I think the point we need to keep in view is that all the mechanisms proposed byt tombigbee et al. are just ways to shift the spending around. Frankly, it’s what we’re doing now, and it’s not a reform. This all seems to be driven by a psychological reistance to the idea of “socialized medicine,” and not by a desire to make the system more efficient overall. In America, we’re addicted to this idea of achieving reform through tiny increments, such as by jiggering with the tax code (see HSAs as an example). I know this is about politics, in that we can pretend to ourselves that because we’re not making a Treasury outlay we’re not spending tax dollars, but it’s still maddening from the perspective of the healthcare consumer, who is given just one more thing to worry about (and gamble on, as well).
I’m here to say that these patchwork solutions are wrong, wrong, wrong. The amount of money we waste every year is staggering, and as tombigbee notes, the demographic trends are not in our favor. We need to solve the problem now before it devours us alive. And frankly, I think it’s not all that difficult, though I think it’s easier when you start at the state level.
Here’s what I would propose. Because I live in Massachusetts, where most people are covered by HMOs paid for by their employers, I would advocate retaining most of the existing system. The only significant change I would make is that the state would pay the cost of enrolling each taxpayer in an HMO of their choice, and the state would fund this by imposing a tax on employment. This tax could be graduated based on the size of the employer, so that a self-employed individual might only pay 10 or 20% of the levy. Why would I do it this way? Because business are already in paying for health insurance. In my proposal, business would simply send their payments to the state, per employee, and get entirely out of the business of negotiating with the insurers, administering the benefit, and haggling with the unions over health benefits. I think, even with a small increase to cover the uninsured, businesses would still come out ahead.
The only other large-scale change I would make would be to make all medical providers bill using a standard medical coding system and claim form, which would probably go to some centralized clearinghouse. The insurers would still negotiate with providers to set their rates, and the HMOs would still have to make themselves attractive to individuals, which would keep some market forces at play in my proposal.
Is this socialized medicine? Only in the sense that the government becomes the one payor. In every other sense, the existing system is retained. Most people would in fact see no change whatever. But you would achieve significant administrative efficiencies, and could then go forward and talk about the shape of the health system of the future. Because that, while a separate issue for the purposes of this discussion, is something that ultimately needs to be looked at.
