What should we do instead of the Obama health reform bill?

by on November 17, 2009 at 7:19 am in Medicine | Permalink

A lot of people think you have no right to criticize a bill unless you propose a better bill.  I don't agree (if the aforementioned bill is bad on net), but in any case I will give this a try.  These are not my first best reforms or even my second best reforms.  They're my "attempt to work with some of the same moving pieces which are currently on the table" set of reforms.  I would trade away the Obama bill for these in a heart beat.  Keep in mind people, with a "no insurance" penalty of only $750, the current bill isn't going to work (and that's ignoring the massive implicit marginal tax rates on many individuals and families, or the "crowding out" of current low-reimbursement-rate Medicaid patients), so we do need to look for alternatives.

Here goes:

1. Construct a path for federalizing Medicaid and put it on a sounder financial footing; call that the "second stimulus" while you're at it.  It's better and more incentive-compatible than bailing out state governments directly and the program never should have been done at the state level in the first place.

2. Take some of the money spent on subsidizing the mandate and put it in Medicaid, to produce a greater net increase in Medicaid than the current bill will do, while still saving money on net.  Do you people like the idea of a public plan?  We already have one! 

2b. Make any "Medicare to Medicaid" $$ trade-offs you can, while recognizing this may end up being zero for political reasons.

3. Boost subsidies to medical R&D by more than the Obama plan will do.  Establish lucrative prizes for major breakthroughs and if need be consider patent auctions to liberate beneficial ideas from P > MC.

4. Make an all-out attempt to limit deaths by hospital infection and the simple failure of doctors to wash their hands and perform other medically obvious procedures.

5. Make an all-out attempt, working with state and local governments (recall, since the Feds are picking up the Medicaid tab they have temporary leverage here), to ease the spread of low-cost, walk-in health care clinics, run on a WalMart sort of basis.  Stepping into the realm of the less feasible, weaken medical licensing and greatly expand the roles of nurses, paramedics, and pharmacists.

6. Make an all-out attempt, comparable to the moon landing effort if need be, to introduce price transparency for medical services.  This can be done.

7. Preserve current HSAs.  The Obama plan will tank them, yet HSAs, while sometimes overrated, do boost spending discipline.  They also keep open some path of getting to the Singapore system in the future.

8. Invest more in pandemic preparation.  By now it should be obvious how critical this is.  It's fine to say "Obama is already working on this issue" but the fiscal constraint apparently binds and at the margin this should get more attention than jerry rigging all the subsidies and mandates and the like.

9. Establish the principle that future extensions of coverage, as done through government, will be for catastrophic care only.

10. Enforce current laws against fraudulent rescission.  If these cases are so clear cut and so obviously in the wrong, let's act on it.  We can strengthen the legal penalties if need be.

11. Realize that you cannot tack "universal coverage" (which by the way it isn't) onto the current sprawling mess of a system, so look for all other means of saving lives in other, more cost-effective ways.  If you wish, as a kind of default position, opt for universal coverage if the elderly agree to give up Medicare, moving us to a version of the Swiss system and a truly unified method of coverage.  But don't bet on that ever happening.

Separate issues:

12. If you can tax health insurance benefits and cut a Pareto-improving deal overall, fine, but I am considering this to be too politically utopian and it's not clear what the rest of that deal looks like.  The original tax break makes no economic sense but you don't want to end up with a big tax increase and a lot more people on the public books with little in return.

13. If the current bill were voted down, you can imagine some version of the above happening, although not necessarily all at once in one big bill.

14. Commission a study of how much the Obama plan is spending per QALY saved.  I agree that more health insurance saves lives, but a) the study should adjust appropriately for the superior demographics of those who hold or buy insurance, and b) the study should adjust for the income that would be lost through mandates and the safety that income would purchase.  I worry greatly that we have never, ever seen this number presented and that if we did it would not be pretty.  In any case, do the study, scream the number from the rooftops, and reread points 1-11.  Enact.

That's my recipe.  It's better than what we are doing now.  You don't have to adhere to any extreme form of economistic or free market ideology to buy it.  It might even be politically easier than the current path, as it "sounds less socialistic."

Neal November 17, 2009 at 7:31 am

What about expanding Medicaid to cover all catastrophic care? What would that do?

Paul H. Rubin November 17, 2009 at 7:51 am

Allow cross state sale and purchase of medical insurance.

WPH November 17, 2009 at 8:08 am

10. One could end fraudulent rescission by requiring a “caveat emptor” approach to preexisting conditions. I do imagine insurers would require more comprehensive tests before granting coverage, though.

The Incidental Economist November 17, 2009 at 8:20 am

I don’t believe any current proposals deal seriously with the cost issue. At best they include demonstrations or pilot projects to experiment with different payment systems. We’ll be very lucky if any of those pan out.

I’m not seeing anything in 1-14 above that addresses this either. So my list would include a 15th item: pay providers for cost efficient care. Now, what the heck does that mean?

yoyo November 17, 2009 at 8:26 am

Well its now clear that you’re a goddamn pinko.

Ryan November 17, 2009 at 8:32 am

On point #3, this is irrelevant if the government decides to work within a “comparative effectiveness” framework or instigate international reference pricing, then further R&D subsidies are meaningless. Pharmaceutical companies are producing high cost/high benefit drugs that don’t necessarily fit into the CER mold. Why produce new cancer drugs if the government won’t fund them once they’re produced?

MBP November 17, 2009 at 8:39 am

Tyler – On #1, why should we federalize Medicaid? What makes the federal government, which is running its own unsustainable Medicare program, better able to administer the Medicaid program than state governments? You may not be aware of the improved efficiency and improved delivery of health care that has been brought to the Medicaid program by private companies over the past 10 years. Many states have outsourced the administration of Medicaid to the private sector which is better able to manage complex conditions among the low-income senior population AND among pregnant women.

Russell L. Carter November 17, 2009 at 8:46 am

Although a few of these are transparently bad ideas, many are not. This post is a big step forward towards a rational debate when compared to the previous “I’m convinced we *must* blow 30% of GDP and condemn millions of (poor) people and their children, it’s simply the best we can do” default approach. For this you deserve two thumbs up, a standing ovation, perhaps even a bit more generosity and patience with your other complaints.

Now of course a right wing think tank will sum up the economics of the set of above proposals in a high integrity analysis and we can compare apples to apples.

Right. I don’t think we’re that far along the path toward rationality yet.

Rick Blaine November 17, 2009 at 8:51 am

Why would you want to “to EASE the spread of low-cost, walk-in health care clinics”, rather than increase?

R S November 17, 2009 at 9:01 am

On the whole, excellent. Not enough incentives for evidence-based health care. I wouldn’t mind paying so much *if I got what I was paying for!* Further evidence that useful, mid-range policy proposals that move the dial in a progressive (with a small P) direction need have no partisan coloration..

Floccina November 17, 2009 at 9:24 am

I like Tylers plan but here is my my plan:

The state would provide insurance to all Americans but the annual deductible on the insurance would be equal to the family’s trailing year adjusted income minus the poverty line income (say $25,000 for a family of 4) + $300. So a family of 4 with a trailing year adjusted income of $30,000 would have a deductible of $5,300. A family of 4 with a trailing year adjusted income of $80,000 would have a deductible of $55,300.

I think that we should at least try this sort of very high deductable plan but if that does not work then we may need to try monopsony and squeeze the providers. The marginal benefit of health care seems so low that the shortages created by monopsony are likely to have little negative net effect as it will free people to spend more money on other things that might improve health.

BTW I will be livid if Obama care makes blue cross eliminate my $10,000 deductible plan.

I am a libertarian and would support more freedom but that seems to not be politically viable, my proposals are compromise.

Russ R November 17, 2009 at 9:31 am

My plan:

1. Accept that no amount of regulating will ever move the mortality rate from 100%, and that nothing in the Constitution gives Congress any powers relating to health care.

2. Inform people that they are individually responsible for their own health, and that nobody else is going to pay for care for them. TANSTAAFL.

3. Allow any individual to purchase any type of coverage from any health insurer in any state, at any price they like. Alternately, allow people to self-insure and pay for their own expenses out of pocket.

4. Allow any health insurer to offer any type of coverage to any person in any state at any price they feel they like. Regulate insurers to verify they have adequate assets to cover their liabilities and risk exposure.

5. Allow any health service practitioner to refuse care to any individual who does not have the means to pay for it, or insurance that will cover the cost.

6. Let free markets work their magic to efficiently allocate health care, while saving billions in regulatory costs and administrative bureaucracy.

That is all.

MostlyAPragmatist November 17, 2009 at 9:53 am

I’m always suspicious of any blog post that cites Greg Mankiw to support a claim. The man is an influential economist (the 19th-most!), but he’s also a disseminator and originator of Republican talking points.

Did anyone read Greg Mankiw’s post or click through to the underlying post? Basically, the point on the uninsured is that:

1) There are undocumented aliens–these were excluded because of a political firestorm from Republicans.

2) It is undesirable to penalize uninsured, “free riders”.

Tyler, granted that the undocumented aliens must be excluded, do you agree that it is undesirable to have healthy people uninsured and not address the free rider problem?

Butch November 17, 2009 at 10:08 am

I would be happy if the Congress would adopt its entirety the plan of any of the following countries (in my personal order of preference): Switzerland, The Netherlands, France.

Oreg November 17, 2009 at 10:32 am

Tyler, what exactly are the goals of your proposal?

Cost cutting seems to be one, laudably, by increasing the quality of essential services (3,4,8), decreasing the amount of unnecessary ones (6,7), and stepping up competition between care providers (5,6). These measures are mostly incremental and should be taken /in addition/ to the fundamental change required to arrive at a sustainable system. [Catastrophic care (9) appears to be provided already in today’s system by ERs but it ignores cost savings by preventive care.]

You seem to give up on universal coverage which is not only an ethical question but, if implemented properly, also makes financial sense: The mandate gets the healthy to share the risk, thereby lowering rates, and it provides preventive care to the poor instead of waiting for them to become expensive ER cases for which the government picks up the tab, thereby increasing rates but lowering taxes. If the net amounts to an overall cost increase it is because of increased welfare to the previously uninsured. You control the level of welfare and cost by the minimum coverage you mandate.

What I’m missing from your list:
* The mandate
* Establishing market transparency by defining a minimum coverage contract that each insurance must offer *to everyone* with no exceptions. There is no proper competition without transparency.
* Severing the counter-productive ties between employment and insurance

Medicare and Medicaid could then be privatized to compete with the other insurers. The government funds would become available to subsidize insurance for the poor, provided by the market. With a mandate and a transparent market there is not need for a public plan.

Jim November 17, 2009 at 10:41 am

Most of those are quite good. Nice work. It’s obvious why they are not in Obama’s plan: his goal is to take over the healthcare system, not to improve it.

But you left out the most obvious, and simple, thing that should be done: allow people to buy health insurance across state lines. The current restrictions are insane, and I have no idea how they could possibly be legal, either. I am forced to buy a plan in my state, while the Governor meets with lobbyists who represent acupuncture, aromatherapy and leeching… and suddenly all of those things are required by law to be in the plan too. My rate goes up; leechers are billing the insurance company $155/hour; Gov gets his kickback. A great system.

I would say that this change alone would make an enormous difference.

anon November 17, 2009 at 10:59 am

Wow, 4, 5, 6,and 7 by themselves would accomplish more than anything being currently discussed.

Dan November 17, 2009 at 11:10 am

Good proposals. 5 is the one most relevant to me. I recently had the flu and wanted to make sure it wasn’t the new swine flu variant, so I went to the hospital after work (which means an emergency room visit). What took an hour and a half could have been done in the first 10-15 minutes if I wasn’t required to see a doctor. The nurses had already told me it wasn’t swine flu and the reasons why. Obviously the doctor had a better medical explanation, but I didn’t need to hear it, nor did I need to tack his services to my bill. But there is no 24-hour walk-in where I live. And if I had waited till the morning, it changes the cost to me, but not to the hospital.

Ryan Vann November 17, 2009 at 11:21 am

I’d like to see a tax exemption factor of about 1.10-1.4 times the cost of care added into the mix. It would incentivize providing care for the unable to pay, or underinsured, wouldn’t cost anything other than reductions in revenue (which is great by me).

John November 17, 2009 at 11:21 am

Ummm or just put everyone on Medicare, the most popular Federal program in existence.

I mean, if you’re not going to end subsidies to employer-based health care and let an actually free market take care of this. I try not to think about that one too hard because it makes me cry at night.

dearieme November 17, 2009 at 11:43 am

“4. Make an all-out attempt to limit deaths by hospital infection and the simple failure of doctors to wash their hands and perform other medically obvious procedures.” The threat of Capital Punishment should do the trick. Dead cheap.

Dan * November 17, 2009 at 11:53 am

@Bob Murphy and many others – Maybe you haven’t heard, but there is no good reason to be a knee jerk libertarian. Libertarian utopias are just as unrealistic and insane as all other utopias. Please learn to work with reality. Which, Bob Murphy, you seem to be of sounder mind than many others, so hopefully you can look at Tyler’s proposals a second time and see that are reasonable for politicians to support. It’s not so much the system that’s the problem here as it is the status quo. It’s our culture, not our bureaucracy, that prevents the highest offices from supporting the simple measures. We can all get behind the obvious solutions, but unless it’s presented to the public as simple and obvious we can’t expect our politicians to have the ability to support them. And politicians cannot be expected to propose revolutionary ideas to the public. I could go on, but hopefully I’ve got my point across.

David Zetland November 17, 2009 at 12:14 pm

Delink insurance from work:
1) Move premia into wages (still tax deductible)
2) Force workers to buy their own insurance (deductible or not) with MSAs
3) Allow markets and incentives and competition to work.
4) Profit!

David Zetland November 17, 2009 at 12:15 pm

Delink insurance from work:
1) Move premia into wages (still tax deductible)
2) Force workers to buy their own insurance (deductible or not) with MSAs
3) Allow markets and incentives and competition to work.
4) Profit!

http://aguanomics.com/2009/08/few-more-thoughts-on-health-care.html

Yancey Ward November 17, 2009 at 12:23 pm

David,

High deductible plans are anathema to most of the standard healthcare reforms originating on the Left. The reason is that such plans are a way for young and/or healthy people to avoid subsidizing routine, non-catastrophic care for everyone else- routine care that such people are less likely to use themselves (the main reasons such plans make financial sense for them to purchase in the first place).

Yancey Ward November 17, 2009 at 12:31 pm

Bernard,

That was required to get Romney to sign the bill.

JohnBailey November 17, 2009 at 12:35 pm

It is surprising to me that there is so little attention paid to the incentives for improving health.

In the current system, the bulk of the incentives are geared toward high-cost care to fix unhealthy behavior.

Only HSA type programs give the participants an incentive to balance cost to effectiveness. Even then, there are no incentives that reward healthy behavior. Most state regulations prohibit basing insurance pricing on healthy behavior.

Bernard Yomtov November 17, 2009 at 12:39 pm

Yancey,

OK. But that doesn’t change the fact that HSA’a are just fine in MA, contrary to some claims being made.

Drew M November 17, 2009 at 12:47 pm

I fall a little more to the libertarian side of this issue, but I realize in this political climate, that the truly libertarian solution to this problem is not going to happen. Thus, I actually like Martin Feldstein’s take on healthcare here: http://www.aei.org/article/101137 .

Sebastian November 17, 2009 at 12:57 pm

I’m with Mick.
“Make an all out attempt” is a less specific political strategy than a Thomas Friedman column (and you really had to throw in the moonlanding there?!) and that’s saying a lot…
More than half of these are cop-outs, distracting from the actual proposal, which I still don’t quite understand. I’m also really skeptical about the political economics of this: Some of the things you want are exactly the type of issues that usually can’t get done in US Politics: Small print issues that are of keen interest to a small, well organized group and not easily publicized to create public pressure.

Dan * November 17, 2009 at 1:12 pm

A properly funded ad campaign could get many of these ideas presented to the public in such a way that politicians would have to act. Which is the best way to handle politicians. Giving them no option but the good ones is the best way democracy can work. Of course, who’s going to organize and execute such an ad campaign? Does Tyler have a working PR department?

m November 17, 2009 at 1:25 pm

v – ease of licensing would reduce supply constraints and expand system capacity.

mulp November 17, 2009 at 1:50 pm

My guess is CBO would put the cost of your proposals at $5 trillion over the next decade.

Keep in mind, CBO rules don’t allow assuming costs will be reduced unless spending is explicitly reduced, otherwise, costs are assumed to continue to increase as the recent trend.

And you are advocating more research which is like Nixon’s war on cancer which exploded costs.

On cost, I think a better case can be made if you were to argue the US should implement one of the existing health care systems; you mention the Swiss system, which is a decade past implementation from a version of US health care circa 1990. In fact, the Swiss began their reform as did several other nations (Taiwan,…) at the same time the Clinton Whitehouse was proposing reform for the same reason: the rising number of uninsured and uncontrolled cost increases.

My simple proposal is for the US Congress to outsource all US health care, public and private, to a foreign nation. Have a commission setting performance standards and seeking bids and picking the lowest bidder. Maybe Japan would win and this boost their GDP enough to put them back in 2nd place behind the US and ahead of China.

After all, are markets and competition the best way to arrive at the best solution? The US health care system fails in every measure I can think of when benchmarked against all the competing systems.

mulp November 17, 2009 at 2:10 pm

I fall a little more to the libertarian side of this issue, but I realize in this political climate, that the truly libertarian solution to this problem is not going to happen.

As far as I know, no member of Congress has introduced legislation to repeal the moral hazard EMTALA provision of COBRA that has been law since 1987.

I wonder if Palin would speak of death panels of bookkeepers if a bill repealing EMTALA were introduced.

But think of it: you are 24, healthy, not finding a job in your profession you graduated in last June, living at home, working as a temp delivering packages, and your friends in the same boat say, “hey let’s go snow boarding when the holiday ends and we’re out of a job.” If EMTALA were repealed, you would respond, “hey man, we don’t have health insurance, no job, no wealth, and the hospital death panel accountant is going refuse us care if we break a leg and are bleeding out on the ER floor – man take responsibility!”

As it is, why not go snow boarding, EMTALA says the public will pay for a broken leg or broken neck, so no need to take responsibility. If young and unemployed, or homeless and middle aged, no need to take responsibility. An infamous homeless guy ran up a million in medical care one year thanks to EMTALA. And a young college guy without a job who breaks his back will likly get more than a million in free medical care, so why should any healthy young person with no property buy health insurance?

Brian 2 November 17, 2009 at 2:44 pm

Maybe some of us want to be able to pay an annual fee to a trusted medical group in exchange for comprehensive care?

Go for it. I’m unaware of any proposed free-market reform that would prevent that. In fact if insurance is de-linked from employment you’ll end up with more options.

Maybe some of us even want to have our employers pay for health insurance which expands the insurance pool beyond the sick who need care right now.

Those words make no sense. First, the “insurance pool” consists precisely of those who are *not* in immediate need of care. If you have an expensive condition and no way to pay for it, you need welfare, not insurance. Healthy people would buy health insurance for the same reason that homeowners buy fire insurance before their house catches fire. Second, what value is there in your employer acting as a middleman? All it gives you is a weak form of community rating, which can be achieved in other ways. Meanwhile it limits your options substantially and makes it so that almost anyone can be wiped out by the combination of a job loss and an expensive illness.

Except when you get a job and sign your life and rights away to an employer who tells you exactly what to do and drops you when you are no longer profitable.

So why on earth would you want those evil and capricious employers to be in charge of your health insurance?

Jim B. November 17, 2009 at 2:57 pm

Here’s a question: How many more people would be insured at any given point in time if COBRA were set up so that it was an “opt out” program instead of an “opt in” program? In other words, exploit human laziness by setting the default when you lose a job to be automatically enrolled in COBRA, and billed for it.

jason November 17, 2009 at 3:25 pm

Rick,
I wondered that too and then decided that by “ease” he probably meant “facilitate,” not “lessen.”

jimbino November 17, 2009 at 5:36 pm

How about requiring:

1. All providers to publish prices for procedures, drugs & devices by CPT code, etc, on the Web, just as Amazon, Walmart, Sears, and Lowe’s do for their products?

2. All providers to take all comers at the same price, without discrimination, as the above also do?

3. Taxing of healthcare benefits in order to level the playing field (or, in the alternative, providing of tax deductions for private insurance premiums and private payments in cash)?

4. Encouragement of importation of drugs and of medical tourism, allowing healthcare dollars to be spent overseas without limitation?

5. Unbundling of services, so that those who pay cash get a discount of 40% for relieving the provider of the insurance/medicare record keeping, delayed/denied payment, etc, and a 3% discount for paying in cash instead of with a credit card?

5. Elimination of all government certification of healthcare providers, drugs and devices (relying on private organizations like JD Powers, Consumers’ Union to protect the consumer)?

Mike M November 17, 2009 at 7:10 pm

Wow this post and the resulting comments shows how hard it really is to get people on board for health care change. I was going to blast a couple things in his proposal, but after seeing every other poster rip apart something about it I thought; if a blogger can’t get even one positive comment on his own fanboi website, then passing a real bill must be a near impossible task.

bdwnnc November 17, 2009 at 7:40 pm

The federal government should open up gym’s – like McDonald’s does with hamburger-joints. These gym’s would be provided for free along with some form of incentive to get people to workout. Each visit and workout would earn some form of credit to a HSA account.

Gordon Mohr November 17, 2009 at 9:10 pm

Will Wilkinson’s 2006 ‘Health Care Fantasia’, while a bit further from the political mainstream than Tyler’s list, struck me as well-thought-out and serious:

http://www.willwilkinson.net/flybottle/2006/03/19/health-care-fantasia/

In particular: it doesn’t call things ‘insurance’ that aren’t, picks a few narrow places where mandates and subsidies may be necessary, and is more honest about how charity cases — the ‘uninsurable’ — are handled.

Ralph November 17, 2009 at 9:54 pm

I think getting all of our plans into one would be a big enabler in cutting costs, so I would support that. That would solve the problem of the elderly vetoing any efforts at cost cutting. The rest sound good, but in your funding for research I would also include cost effectiveness research.

Steve

M1EK November 18, 2009 at 12:18 pm

Nobody should be allowed to talk about HSAs at all without first acknowledging that they function as yet another scheme to reward the wealthy – their benefit accrues in direct proportion to one’s marginal tax rate, so they do virtually nothing for the people who need the most help today paying for health care.

The fact that you LIKE yours is meaningless. I like mine too, but it’s still a giveaway (in my case, only 25% – compared to the 36% or whatever John Mackey gets, compared to the basically 0 benefit his front-line employees get).

David November 18, 2009 at 7:57 pm

Shorter M1EK: Incentives work.

BTW, you forgot HSAs that are funded by employers. That is net zero tax benefit to the employer and much benefit to the employee. In NY a CDHP plan is nearly $7,000 less than an HMO plan including the whole deductible. Cheaper plans mean more people are covered. That’s helpful.

M1EK November 20, 2009 at 11:25 am

David, that’s hypocritical – everybody on the glibertarian side of the fence insists that we must count employer contributions for things like social security as foregone compensation; why not also consider those HSA contributions the same way? At which point, the benefit to the employee is, again, determined by their marginal federal income tax rate (for many of Mackey’s employees, effectively zero; for Mackey himself, somewhere in the mid-to-upper 30s).

Jim Hlavac November 21, 2009 at 11:16 am

What you are proposing is just rearranging the chairs on the Titanic. If “tax credits” are good — so are tax cuts. If “competition” is good — get the government out of health care. If government is incurring costs and deficits they cannot sustain, then the solution is not more government or rearranged government. The solution is in far less government. A solution lies more in having every American save their own $25 to $50 a week for their working lives — even if you have to mandate it — and at just 5 or 6 percent interest in a bank account — even if that has to be mandated, too (might even shore up banks who would have all those deposits. And those deposits could be insured in an FDIC sort of way) then over time every American would have nearly a million bucks to handle their own health care and retirement. Already Social Security, Medicare and Medicaid simply take the $25 to $50 and create the middleman of government and insurance companies.
And if it took us 70 years to get us into the mess to get out of it will take a generation or two, also.
But to let people keep their own money will give each individual the power to make decisions themselves, and the suppliers of such services would be very responsive to the demands of those who are paying for it. By inserting either government or insurance companies through work or plans, or HMOs or whatever you call them, will only give suppliers the incentive to listen to those paying for the service — which would then not be the patient whatsoever, but some third party payer. Finally, it is no business of government or anyone really, what you think is “too much” spending on health care. We would not tolerate it for cars, houses, food and clothing, or for entertainment, computers or any other thing — “too much” spending on any of these is simply no one’s business — why should it be different for health care?
No, sir, your solution is just as convoluted as the current plan.

DragonScorpion November 24, 2009 at 4:20 pm

I oppose the so-called public option, I’d like to see a non-profit, member-owned, health insurance cooperative take it’s place. I think the Democrats are making a very big mistake if they demand a public option as (1) the bill might not pass then, (2) the public option will forever be tied to them.

I really liked many of the ideas that you proposed here. Where you lost me on credibility, however, was early on when you referred to the current legislation from the House and the Senate as “Obama[‘s] bill”. It’s like when people call health-care reform “Obamacare”. It smacks of partisanship, for one, and it is often a cheap attempt to demonize something by attaching a presumed menacing label to it. And, among irrational people these days, Barack Obama represents a sort of boogyman.

The bill passed by the House is not the “Obama plan”, it’s (largely) the House Democratic plan with some Republican provisions tacked on. The bill being debated in the Senate is not the “Obama plan” it is (largely) the Democratic plan from the Senate. The President hasn’t written a plan, he hasn’t even taken the lead on a health-care reform bill.

Freddie O'Connell January 20, 2010 at 2:25 pm

Most of the proposals I’ve seen (House Republicans, Mackey, etc.) that offer alternatives to the Obama approach to healthcare, including this one, seem to focus only on controlling costs. That is a noble and important goal, but I don’t see anything among them that seeks to expand access.

Is this a problem that simply isn’t interesting to solve to the market-first/market-only crowd? Are people with pre-existing conditions or who lose employer-based coverage or who become trapped by an expensive adult-onset chronic condition considered expendable? Or is it considered acceptable to leave them trapped in Medicaid-capped penury with no real assets for the duration of their pre-Medicare lives?

Private health insurance, as a market concept, isn’t interested in ensuring that universal affordable healthcare exists. In my mind, this motivation for tackling healthcare reform is on equal footing with controlling ever-rising costs. Why is it given such short shrift by those opposed to something more “socialistic”?

Jonathan January 20, 2010 at 6:04 pm

Expand the roles of pharmacists and nurses to be more like medical doctors? That is an utterly absurd suggestion! Pharmacists aren’t trained to diagnose and they are busy enough as it is counting their pills. And FYI, Nurse Practitioners (NPs) order more diagnostic tests than primary care physicians because they have less science background and are more reliant on protocol-based medicine. Thus your call for more NPs will only increase health care costs. Secondly, NPs and pharmacists already make 6-figure salaries working just 40 hours a week. Primary care doctors work 60 hours to make that.

Weaken medical licenses? I can see an ad already “Health Care Reform Brings You Barefoot Doctors.” Medicine is not investment banking. There are real human consequences of incompetence in medicine beyond 7 years of bad credit. The typical doctor has a 3.7 GPA and at least an 80th percentile on his MCAT. No other profession has those qualifications, certainly not nurses and pharmacists. Medicine is one of the last truly meritocratic professions left in America, and you want to get rid of those standards by letting in all the med school rejects to become doctors.

You know why GM failed? Because it was managed by a bunch of penny wise pound foolish paper-pushers like you instead of automotive engineers. We don’t want your type to f’uck up medicine now.

Craig Falls January 21, 2010 at 8:45 pm

For what it’s worth, my girlfriend is working on a masters in public health at Mt Sinai and agrees with basically all of Tyler’s points, some emphatically (8, 6, 4). She claims most of these ideas are pretty well agreed upon among experts in that field, except the more economics-oriented points such as 12, which they really don’t talk about much, since it’s outside their area of expertise.

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