Sunday, May 8, 2016

Healthcare in the USA (II)

Seven years ago I wrote a blog entry about Obamacare. It basically expressed a feeling - that the system in Europe, problematic as it is, at least gives one the feeling of security when it comes to healthcare. If you get ill, you go to the Doctor’s, period.  There is never any question of not being treated.

Now Obamacare has been tested I think it was an improvement on the previous situation,  with about 10 million more insures, I believe, but we could, eventually, aim to replace it. Thinking about things, in an idealistic world, the ‘individual mandate’ would indeed not exist.  That is, one should really be able to opt out of buying health insurance if one wishes. People should have the right to take a big, maybe stupid, risk, keep their insurance premium money, and not pay health insurance, even if they can afford it; just as they have the right to not insure against damage of their own car.

Now, the problem is, that if that right - to not buy insurance - is going to be given, for it to work you really have to not treat someone who is sick or injured, could afford insurance but decided not to pay for it, and doesn't have the money to pay for their treatment. You really have to leave them to their own devices, and even, if necessary, to die. And that's, of course, not what happens, even in the bad old USA.  Emergency rooms always treat patients; it’s basic compassion. And thus, a large part of the motivation for getting insurance in the first place disappears, and on top of this we get the consequences of enormous unpaid costs, medical bankruptcy nonsense  etc.

So the USA really needs to decide. Either you make insurance compulsory, as does the rest of the first world, or you don't treat people who don't get it.  Having it both ways doesn't work. Either we have the individual mandate or dispassionately insist on no treatment for the uninsured.   The US individual mandate, as in Europe, works better than the pre-Obamacare zoo. However, although I know of no precedent, the insurance-or-no-treatment model could conceivably work better, while giving people more freedom of choice. What you’d find, maybe, is that, the extra motivation might even lead to an even larger proportion of people getting insurance, and voluntarily, than they do under Obamacare. But it would be scary as hell. So guys, keep the individual mandate for now, but work to building a system where it is no longer necessary i.e., where health costs are so low  that everyone voluntarily buys insurance anyway. This requires bringing bring costs down, through increasing flexibility, introducing cross-state and international competition, dissociating insurance from employment, tort reform, preventive care incentives, analytics, targeted therapies, innovation etc. But that discussion, as they say, is another kettle of fish.

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