Universal Healthcare as the solution.

We would go a long way toward controlling costs if we would do the following things:  1.  Emphasize prevention.  If insurance companies were allowed to sell health insurance based on the health of the individual (like they sell life insurance based on the expected life of the individual), there would be incentives to remain healthy.  Businesses could buy better coverage or at lower prices if they could show that they have healthy populations.  2. If we had 24 hour care supplement insurance to replace Worker’s Compensation insurance, the same company would cover an employee whether his lung disease was the result of smoking or his work environment.  In the current situation, the worker’s comp company fights with the regular health insurance company to see who pays and how much.  Legal costs, alone, add dramatically to the cost of his treatment.   3.  Pass a cap on awards, especially “pain and suffering” awards for medical malpractice lawsuits.  

2. Healthcare Delivery  Do the economies of scale offered by a huge government health system offset the one-size-fits-all care and impersonal treatment that normally result from putting care in the hands of a large organization like the federal government?  My belief is that working within a government health system would more resemble working with the IRS than working with a local clinic or hospital.  Kaiser Permanente is a huge HMO.  It has done a great number of things that are very positive and usually ranks near the top in cost containment, customer satisfaction, and prevention.  Even though it is a good example of how a huge organization can give (generally) good care, I seriously doubt that a federal government delivery system could do what Kaiser has done.  And, though Kaiser is near the top in customer satisfaction, that still doesn’t come close to the satisfaction levels of patients of small local clinics.  Most consumers don’t like working with the IRS and will want nothing to do with a federal government controlled healthcare delivery system.

3.  Prescription Costs – I believe that the U.S. and Switzerland are the only two countries that pay full price for prescription drugs, but,  that is only part of the reason drugs are so expensive.  The cost to bring a new drug to market are driven by FDA requirements that exceed those of almost every other country.  We need to look to see if this system can be improved.   We tend to believe there is a silver bullet out there for every problem.  It is easier to prescribe a pill than to change behavior.  Doctors are trained to ‘fix’ things with drugs.  We need to look carefully at this paradigm.   Many drugs are badly overprescribed. This greatly increases medical costs in general.   It has been argued that much of what is prescribed for the aged and most prescriptions of ridilin are used to control patients behavior to make it easier to care for them.  

4.  Legal Costs – I think that our legal system drives costs for care higher than they would be if limits were placed on awards in most malpractice litigation.  I also believe that the adversarial relationship between the Worker’s Comp and Health Insurance companies drives legal, and therefore medical insurance, cost upward significantly.

5.  Prevention – The key (and one of the few) success of many of the nationalized healthcare programs in Europe is the emphasis on prevention.  The only true way to lower medical costs is to require fewer medical interventions.  Prevention is the path to this goal.  There are lots of ways to approach this, worthy of at least another post, but I like the annual risk assessment and health screening used by Kaiser Permanente better than any other ideas I have seen.

6.  Portability – I think that a good argument could be made for encouraging both insurance companies and employers to provide portability to the insurance plans they offer.

7.  Insurance – I like Mr. Obama’s idea of an insurance plan for catastrophic care.  All basic insurance could be reduced in cost dramatically if the cost of catastrophic care could be insured outside of the regular plan.  How this would be done in a cost effective way, I am not sure, but would like to hear ideas.

8.  Stem cell Research/Cloning/Abortion/Euthanasia/Assisted Suicide – Each of these items becomes a hot potato issue and can derail honest discussion of the basic healthcare delivery issue.  I think that these fall mostly in the area of personal decisions.  Handling these things at the State level and even the local level sounds like a better solution to me.

9.  Bonus Issue – Is healthcare a right or a privilege?  As I said above, I think the major flaw in Mr. Obama’s plan is that it is based on the false premise that Healthcare is a right.  When I am in a cynical mood, I think the only justification for calling healthcare a right is to bring the power (that comes with controlling the healthcare of the people) to the Central Government.

I think it is important that we have a national discussion of healthcare delivery.  Though far from perfect, I think it would be very instructive to look at the history and practices of Kaiser Permanente.  Their success is based on three key practices which I think we would be well served to consider:  Pay Doctors who are part of an HMO a Salary thus removing incentives to perform unnecessary procedures; carefully manage hospital stays and move patients to less expensive clinics or home for much of the recovery period; and most important, in my mind, is their emphasis on prevention – annual health assessments.

I would appreciate your thoughts on any and all of this.

Here are links to the Intro, the first, second, and 3rd posts on this subject.