Law in Contemporary Society

How to Fix Healthcare

This came up yesterday in class. This is my idea of how to set up a working system of healthcare. If we want to fix healthcare, these are the objectives:

  1. Universal coverage. This should also be mandatory, given that empirically most people do not have the self-discipline or foresight to save up for a rainy day and are when injured usually left without coverage unless covered by a mandatory system.
  2. Prevention is better than healing. A system must set incentives persons to seek healthy lifestyles and to not let problems exacerbate. Similarly, as a matter of justice, persons should reap the benefits of living healthy and bear the costs of smoking and drinking.
  3. Avoid socialism. We must avoid the system in which everyone contributes to a big pot and takes out as much as they need. This has been proven to lead for people to contribution the minimal amount possible and to take the largest amount possible. It also creates no incentives for objective B.

  • This is not an argument against socialism. It is an argument against all forms of loss-spreading through group insurance.
  • It is an argument for individual responsibility, and I believe that a socialized system does not function substantially better than one where insurance companies compete in the open market. One might for example point to the early Jamestown settlement in which exactly that happened which I described.(see below) Though I do admit the point that a certain amount of risk-sharing is inevitable. I was referring to socialism in a more extreme sense. The bottom line is that patients themselves ought to be able to decide how to improve their quality of life. Any governmentalized system necessarily has some formula for what treatment is the most efficient improvement of life quality, given that the government has limited resources and an unlimited means of spending it. This will necessarily create dissatisfaction, endless debate and unnecessary overheads which can be avoided through patient choice.

  • *No* developed society attempts to deliver health care on an individual-risk basis.
  • This whole plan as I have outlined it is based on the Singaporean model of compulsory savings.

  • *No* health care economist has ever suggested it can be done.
  • Tim Harford did in 'The Undercover Economist', 2007 Random House Paperback, pp123-128. He also writes for the Financial Times.

  • You needed to explain not only how you got smarter than the rest of humanity, but why everyone else is wrong.

  1. At the same time, certain procedures ought to be covered by society at large. But this must not extend far enough to negate the incentives set in B.
  2. Minimize administrative costs. Fighting insurance companies in the courts for treatment and complex coverage schemes should be avoided as far as possible.

And this is how it’ll work:

  1. Every working person will automatically have $1,000 deducted from his paycheck per year. $1,000 is around the amount which the average citizen spends on medication, doctors, etc per year. This money does not go into a central pot but is paid into a personal bank account. Every citizen has a personal healthcare bank account which can only be accessed by doctors and pharmacists and hospitals. This creates universal coverage.

  • Nonsense. In the first place, despite the false statement in the last sentence--which you disown at the end but did not correct--taking money from "every working person" does not create universal coverage.
  • Correct. Bad phrasing/writing on my part.

  • Between the "unemployed" and the "labor force reserve" (non-disabled adults no longer looking for work but desiring employment) we now have fifteen million workers without jobs. Also not working are the 25% of the population who are children, (that would be 77 million kids including 21 million people below age 5), and the almost one-sixth of the population above retirement age already enrolled in the socialized medicine system called Medicare, which is overwhelmingly loved by voters.
  • I dealt with the employed people first. Start with the easy part.

  • Your "universal coverage" uncovers far more of the population than the 42 million presently without coverage, a fact you never see fit to disclose. Second, your $1,000 figure is ludicrously incorrect as an estimate of "what the average citizen spends per year."
  • Not quite 'ludicrously incorrect'. I wrote this piece from memory based on a the aforementioned book, which I have re-ordered from amazon. Given that the topic came up in class, I was eager to put it out there, so I jumped the gun. I now have the book in hand, so here's the numbers (I was off by $500): $1,500 is roughly the cost, in taxes, of both the UK and US health care systems (p126) per person. This could be subtracted easily from taxes and put in the aforementioned account; people who pay less taxes would receive government aid for their account. Again, at page 127, "the typical Singaporean lives to the age of eighty, and the cost of the system (both public and private) is a thousand dollars per person." Around $700 is private, about $300 is public.

  • More sources: "Here are some comparisons: Life expectancy at birth in the United States is 78 years; in Singapore, 82 years. The U.S. infant mortality rate is 6.4 deaths per 1,000 live births; in Singapore, just 2.3 deaths per 1,000. But the United States has far more caregivers: 2.6 physicians per 1,000 people, compared with 1.4 physicians in Singapore. The United States has 9.4 nurses per 1,000 people; Singapore, 4.2. And it has six times as many dentists as Singapore and three times as many pharmacists.

    The World Health Organization’s most recent full report on global health statistics says the United States spends 15.4 percent of its GDP on healthcare, while Singapore spends just 3.7 percent.

    What’s the reason for Singapore’s success? It’s not government spending. The state, using taxes, funds only about one-fourth of Singapore’s total health costs. Individuals and their employers pay for the rest. In fact, the latest figures show that Singapore’s government spends only $381 (all dollars in this article are U.S.) per capita on health—or one-seventh what the U.S. government spends.

    Singapore’s system requires individuals to take responsibility for their own health, and for much of their own spending on medical care..."

  • Per capita health care expenditure in the United States was $5,711 in 2007, and according to recent estimates (final numbers not yet available) substantially higher in 2008. So even assuming you recoup insurance overhead (which runs at 15% in the US as opposed to 2% in Canada, suggesting that free enterprise is much less efficient at running comprehensive insurance schemes than is socialism), the average four-person American household would need five times more per person than your innumerate estimate.
  • Well, there are no sources quoted for these numbers either. At this point, it appears that we are arguing about facts in reality as opposed to ways to solve problems arising from the facts. Naturally the former must take precedence to the latter. I would be delighted to look at your sources.

  • Third, you make no actual provision for catastrophic costs, which you absurdly define as "car accidents and organ transplants,"
  • Examples, not definitions. I specifically said 'such as'.

  • rather than breast cancer, childbirth complications, appendicitis, infectious disease, and all the other acute care needs of real people. As for long-term chronic care, there is no system on earth efficient enough (even the socialized systems of Finland and Japan, which deliver superior health care at slightly more than one third of the US per capita cost) that can manage diabetes or kidney disease for $1,000 per year.
  • I absolutely agree. Which is precisely why such catastrophic costs ought to be borne by the society (call that socialism - in which case we are arguing about the semantics of that word.) The idea that extreme costs, as opposed to preventive costs, are covered by the society at large is central to this plan.

  • Yours is basically a scheme for taking care of healthy, working, rich people--they are not the problem. For the real problem, you have nothing to offer.

  • I'm not going to spend editing time on the rest of this unless it is radically revised; suffice it to say that the quality of the facts is no better and the politics remains impossible.

  • This writing earns negative commitment and improvement scores: you are not committed enough to the enterprise to check your data, or to edit your own arguments with even an ordinary degree of skepticism. There is no improvement over prior writing. Not even the trivial effort necessary to get correct statistics has been taken. The more stuff like this you write the lower your grade is going to get.
  • That is naturally your prerogative. I should have waited for my sources. I would like to offer one point however: Both in class and on the wiki, we spend a lot of time discussing the flaws of the systems around us, how they do not work, how very little justice is done, how we are all conned. Except for the discussion on whether to change the system from within or without (the lawfirm), there is little concrete debate about the nuts and bolts of how to create something better. Concerning healthcare, the insurance-based market used in the USA seems unsatisfactory, Mr Obama said as much in his recent debate. The British system sweeps away the market almost completely; decisions of what is covered are taken by bureaucrats, there is little patient choice. The system appears to be working well, but has its problems, being costly and creating little to no incentives to live healthily or to contribute much and take little. I proposed a system which might marry the best of both worlds. You obviously don't like it. But I understood the purpose of the wiki to pose, exchange, edit and improve ideas. It was once mentioned in class that the desire to 'break' every new idea ought to be resisted. I also remember a call for creating, as opposed to joining, something new, to build. Guilty as charged.

  1. Every person can choose for him- or herself what to do with this money, whether to see an ophthalmologist or dermatologist or dentist or none that year. This is preferable for a number of reasons.
    1. First, it eliminates the middle man of the insurance company or the government dictating what is and is not covered by the healthcare system. This practically eliminates administration costs and gives power to the people.
    2. Second, consumers have the most information on what they actually require. This limits waste. Although it can be argued that individuals have insufficient medical knowledge to look after themselves, this is incorrect. Firstly, knowing when and how to see a doctor is not difficult to understand. A car requires maintenance, as does a human. Secondly, it is common economic knowledge that it is in the interest of the seller to supply the consumer with honest and accurate data. [] This is a system which emphasizes personal responsibility.
    3. Third, this will create open competition between doctors and pharmaceutical companies, which improves quality and lowers costs.
  2. The bank accounts at all times are property of the individual. This prevents the state from using the money for anything else, as it happened in Germany with the generation-contract. Upon death of an individual, the money passes to the next of kin, but again only to their healthcare accounts.
  3. Given that the accounts cannot, by definition, ever default, they will be highly attractive to banks, which will in return have an incentive to provide high interest on these accounts. It is up for discussion whether every bank or only one bank should be permitted to host such special accounts.
  4. Given that by and large people get sicker the older they get, expenses can be expected to be low in the first few years. Compound interest accrues. After twenty, thirty, forty years of annual payments and compound interest the bank account can have grown respectably. Once a person goes into retirement, the healthcare account may also be used to finance retirement, but again not for luxuries but only for housing and healthcare, which are the two biggest expenses which seniors face.
  5. This system creates real incentives for people to eat their vegetables and exercise, as they have hard-cash motivational carrots dangling in front of them. Moreover it also avoids the injustice of having people cover other people’s expenses.
  6. A small communal side-pot for expensive treatments, such as car accidents and organ transplants must be created at a cost of about 1-3% of income. These procedures are likely to exceed the individual account’s capacity, but are comparatively rare. There is no injustice in this under the Rawlsian social contract – the person in the car accident could be me or you and such an accident cannot be avoided by not smoking or working out regularly. It is fair in these instances to rely on society to bear the costs.
  7. It is true that some people are born sturdier, healthier than others who have notoriously higher blood pressure or inclination towards certain illnesses. The point of this system is not to provide equality in genes, but to provide healthcare. Some people are born tall, others are born short. Everyone has to make the most of what they have got and a healthy lifestyle goes a long way to change your odds of sickness.
  8. That said, as a matter of the social contract, we will want certain disabilities to be cushioned by society. Most people would agree that a child that was born blind should receive help from the community; this could be your child, this could be you. Where exactly the line ought to be drawn between what the community should compensate and what an individual ought to live with will depend on the culture of the society and democratic process.
  9. Having dealt with the employed, we must turn to those not covered under this scheme: children and those without salaries. This is probably where the largest discussion and disagreements may be voiced. Regarding children, it is probably advisable to have them covered under a communal system; the same may be true for the unemployed.

Yes, this system relies on a working banking system and lack of hyperinflation. This point of this system is not to fix or explain the banking system but to provide healthcare.

  • As mentioned above, this is from In Pursuit of Happiness: American Conceptions of Property from the Seventeenth to the Twentieth Century, William B. Scott; Indiana University Press, 1977, page 6 "In America landownership had not always been consid­ered a right. At Jamestown the Virginia Company insisted that all land remain under company ownership as accorded by its royal charter. The Virginia Company required all of its employees to contribute "the fruits of their labor" to the common storehouse. The company distributed food and supplied to each according to his needs. After several years of near starvation the company abandoned its policy of corporate ownership and gave to each settler a three­ acre garden to support himself. This seemed to work. "For formerly when our people were fed out of the common store and labored jointly in the manuring of the ground and planting corn," noted a visitor, "glad was that man that could slip from his labor, nay, the most honest of them in a general business, would not take so much faith­ful and true pains, in a week, as now he will do in a day, neither cared they for the increase, presuming that how­soever their harvest prospered, the general store must maintain them, by which means we reaped not so much corn from the labors of 30 men as three men have done for themselves since the private allotment of land."

-- TheodorBruening - 27 Feb 2009

Thanks Theo, I appreciate your effort to contribute an idea for a solution. Too often in life we, and I include myself in this, are all-too-ready to criticize without offering any alternative vision.

I also wanted to speak in favor of community insurance schemes. We have several such schemes in each Australian state. The one that I think of most positively is for third party motor vehicle injury. When every vehicle is licensed (at a cost of around Aud$200 per year) the owner must pay approximately Aud$235 per year in a compulsory insurance premium. Payment of that premium removes tort liability from any licensed driver who is not under the influence of drugs or alcohol for any personal injury associated with the use of the vehicle. Injured persons instead claim against the statutory insurer. This system works remarkably well.

The Singaporean health system does have many advantages. For this reason it was used as a model in my 'Public Policies in Asia' class in my political science undergraduate arts degree. I suspect that the system that you describe is more workable in the United States than a Canadian, Australian or UK-type of government-provided medical care. I say this because it seems that there are many Americans who are deeply averse to the government provision of services such as healthcare.

-- PetefromOz - 03 Mar 2009

I spent almost half an hour deciding whether or not to post this here on the wiki, to send it as an email to Eben, or to ask about this during Eben's office hours (I keep looking for an excuse to finally go to office hours...). Ultimately, I decided to post it due to our consensus in OnWhyIAmReluctantToTalkInClass that it is better to discuss these questions openly than to selfishly save our participation for one-on-one interaction with the professor. Especially considering that I am not living up to my own goals to participate more despite my general insecurity surrounding the class, it seemed appropriate to post. I apologize in advance if this was not the proper medium.

My question is more meta, since I don't have a clear enough picture of either argument - or health care in general - to really weigh in on the substance. Question: How should we distinguish between a piece of writing that perhaps bites off more than it can chew and thus presents an incomplete argument from a piece of writing that attempts to build something - assuming, that is, that we value the latter?

Again, sorry if this is not a good forum. Reading this, it felt to me like daddy just hit mommy at the dinner table and even though I want to sit quietly and eat my peas, maybe it's better to articulate how Eben and Theo's exchange can help us learn to write more strongly in the future.

-- MolissaFarber - 03 Mar 2009

Theo's mistake was glaring; however, I don't understand why he deserves negative improvement scores. Though marred, he offered a possible solution which I'm sure took considerable time to write. Perhaps it would have been better to point out his errors and then ask him and the class at large whether this is an idea we can build on or an idea we should abandon.

-- JonathanGuerra - 04 Mar 2009

"Perhaps it would have been better to point out his errors and then ask him and the class at large whether this is an idea we can build on or an idea we should abandon."

Maybe I'm misreading you, but this seems to be more of a suggestion to Professor Moglen. As far as actions within our own control (disregarding, for the moment, the extent to which we can make things happen in class using our words) how we as students can improve our writing from this discussion? I'm sure the lesson here is not "write about small topics and avoid taking on something that you cannot completely defend," since that seems like a too-easy solution. Still, that's ultimately the lesson that keeps coming into my head when I think about this.

-- MolissaFarber - 05 Mar 2009

It is not small bore to talk about one's own life. The question at hand is not, "how can a group of mandarins create a better health care plan for the US," but "What are we going to do with our lives?" Regardless of the validity of Finland's or Singapore's health plan, no one is going to appoint us grand health poobah before we have done something else. What is that something else?

-- AndrewCase - 05 Mar 2009



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r14 - 07 Jan 2010 - 22:49:04 - IanSullivan
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