Monday, July 12, 2004

What should government-based single-payer healthcare be? Should it be focused on an effort to provide basic coverage for the uninsured, or should it focus on placing everyone in the same boat in the pursuit of "fairness"? Or put more simply, do we want a "one-tier" or a "two-tiered" system. Ronald Bailey at Reason Online asks Why shouldn't more money buy you better health care? It boils down to the "healthcare is different" argument:
In free markets most goods and services are differentiated by quality and customers get what they pay for. The more one pays, the better one expects to be treated. But many bioethicists think that medicine is different-that "health care is a right." But this mentality leads them to the position that we only have a right to the health care the state chooses to give us-and that we ought to be, or at least will be, denied anything better.

Mr Bailey then goes on to give Dr. Caplan credit for agreeing that "access to a minimal package of health care" is society's obligation. A position later claified in the same Fresh Air interview cited by Mr. Bailey:
GROSS: Chris Butler of Independence Blue Cross of southeastern Pennsylvania was saying if you look at some of the national health plans in other countries, you'll see that shadow systems emerge; that people end up wanting to get coverage beyond the basics that you're give in that plan. So you have all these, like, other basically insurance companies that develop, and people with money buy into those companies, so that they could get quicker service or better service than the basic government plan will give you. Sherry Glied, would you agree with that perception?

Ms. GLIED: Well, I think many systems operate very much and very intentionally on that premise. England does, France does. Germany has a private health insurance system. So the question: Is that a failing of those systems, or is it a success of those systems? I think what you might say is, look, we want to have some basic level of care that everyone's entitled to, and those people who want to buy out of that, you know, go ahead and let them do that. We don't even have that basic level of health care for everyone. So I don't think that it's legitimate to complain that other people have two-tier systems when we don't even have a one-tier system for people who are really in need.

GROSS: Art Caplan.

Mr. CAPLAN: Yeah, I think Sherry's on the right track here. It seems to me we have the same buyout, if you will. We have people these days selling boutique medicine. So if you pay an extra fee to your doctor, then your doctor will call you back or make themselves available to you. If you pay that extra amount, you can get little e-mail messages and communications. This whole area of boutique medicine is rapidly growing within our private sector on top of, if you will, the standard benefits. So we've got some of that.

All that said, the greatest enemy I think of getting universal health care insurance is arguments about the ceilings of health care. A lot of people say, 'But if the British have buyouts and the French have buyouts, that isn't fair. Everybody should be in the same boat.' I think the problem is to agree on what's the minimum. Let's agree on what's in coach. Let's agree on what we're going to have in the back of the plane. Then we can argue about first class.

But should you get pretzels and a Coca-Cola in coach or not? Let us examine the changes in TennCare:
In his column Caplan decries recent reform proposals for Tennessee's state Medicaid program. The reforms, known as TennCare, were launched with much ballyhoo 10 years ago. They involve the state government taking its allocation of federal dollars for Medicaid and using it to cover not only those residents who met Medicaid poverty guidelines, but also other poor residents lacking health insurance. As with most any open-ended government entitlement, TennCare is heading for bankruptcy. So the Tennessee legislature passed a reform earlier this year under which medical necessity would be defined as the least costly "adequate care," instead of the traditional standard of "most effective" care.

Although a bit vague, the concept of "adequate care" encompasses such things as requiring doctors to prescribe generic drugs whenever possible; limiting the number of prescriptions to no more than six per month without special permission; requiring co-payments from patients in order to cut down on frivolous visits; and an annual limit on the number of doctor visits. Instead of prescription medicines, TennCare patients will have to buy over-the-counter medications like Prilosec for controlling stomach acid and Allegra for allergies.

In Dr. Caplan's own words:
It is making over its state Medicaid program known as TennCare. If this program gets implemented, many of the poor, elderly, children and disabled in Tennessee who rely on Medicaid will be told simply to get over it....Gov. Phil Bredesen, a former HMO entrepreneur, sees the challenge of health care for the poor in Tennessee in very stark terms. In a speech last February, the governor described the state Medicaid program as nothing more than an open checkbook that is continuously being raided by "doctors and hospitals and advocates" who "decide what is needed."

Well, who should be deciding what is needed for medical treatment if not doctors and hospitals and advocates? Not under TennCare, if the governor gets his way. Bureaucrats, not doctors, will pick how the poor get treated.

Historically, decisions about what drugs or treatments a patient received were chosen by a standard of care known as "medical necessity." Doctors determined what was medically necessary based on local standards of medical practice, and if they did not practice according to this standard they could be found guilty of malpractice. TennCare does away with the established standard and replaces it with a new one - "adequate care." If a bureaucrat in the Tennessee department of health thinks a low-cost drug or treatment, or even no treatment at all, is "adequate," then that is what TennCare will provide.

Under the new definition, preventive care and many pain medications will no longer be funded. And only generic drugs will be available to treat poor kids with life-threatening conditions such as cystic fibrosis, cancer or asthma, and no prescription antihistamines or gastric-acid reducers for anyone of any age. If you want to protest these inadequacies, you might be able to find a doctor willing to plead your case to a special state-established foundation.

Aren't generic drugs just as good? Isn't Big Pharma being greedy and evil for not making more of it's drugs available in generic form? Isn't the main advantage of current prescription antihistamines, their non-sedating nature, more of conveniencece than of effectiveness? You can buy generic Loratadine from CVS for less than fifty cents a pill. 60 Famotidine will cost you $11.99. Which is better, cutbacks like these or reducing the number of people eligible for the program?
BTW, Dr. Caplan is no fan of "concierge medicine" either.
There are several reasons that some oppose a "two-tier" system:

There are concerns that the "secondary market" insurance wil be primarily utilized by younger and healthier individuals. As they become older and sicker they would drop their secondary insurance and fall back into the "single payer" pool. This would increase the burden on the system. The problem I have with that argument is that they would be paying for the single payer system throughout. A good analogy is when parents send their children to private or parochial schools. They pay tuition as well as the school taxes for the public schools in their community.

Support for the system overall will diminish if were are not all in the same boat. Under this theory those that can afford secondary insurance will not feel the need to support the program overall. The same argument is often used in the debate over means-testing for Medicare. This could apply to providers as well. The fear is that the single payer group would be treated as second class citizens and receive second class care.

It's not fair that "the rich" can buy themselves additional coverage that helps them avoid the messy details of a single-payer system. Well the obvious retort is that life isn't fair, but that reeks of sophistry. But then again the "not fair" argument itself is sophomoric and naive. It ignores the way the real world works. Suppose a "one size for all" plan is put into place. How long before offshore insurance companies open up with services provided offshore, much like the "riverboat casinos"? Not very long. What about taxing the premiums or benefits or procedures? While this could satisfy the vindictiveness of some, it would be counter to the fairness argument since it could price many out of the "secondary market"
But he still hasn't come up with a convincing answer to the question: What's ethically wrong with people with means doing "whatever they want" with regard to their health care? They can already do whatever they want with their educations, jobs, housing, food, and so forth. So eager is Caplan to play class warfare by contrasting concierge care with adequate care that he actually misses the main lesson to be learned from TennCare-that any government-run national single payer system would inevitably run up against fiscal limits and impose rationing on everybody. Bureaucrats would then be making health care decisions for us all. But then at least we could share the "solidarity" of all having the same equally inadequate health care.

The question is: are single-payer advocates willing to accept a two or more tier system to insure universal coverage? Because in the United States, that is what it is going to take.
Other views from Galen and Mr. McBride.
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