In The Blogs

The Swiss System

| Tue Nov. 17, 2009 8:26 AM PST

Tyler Cowen has a list of 11 healthcare reform ideas (plus three extras) over at his site today, and he says he would "trade away the Obama bill for these in a heart beat." I wouldn't, for reasons having more to do with future reform than with anything on the table today, but there's plenty to agree on here. Tyler would like to federalize Medicaid, spend more on medical R&D, make an "all-out" effort to limit hospital infections, encourage the spread of walk-in clinics, and a few other things that I've written in favor of before. So bring 'em on.

But he's also in favor of limiting universal coverage to catastrophic care, which I'm not so keen on, and thinks that universal coverage is pretty much impossible if you try to build it on top of our current jury-rigged system:

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.

I'm sympathetic to this idea, but I'm not really sure why it has to be true. The current bills pretty clearly move us along the path toward a Swiss system — not my first choice for a model to follow, but certainly better than what we have now — and I don't think that the existence of Medicare as a separate part of that really stands in the way. A single comprehensive system for all would probably be better and more efficient, but it's hardly an absolute precondition. My own guess is that a decade or two from now we'll basically have Medicare for the elderly and the Swiss system for everyone else. Austin Frakt adds this:

The current debate over health reform is just the beginning–call it Health Reform Debate 1.0 (beta). Debate 2.0 will be about costs, specifically about payment reform....Therefore, I’d like to add a 15th item to Cowen’s list: payment reform that compensates providers, at least in part, on the basis of quality and cost control. That’s very vague. One can conjure up some specifics and some have. Few are thoroughly tested and none have been anywhere near the center of political debate. But they will, and soon.

Agreed. Coverage first, cost controls second. It would be great to do it all at once, but politically there's really no alternative to the way we're doing now.

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Kevin Drum is a political blogger for Mother Jones. For more of his stories, click here.

Comments

A bird in the hand...

Submitted by low-tech cyclist on Tue Nov. 17, 2009 10:06 AM PST.

Jeez, Cowen, we can all come up with way better universal health care plans than this one.

But this one has a half-decent chance of being signed into law. All those pony plans don't. Not Cowen's, not mine, not anyone's.

We'd all trade the bird in the hand for the two in the bush, if the two in the bush were suddenly in hand. But talking about which way-out-of-reach plan you'd trade the current proposal for is really silly, unless there's some insight to be gained here. An insight more profound than 'any clear, simple, effective set of ideas won't retain those characteristics after contact with the U.S. Congressional legislative process,' that is. And that's about all I see.

Perfect is enemy of the good

Submitted by Anonymous (not verified) on Tue Nov. 17, 2009 10:52 AM PST.

I for one wanted a health care reform bill that eliminated the ties to employers that keeps employers trying to nickel and dime my care, investigating my lifestyle choices, and that ties me to one particular employer and afraid to lose my job. And oh yeah, ask GM, it also makes international competition that much harder.

But the Perfect is the Enemy of the Good. 45,000 people die each year with no health insurance. That's a Vietnam Wall of deaths, and one that should be paraded in front of NOW headquarters.

Swiss system

Submitted by low-tech cyclist on Tue Nov. 17, 2009 10:07 AM PST.

Having participated in dozens of Swiss System chess tournaments in my younger days, a link was obligatory.

Why are you "not so keen" on

Submitted by M. (not verified) on Tue Nov. 17, 2009 10:49 AM PST.

Why are you "not so keen" on limiting universal coverage to catastrophic care? Part of the problem with healthcare costs, although not all of it, is the fact that with the insurance system as it is, and most definitely with the system as the House bill would have it, the people who are receiving the care are too often not the ones paying for it. A major issue with healthcare in this country is that it's badly overused, and things like cost control or cost effectiveness never really come into play.

I'd love to see a healthcare bill that limited its scope, as far as universal coverage and utterly loathsome universal mandates, to catastrophic care, and left the rest alone. All of the "systems" that we hear about -- especially on this site -- are European. Do we go the way of the Brits, the French, the Germans, the Swiss? What about Chile? Last I heard, their healthcare system was doing wonderfully. Care to guess how it's structured?

M: "All of the "systems"

Submitted by alex (not verified) on Tue Nov. 17, 2009 12:36 PM PST.

M: "All of the "systems" that we hear about -- especially on this site -- are European."

They moved Canada?

M: "Do we go the way of the Brits, the French, the Germans, the Swiss?"

Not the Brits, but the French, the Germans, the Swiss? In a heartbeat. True universal coverage and at least 1/3 less than our costs, comparable (in some cases better) outcomes, no ridiculous financial burden or loss of coverage if you're unemployed, no recisions - count me in!

M: "What about Chile?"

Great choice - Chile has a per capita GDP that's less than 1/3 of ours. Think that might affect what they can afford?

As to the systems discussed on this site from time to time, which have included Canada, Australia and Japan, what they have in common along with Western Europe, is that they're all wealthy countries like the US. As a greedy American, I want a plan that's at least as good as what a bunch of cheese eating surrender monkeys can afford.

Conceptually, catastrophic

Submitted by urban legend on Tue Nov. 17, 2009 1:37 PM PST.

Conceptually, catastrophic coverage should be socialized, and it is here that we will get the most bang for the buck in controlling costs. Imagine the difference in premium cost between a policy with unlimited exposure -- the situation other than lifetime caps we have now, i.e., at least $1000 per month -- and, assuming a government plan is picking up everything beyond, say, $10,000 for a family -- a policy that covers only the amount above a modest deductible up to that ceiling of $10,000. How much would you be willing to pay a year for that coverage of costs your family incurs from $500 to $10,000 -- that is, before you would say, "I'll take my chances. We could survive a $10,000 hit"? Maybe $1500-2000 per year, or about $125-170 per month? (Of course, that decision is highly dependent on income and health, but a quick look shows that there comes a point early for probably most families where the cost of that "gap" insurance becomes a likely losing bet. If your family typically pays about $1000 per year in healthcare costs, and you know you are automatically covered for anything above $10,000, you aren't going to pay $500 per month (or $6000 per year) for a policy that covers you just for that gap.)

My bet is a careful analysis will show most of the industry's profit is built on top of the contingency of paying for catastrophic costs. That's why eventually we should get to that step -- and why Kerry's reinsurance plan was a step in the right direction.

Instead of catastrophic

Submitted by Th (not verified) on Tue Nov. 17, 2009 1:55 PM PST.

Instead of catastrophic coverage I would like a very bare bones single payer for all with private supplemental coverage. Catastrophic coverage will mean that health maintenance is neglected until problems are very expensive.

Cost controls later?

Submitted by rhinoman (not verified) on Tue Nov. 17, 2009 2:52 PM PST.

Seriously, Kevin?
"Coverage first, cost controls second."
The reality is,
"Coverage now, cost controls never."
You're a smart guy. Explain to me how the medical cost control bill makes it through Congress.
Take your time. I'll wait.

hate to say it

Submitted by Anonymous (not verified) on Tue Nov. 17, 2009 4:29 PM PST.

...but as a lifelong Democrat (but one who voted Anderson, couldn't bring himself to vote for Mondale, and who voted for Dole...go figure), I've finally decided that it's time to call the "conservative Dems" bluff. This "debate" has been going on too long and produced too little of value. If it health care goes down in flames, so be it, and I for one, will donate money to sink their careers.

A thread containing a

Submitted by Anonymous (not verified) on Tue Nov. 17, 2009 6:46 PM PST.

A thread containing a conversation and discussion of experiences in a hospital was removed. The thread was moderate, on topic, and yet NannyJones removed it without explanation.

Why is NannyJones such a fucked up wanking censor?

Oh, go fuck yourselves.