Victor Fuchs is a health care economist who among other distinctions wrote a famous book called Who Shall Live, which Prof. Fuchs discusses here. This week in JAMA (subscription only, but here's the opening paragraph. A big razzie to JAMA for making this closed access.) he discusses the prospects for health care reform. Since everything he says is the pretty much the same as what I have already said here in recent weeks, he must be right.
Fuchs says, first of all, that the Clinton effort failed because, while a majority supported reform of some kind, proponents never got behind a single plan but rather divided their energies, while opponents were united; and that the public never properly understood the issues. Both true. Alas, the situation is really no different today. Also true.
Given that we are in a period of economic decline, Fuchs argues that controlling costs has to be a salient goal of reform. Hey, I just said that a few days ago. Fuchs makes the following points about cost containment:
- The best shot for a quick knock down of costs is reducing administrative expenses. These are what insurance companies provide, and also come along with means tested programs. Universal coverage will pretty much pay for itself if it eliminates this waste. (However, as the wise professor is surely aware, the insurance companies aren't going to sit still for that. We will without a doubt see an encore by Harry and Louise or their modern descdendants.)
- Long term, we need an equivalent of the UK's NICE. How often have I said that? As I also noted a couple of days ago, conservatives -- pretending to stand for freedom but in fact standing for drug and medical device manufacturers who fatten their campaign coffers -- call efficient and effective medicine tyranny. This is utter nonsense, but will the people listen to Victor Fuchs, or the idiot talking heads on teevee?
- Ultimately, cost containment requires establishing global budgets (as the UK does for all health services and Canada does for hospitals, although Fuchs doesn't mention it). Yes, but just wait for the screaming and yelling about rationing. Again, will the people get this, or will the hair-hatted phonies on teevee scare them with images of sending Grandma off on an ice floe?
- More emphasis on preventive medicine may be good for our health, but it won't save money. Hey, didn't a blogger we all know just talk about that?
- Electronic Medical Records aren't cost effective for small physician practices, although they may have a payoff in large systems. See above bullet.
Fuchs also draws attention to the likelihood of adverse selection torpedoing a proposal to offer a Medicare buy-in to people age 55-64. Maybe a good point, on the other hand that would not be a problem if we had mandated coverage, because the Medicare buy-in would likely be the best deal for everyone. Of course, it would also set the insurance companies on the slippery slope to oblivion -- a good thing, but here come Harry and Louise.
So, the bottom line is, good public policy will be very tough politics. Let's not waste time in yacking about it, however. Organize!