Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Only Three Things Wrong With American Healthcare

{William Bingham class=}
American Healthcare

Although Congress is offering several thousand pages of proposals for healthcare "reform", none of them even mentions the three main difficulties, to say nothing of fixing them. Let's be terse about this:

1. Health insurance is fine, but if you make it universal, there is no impartial way to determine fair prices. Somebody must haggle with the vendor in order to introduce the issue of what is the service worth? The customer doesn't care what it costs to make, or whether the vendors are being paid fairly. If everyone is insured, no one cares what it costs. Not only do all costs rise, but they rise without coordination, without a sense of what each component is worth, relative to alternatives.

2. Employer-based insurance is fine, but it ends when employment ends. You just can't stretch employment-based insurance because you can't stretch employment.

3. State Medicaid programs are fine, but just about all fifty states are going broke trying to pay for it. Extending it to more people by raising the income limits just makes things worse. Items 2. and 3. are related. Trying to do both -- expand Medicaid as employment shrinks -- during a recession is incomprehensible. Item 1. (price confusion) gets drawn into this because the States try to pay less than it costs, hoping to shift the deficiency through hospital cost-shifting, utterly confounding the information which prices provide. The doctors have no way to tell which is the cheapest approach to a problem, so they don't try. Without control over prices, we can only control volume.

That's really all there is to this mess. Not one word of the current legislation even mentions these problems, so of course the legislation blunders. Even a child can see that compulsory expansion of benefits to universal coverage will fail if you can't pay for what you already have. No one will make sacrifices for a new system if the sacrifices seem futile. They are futile, so leave me alone.

The current administration has been compared with bank robbers who see they are trapped and decide to shoot their way out. Let's see them try to shoot their way past the first Tuesday after the first Monday in November.

Originally published: Thursday, December 17, 2009; most-recently modified: Sunday, July 21, 2019

In general, due to historical reasons following WWII the US is the only industrialized country that associates health care (and health care insurance) to employment. This would be a great public policy discussion, but let’s leave that very broad issue aside and focus on more fundamental issues:

1. Free Riders. That is what Mitt Romney did in Mass. Why should I subsidize people who receive free health care?
2. Pre-existing conditions. With pre-existing conditions (for example my wife with Stage IIIb breast cancer) a person might be uninsurable in the private health care market – like my wife or would have to pay exorbitant premiums as insurance companies, as private for profit entities, can cherry pick their customers.
3. Health care. The right is positioning health care as a choice. Well it is not. Everyone without exception needs healthcare – starting at birth. It is different from mandatory car insurance – the big difference is that one has a choice of owning or not owning a car but if one owns a car, one does have responsibility to the greater society. Just like following rules and signs of the road – if one chooses to drive. One does not have a choice of being alive (in general).

Whether the individual mandate is constitutional or not, if the Federal government is exceeding its authority, etc – I will leave it to our fine judicial system to determine those issues.

However what is missing from the right other than the mantra from the GOP candidates: “on the first day in office, I will repeal Obamacare” is:

What is the GOP alternative to Obamacare? And specifically how does the GOP plan to address:
1. Free Riders
2. Pre-existing conditions (insurance at an affordable level)

Best regards,
Posted by: Luca   |   Mar 12, 2012 4:33 PM
I read your profile and you sound lovely!

My name is Tom Degan and I am a writer and video artist from Goshen. Might I send you an additional photograph or two? Here is the address of the political blog that I write:

I started writing it in June of 2006 and in the last year it has started to get a bit of national attention which pleases me to the end of the earth and back again. You will be able to find some more photos of me there. Hope to hear from you soon!

All the best,

Posted by: Tom Degan   |   Dec 18, 2009 7:51 AM