Thursday, July 2, 2009

Healthcare and the Public Good

A public option in health insurance is not something to be feared. For many of its critics, the idea seems to be morally repugnant, corrupting the purity of an imagined, natural free market. But, we must keep in mind that markets are what we make of them, and healthcare is already one of the most regulated markets out there. And for good reason: there is a public good and commitment to the dignity of life that we do not want to fully and completely entrust to profit-seeking competition. So we use regulations to produce incentives that hopefully promote a common good.

The incentives don’t always work. They may be ill-conceived, corrupted by self-interested lobbying, or simply produce unintended, perverse outcomes. And often a healthy dose of private sector competition is just what the system needs to weed out inefficiencies and provide better service. But this does not mean we should disavow our responsibility to structure the market in such a way that it produces the greatest god for the greatest number.

So: there is no inherent reason why the government should not participate in the health insurance market (and indeed, it already does), and government agencies and civil servants are not inherently any less efficient than private sector enterprises (as discussed in the previous post about the virtues of civil service). In fact, Medicare has much lower administrative costs than private insurers. (How much lower is a point of contention, but it seems at least ½ as expensive.) There are serious problems with Medicare and how its keeps costs down—reimbursement rates shoved down doctor’s throats, no compensation for communication with patients outside of an office visit, and so on. Yet, there is room to improve in these areas and still do so cost-effectively.

Any government health insurance should promote not just low administrative costs but use incentives to promote general wellness—which will be good for the nation as well as the bottom line. Pay doctors to keep in touch with patients via email, encourage this and other forms of relationship building between a doctor and patient. Perhaps, dramatically increase compensation for an annual well-patient check-up, help doctors meet their overhead while keep patients healthy (as the new breed of boutique practices does) and improve delivery by having a provider who knows one’s whole medical profile. Empower pharmacists to prescribe certain medications for common illnesses; increase the number of nurse practitioners and what they can do; encourage midwifery. Such reforms can be highly cost effective while also improving the quality of patient care.

We also need to tackle eating (starting with healthy cafeteria food in our schools) and exercise (by making cities more bike-friendly, for example). And we could use a new Hippocratic Oath and new social contract between doctors and patients to reduce lawsuits and improve care. More on those ideas later.

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