Health Care Strategies
Mark Kleiman observes that "since its reform under Bill Clinton" the Veterans' Administration health care system "now has the best medical-records system going and produces high-quality health care at a reasonable cost" and wonders if we couldn't "move a baby step toward national health insurance by allowing non-veterans to buy into the VA system at a price equal to whatever the VA figures is its marginal cost?"
The initial, emotional reaction from veterans' groups might be opposition, but surely having a bigger client base would strengthen the VA system politically, against the moment — coming soon — when we're no longer at war and when, accordingly, treating veterans well starts to lose political saliency saliency.I'm sure this isn't a new idea. Is there a good article that canvasses the pros and cons?
Phillip Longman's 2005 Washington Monthly article "The Best Care Anywhere" laid out how the VA came to be such a solid system and considers a related idea: "What if we expanded the veterans health-care system and allowed anyone who is either already a vet or who agrees to perform two years of community service a chance to buy in? Indeed, what if we said to young and middle-aged people, if you serve your community and your country, you can make your parents or other loved ones eligible for care in an expanded VHA system?"
Why make public service a requirement for receiving VHA care? Because it's in the spirit of what the veterans health-care system is all about. It's not an entitlement; it's recognition for those who serve. America may not need as many soldiers as in the past, but it has more need than ever for people who will volunteer to better their communities.
Obviously, adding something like a community service requirement makes this somewhat less attractive as health care policy, but does have political benefits in terms of reducing the negative initial emotional response from veterans' groups that Mark worries about. I, however, worry that this is the kind of small-scale change that shrinks rather than grows the constituency for a more systemic reform over the long term. To me, it's always seemed that instituting universal health care for children, as Jonathan Zasloff proposes is a constituency-building small reform and thus, the sort of thing one should look at doing. Steve Teles, however, disagrees:
It gets over some political obstacles in the present (since kids are sympathetic and relatively cheap to cover) but it also gets rid of one of the most attractive public faces of the health care coverage issue. So far as I know, no country has ever moved toward universal coverage one demographic group at a time--arguably, that was THE great mistake the U.S. made by starting with coverage of the elderly (as opposed to Canada, which started by covering hospitalization and moved on from there).
I think the dynamics of health care for kids would be different from health care for old people. For one thing, the definition of "kids" has a natural sort of elasticity to it. So the program starts out covering everyone 18 and under. Then it starts covering you up to 25 if you're in school. But then maybe it just covers everyone up to 25 and so forth.
More to the point, since people are young before they get older, if everyone grew up being covered by a well-designed single-payer health care system then middle-aged voters would be much less inclined to believe insurance company scare stories about "socialized medicine" -- since socialized medicine would be something they'd all grown up experiencing.
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"move a baby step toward national health insurance by allowing non-veterans to buy into the VA system at a price equal to whatever the VA figures is its marginal cost?"
What about allowing states to buy their whole populations into the VA system on that basis? That way universal healthcare could spread state-to-state based on an existing infrastructure with many fewer difficulties than setting up a completely new universal healthcare system in just one state?
I like both the ideas of introducing national health care incrementally and structuring it on the existing-and-successful VA system.
The large fly in the ointment of an incremental approach is the LARGE number of Americans (30-40 million, I believe) who have NO coverage at all. I can't really see a fair way to say, "Well, some of you get coverage and the rest of you should avoid getting sick." Any national plan, it seems to me, will have to be available to anyone who needs it--not just kids under 18 or those who can spare two years of their life to do community service.
The all or nothing mentality is a looser from the start. Simply because the 260 million people who do have some kind of insurance see no urgent need to have anything changed..... So... 40 million against 260 million... That's why we don't have universal health coverage.....
Every segment that is added at any time contributes to the fulfillment of the goal of universal coverage. So.... let's just start doing more of that, even if not perfect, and less talking about "the best" solution....
Following up on tuti uniti's comment (shouldn't that be "tutti uniti," by the way?): remember that the "40 million" uninsured is not a static population -- it's the average number of uninsured at any given time, but people move in and out of the ranks of the uninsured, so it's not a superstable constituency on which to build a political movement.
The fact that the 40 million is unstable should play in our favor rather than hurt us, I would think--that means there are many more than 40 million people out there who have a recent memory of lacking health insurance, and more than 40 million who might fear the loss of their benefits in the future.
I thought one reason that the VA program is so good is that it builds records on its patients, a long term process. Which means that things like adding whole States or some other large demographic group would probably significantly reduce the quality of care for a time, and so might discredit the system. Allowing people to opt-in after community service, or covering children, or somehow adding in other groups that are likely to be healthy and not expensive when first added seems like it would be less likely to hurt the system. Maybe, now that I think about it, allowing starting school teachers to pay for VA care might be a good way to expand it and increase the incentive to take a teaching job?
how about expanding the military to include a branch focusing on nation building?
A comment above mentioned allowing states to buy in. How about just providing monetary incentives for states that have percentage coverage of their population? In any way that they choose. If they want to buy into the VA system, sure, we can let them. If they want to go the MA route, fine. If they want to come up with their own clever experiment, let the states try that. The funding from the federal government will help the states to afford this.
It seems like a win-win for the democrats: they can take credit for any improvements in the health care situation, and blame someone else (the states) for any problems.
Best of all, they don't have to propose a specific plan. Any plan that is proposed by congress will have immense opposition. (At best, in your liberal utopia, some 40% of the country will hate whatever plan is proposed.) You don't have to fight the insurance companies; you don't have to fight the doctors: you are just providing more funding for necessary health care. The states can use it however they want. The only catch: the more people who have health insurance in your state, the more money you get. Make sense?
This isn't policy, just anecdote: I'm 47. I'm self-employed. I can't even get *accepted* into most health plans. I certainly can't afford any of them. I have no idea what I'm going to. Hope I live long enough to get taken care of under Medicare/Medical? I understand, somewhat, all of the "well, let's take care of the kids, and then over time we can sneak in the rest" sentiment. But, uh. Over time I'll be dead. It'd be nice to be able to go to a doctor before then.
Tatere-
I happen to be in the same boat as you (although I've been lucky to earn enough to be able to afford health insurance.) Your comment defintely puts a human face on the underlying problem.
The auto companies complain that supplying healthcare insurance for their employees puts them at a terrible disadvantage vis a vis foreign companies that operate where universal coverage is the rule. This is probably true of many industries, and thus, universal healthcare might be good for employment and corporate profit. Framed like this, it almost sounds Republican. Increased taxes would possibly be less than decreased insurance expenses.
I've thought of a similar idea. Instead of just covering kids, devise a plan where evereyone under 25, and everyone over 60 is covered.
The cutoff point shouldn't be 18, because it will feel less real and painful, because 18-year olds are like that, and a lot of them will be covered by their parents for a while, and also it will be wrapped up with becoming responsible for yourself in general, and not seem unfair.
If it runs out when you're 25, you'll be more concerned and aware of it. If you cover some adults the pressure to expand coverage will be stronger.
The fact that it's more arbitrary will make it harder to get passed, but also make it more likely it will get expanded. (The youngest and oldest workers do need UHC more the most, so it's not completely arbitrary.) After all, the US already have UHC for seniors, and it hasn't created much pressure to get everyone UHC. It seems non-arbitrary, and like a different thing even though it's not, and the same may be true of UHC for kids too.
If the Democrats are smart, they'll introduce a bill that would make pay for cancer treatment for all - regardless of age, insured status, whatever. When/if the Republicans object on "socialized medicine" grounds, the Dems would have the an excellent response: "we're trying to treat cancer. You don't like cancer, do you?" Then, a couple years later, the Dems could try to tack on AIDS coverage. When/if the Republicans object, the Dems would have the same response: "you don't like AIDS, do you?" And so on and so forth until it's a complete single-payer system.
If the coverage is universal, the people who are covered today will see little difference. If they want additional coverage, they are certainly in a position to buy it.
The big picture is that we spend 15% of our GDP while similar countries spend 10%, but they get better results providing health care for their money.
The savings come from the universal aspects of their coverage, not least the ability to constrain prices by aggressive bargaining with suppliers.
The question is, how do we get the savings, that is to say, what practical steps need be taken? It remains necessary to collect the 10% of GDP to pay for the care, but also important to distribute the 5% that is saved to the right people. That might involve mandating increases in pay by employers relieved of the necessity of providing coverage to employees, or it might involve investment in the building of clinics or the provision of services.
Introducing a patchwork of bandaid repairs is the worst approach. Every such 'fix' becomes a perpetual hostage of legislative fortune, administered by empire-building bureaucrats who can be trusted, in any case, to ignore the legislative intent and mandate of the legislation that funds them. The intended recipients are harrassed by means tests and the providers by authorization demands. The worst approach.
Minipundit has a good idea. For example, people in car wrecks are universally treated with no regard for their ability to pay. A crash victim airlifted to a hospital for emergency surgery and intensive care has "spent" about $200,000 in the first two days, and legislatures and hospitals routinely pick up the bill for people who can't pay.
Of course, given the position of the automobile in American life, this might be regarded as more of a set of religious rites than the provision of health care.
Re: A crash victim airlifted to a hospital for emergency surgery and intensive care has "spent" about $200,000 in the first two days, and legislatures and hospitals routinely pick up the bill for people who can't pay.
Assuming that their own auto insurance does not pick up the tab (in some states including my own this is required), and that they can't sue successfully for compensation, people in the situation you describe often end up bankrupt with huge health care bills. Neither hospitals nor the states simply "pick up the tab".
Allowing people to buy into the system with public service or some other feel-good activity will just lead to corruption - the qualification process will become a sham.
A universal or national health service is coming. It will probably be in 2008 since Democrats now control congress. Bush will sign it, he has no real principals about many domestic issues. Then we shall see how it works.
But why trash a good system with some scheme of letting some civilians, but not others, into the VA hospitals based upon imaginary public merit.
The trouble with the VA system (which like Kaiser Permanente) gets superior results with less money than any third party payer system (including Medicare) is that its hard to scale it up without running into the socialized medicine problem. I don't mean socialized medicine as conservatives mean it (which is any government intervention with the health care market), but rather if every doctor and nurse is a government employee and every hospital is federal property, that's a very big transition for every medical practice and hospital in the country. The existing VA system is hard pressed to handle the veteran population as it is, even allowing people to buy in to the system will require adding a lot of prefessionals to the payroll and Uncle Sam buying a lot more hospitals.
Expanding Medicare is the better bet, it won't change how medicine is practiced. Instead of having to deal with all sorts of different private health plans with different coverage requirements, there will be only the existing Medicare billing system to deal with. Of course the VA's IT program should be expanded so everyone's health records are on a central database but without setting up a universal system first, a lot of uninsured people will still fall through the cracks.
You think too much, all of you. This is really very simple if you've got the will to do it. We'll have to wait for '08 and the likely senate pick-ups and white house, but that's really all. Theres no need for decades of ground laying. no need for baby steps.
Get as much dirt on conservative democrats as possible. Every bribe, every blow jobbing intern, every fucking imporpiety you can muster. Then show it to them and make it clear you'd rather have this bill than their seat in congress. Make it clear if they eve nadd an ammendment to the bill their going down and you don't care if it's the primary or the general. Do not allow Republican ammendments either.
Then, ignore the attack ads and the threates from corporate america. They have no real power beyond money, and if we ram healthcare through money won't matter anymore because we'll have a lock on congress for decades. Ignore polls that turn against us, because when we have the program, that won't last long. You can't glimmer over Aunt Edna finally getting that operation she needed.
If the bill is even kind of decent, you'll make Matt's post against 'realignment' look foolish.
A comment above mentioned allowing states to buy in. How about just providing monetary incentives for states that have percentage coverage of their population? In any way that they choose.
Or better yet, the federal government could (with or without a substantial increase in funding) make Medicaid transfers to the states contingent on reaching 99.9% coverage of their populations. Give the states, say, five years to get their individual universal healthcare plans up and running, allow them to do substantial experimentation. No state can face the absolute fiscal mental that would accompany being denied these federal dollars. And even if one or two did, I could live in a country where, say, 48 of the 50 states guarantee universal healthcare coverage.
By the way, the real problem with letting folks buy into the VA, or Medicare for that matter, is that a lot of them are likely to be those icky unhealthy people that private insurers won't touch with a ten foot pole. That'll be expensive. The government should just tell them all to convert to Christian Science.
Then, ignore the attack ads and the threates from corporate america. They have no real power beyond money, and if we ram healthcare through money won't matter anymore because we'll have a lock on congress for decades.
Or, better yet, get a bunch of CEOs in a room and say "we're gonna solve your healthcare cost issues if you get on board."
This is one thing that puzzles me about the botched HillaryCare fiasco. Admittedly I wasn't following policy wonkish details very carefully back then. But, even back in 1993 and 1994, there should have been lots of deep pocketed players that could have benefited from a universal healthcare proposal that was properly drafted with enough sweeteners. Like, for instance, private healthcare companies (couldn't they have benefited from an additional 30 million customers?) and physicians (ditto). It seems to me that the Clintons were awfully naive. It perhaps would have made their plan more expensive, but I don't see how you get top down reform done any other way. In other words don't ignore the attack ads; prevent them from being aired in the first place.
Re: That'll be expensive
Most of these folks (if they do not have insurance) end-up being covered by Medicaid anyway, at least as soon as their illnesses grow so expensive to treat that they qualify after spending down all their assets. And those who end up on disability (eventually) get Medicare.
In no way will universal healthcare bring new costs into the system: all the costs we would cover openly are already covered one way or another (even if via the bankruptcy courts, driving up the cost of care for everyone else).
Development Emergency Medical Service in America has received the second wave, improvement of quality of service and speed of reaction WBR LeoP
The problem of reception Medical and health insurance for unemployeds interests WBR LeoP
"move a baby step toward national health insurance by allowing non-veterans to buy into the VA system at a price equal to whatever the VA figures is its marginal cost?"
What about allowing states to buy their whole populations into the VA system on that basis? That way universal healthcare could spread state-to-state based on an existing infrastructure with many fewer difficulties than setting up a completely new universal healthcare system in just one state?
Most of these folks (if they do not have insurance) end-up being covered by Medicaid anyway, at least as soon as their illnesses grow so expensive to treat that they qualify after spending down all their assets. And those who end up on disability (eventually) get Medicare.
In no way will universal healthcare bring new costs into the system: all the costs we would cover openly are already covered one way or another (even if via the bankruptcy courts, driving up the cost of care for everyone else
This is one thing that puzzles me about the botched HillaryCare fiasco. Admittedly I wasn't following policy wonkish details very carefully back then. But, even back in 1993 and 1994, there should have been lots of deep pocketed players that could have benefited from a universal healthcare proposal that was properly drafted with enough sweeteners. Like, for instance, private healthcare companies (couldn't they have benefited from an additional 30 million customers?) and physicians (ditto). It seems to me that the Clintons were awfully naive. It perhaps would have made their plan more expensive, but I don't see how you get top down reform done any other way. In other words don't ignore the attack ads; prevent them from being aired in the first place.
The trouble with the VA system (which like Kaiser Permanente) gets superior results with less money than any third party payer system (including Medicare) is that its hard to scale it up without running into the socialized medicine problem. I don't mean socialized medicine as conservatives mean it (which is any government intervention with the health care market), but rather if every doctor and nurse is a government employee and every hospital is federal property, that's a very big transition for every medical practice and hospital in the country. The existing VA system is hard pressed to handle the veteran population as it is, even allowing people to buy in to the system will require adding a lot of prefessionals to the payroll and Uncle Sam buying a lot more hospitals.
I like both the ideas of introducing national health care incrementally and structuring it on the existing-and-successful VA system.
The large fly in the ointment of an incremental approach is the LARGE number of Americans (30-40 million, I believe) who have NO coverage at all. I can't really see a fair way to say, "Well, some of you get coverage and the rest of you should avoid getting sick." Any national plan, it seems to me, will have to be available to anyone who needs it--not just kids under 18 or those who can spare two years of their life to do community service.
Following up on tuti uniti's comment (shouldn't that be "tutti uniti," by the way?): remember that the "40 million" uninsured is not a static population -- it's the average number of uninsured at any given time, but people move in and out of the ranks of the uninsured, so it's not a superstable constituency on which to build a political movement.
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