• Is American health care locked in?

    Tyler Cowen got my brain flowing with this opening paragraph to a post he titled “Does the UK have the best health care institutions in the world?

    Not in the present day time slice sense (“did he write “best,” didn’t he mean “worst”?”), but think of it over time.  There is a big lock-in effect.  The United States, for instance, cannot easily switch into another way of organizing its health care system.  Obamacare is built upon current institutions and, for better or worse, does more to lock them in than to modify them.

    “Locked in” is not well defined so one can argue, and I will. The ACA is misunderstood if one thinks it preserves current structures of our health system. Of course it does that initially. It has to. The law couldn’t exist otherwise.

    But the law has a lot in it that can cause our system to evolve toward something quite a bit different. Accountable care organizations (ACOs) can reshape how health care is paid for and delivered. The Cadillac tax can, gradually, erode incentives for employer coverage. The exchanges will finally create insurance markets for a population of individuals who have never been able to participate in one. If those things happen they set the stage for future changes. Is an all-payer system possible, likely, or even necessary someday?

    These are big changes. One can argue about whether or not they’ll happen or be allowed to work. Will Congress undo aspects of the law? Will interest groups have their way with regulations? Will states resist? If so, those would not be evidence that the law locks in current institutions but that our system of governance is resistant to change. That is, it’s more likely that the lock in is, itself, locked in. The law attempts to, gradually, release us from its grip.

    • It seems that we could do so much more in one fell swoop by mandating the for profit health care corporations rewrite their articles of incorporation to become not-for-profit. It makes no sense to have a profit motive between the patient and the health care provider. The insurance companies should be in the business of making the work happen and the health care be provided as economically as possible. As soon as there is a profit motive, the motive is to just keep spending down which inhibits medical services being provided due to cost containment policies.

    • The only important feature of ACA is near universal coverage, and that is not yet locked in.

      If you look at all the health care systems that match or exceed the US health care, numbering in the dozens, they are extremely diverse, but they all have one thing in common, near universal coverage.

      The code word for excluding from health care those who are expensive to cover is “market based”.

      Republicans are likely going to strive to allow States to implement “market based” health systems,and at least one Democratic Senator is jointly sponsoring a draft change that will have some such working. The liberal reason for supporting this is to gain amendments for their States, and for conservatives is to ration care in their States by denying access to classes of people like the working poor as a means of controlling government spending. And shifting the costs, perhaps higher costs, elsewhere.

      In the abstract, as a liberal, I think having 30 conservative States without a universal coverage system which tries to control costs by denying health care to some, but ending up with more expensive care being billed to someone, will address the problem comparing the US to the three dozen OECD nations plus a dozen others. When the US without universal coverage is compared to those with universal coverage, it is Canada has healthier people or fewer immigrants (both false), or Germany has citizens who follow orders, or Israel is healthier because of Jewish dietary law, yada yada. Well, let’s divide the US into two groups to see which produces the most efficient health system.

      But again, the only important thing to lock in is universal coverage, even if universal coverage is locked in only for Mass, California, NY, Maryland, Conn, etc. The record in Mass is like that in Switzerland and Canada, et al. Only a minority is willing to give up universal coverage. The way universal coverage is provide is irrelevant to improving efficiency. Efficiency is the quality of care per unit cost for society as a whole. With universal coverage, everyone favors public steps to reduce costs from banning lead, to immunizations, to clean water, to child wellness, to better nutrition, to better end of life management, more hospice care. Even tort reform is possible because a medical screw up means 1) poor quality care and 2) everyone pays for the health care costs of the screw up – no one needs to sue to pay for the care insurance won’t pay for.

      I say again, the only important thing to lock in is universal coverage, even if it is for only a couple dozen big “liberal” States.