Wednesday, March 02, 2005

Health Care Reform

Tipped off by the Middle Earth Journal, I just read an article entitled The Health of Nations, posted on The New Republic website.  It was written by Dr. Arnold Relman, who was pretty good credentials.  He agrees with me, in part, by advocating a limited national health insurance program.  He actually proposes a more complex solution, that would include a national system to provide basic care for everyone, then a hybrid system that would provide everything else.  He takes great care to point out the problems with the current plan of consumer-driven health care.  (CDHC is a euphemism for the current plan of promoting high-deductible insurance plans with health savings accounts.)  For example:
For a start, high-deductible insurance is not likely to produce reductions in expenditures, except among low- and modest-income families, who would feel financial pressure to cut their doctor visits and their use of other medical services. There is good experimental evidence that high deductibles have such selective effects, which expose the most vulnerable patients to greater health risks. Higher-earning beneficiaries would not feel such pressure and would continue to use all medical services freely. Whatever reductions in total expenditures might occur would be achieved largely through reducing services to those with lower earnings.
I don't have a lot to add to this, except one thing.  One problem with the CDHC concept, that Dr. Relman did not mention, would be a consequence of the problem noted in the citation.  If there were a subset of patients who were willing to spend freely, then physicians would have an incentive to tailor their practices to attract those patients.  That would mean all kinds of nonsense, such as big offices, luxurious waiting rooms, and the like.  Not all would do this, of course, but there still would be a problem.  The physicians who actually tried to keep costs down would be "rewarded" by having a higher proportion of patients who are trying to skimp on health care expenditures.  Those patients, on average, are a lot harder to treat: it is easier to get the job done, when cost is no object. 

Of course, some well-off patients will not be attracted by fancy offices.  I know a guy with good insurance who still goes to a community clinic.  He does that because he believes in the place, and he knows that some of the profit they make seeing him will be used to subsidize care for indigent patients.  But most people are not like that.

Maybe I'm wrong, having gotten rather cynical about the difficulties involved in reforming the health care system.  After all, there still are a lot of idealistic physicians out there.  I just don't like the idea of giving anyone an incentive to waste money, at the same time as making things more difficult for those who are frugal.