Yeah.. it sounds like a good idea to me. I wish it could happen but like you, I know it won't because they really don't give a shit. None of them.

No, it probably won't happen, Ric. But I still think that speaking about it helps to focus on the nature of the problem—the lack of actual motivation by the people in power.

I think aligning incentives around a number of aspect of healthcare would be very effective. One of the big problems is that if I'm sick, my doctor has incentive to keep treating me (keep me sick enough to need treatment, but not sick enough that I die), and my insurance company has incentive to pay for nothing and minimize my treatment. I can imagine aligning hospital and doctor incentives around patient outcomes. When it comes to health insurance, however, *by definition* a for-profit insurance company is in business to pay out less than they collect in premiums, in aggregate. They always have incentive to find ways to avoid insuring people and minimize their payout when someone files a claim. That's why I favor having at least one government / not-for-profit insurance in the mix.

Hi, Stever! Good to see you here. You might also enjoy my related article Medical Care and the Free Market Catch-22, which addresses some of the realities of what you propose... not that this modest proposal of mine is especially in touch with reality. :)

“Sorry. I did the best I could. Maybe next year.”

This is exactly what I don't want to hear, but still wince at the thought of hearing it.
I fear little will change until we get Corporate America out of Washington. The next can of worms is to reign in the Wall Street crowd that is back to business as usual. I've been doing more to fight for health care reform than anything I've done in recent history (mostly a personal letter writing campaign), but I just don't get a fuzzy feeling about it at all.
It's been my observation that money trumps moral obligation at every turn in Congress. Seems that the Baucus Bill is an incredible joke that wants us to just write a blank check to Big Insurance. They can have my whole checking account. It's empty.
To me, it looks the gang of six was on a two month stall tactic designed by the insurance companies so that the cockoo "grass roots" movement could get a footing and disrupt the process. We all know who owns Baucus and it ain't the American people.

Michael, right. That's why I think if we could cripple Congress's health care, they'd come to see lobbyist influence as less intellectually tolerable than they do now. You could probably never get money out of the equation, but you have more hope of getting things arranged so that Congress cares about money more than they do now, so they look at lobbyists less as fun things and more as concrete obstacles to something they (the Congressfolk) want.

Hi, Kent - excellent idea, of course. I refuse to be discouraged despite the evidence. My suffragist grandmother fought a lot harder than this, and woeful energy doesn't help. I say, let the wingnuts speak with whatever words they want - that way we can see 'em coming! I've given myself a stern talk about participating in this effort since my friend says - it' s as though we worked hard to ensure that the best Christian would be thrown to the lions, and now we're just watching. I'm ashamed that I've just been watching until now, but no more. Glad to see you're still in the thick of it all, Kent - the sane voices need to rise in chorus!!

Hi, Travellini. Great to see you around, too... it's been a while. Regarding people just standing on the sidelines on this, I think another reason for that is that some people don't realize the line between “comfortable” and “uncomfortable” can shift, and people who thought they were ok can suddenly find themselves not being. One's place in the world can be so fragile sometimes, especially in the present economy.

Exactly. They have no personal stake in this. They can mouth the right words and pretend to put up a fight, but we all know how it's going to come out.

I'm all for passing a law that give both Congress and health care executives the same coverage as I have. None. Either cover all of us, or cover none of us. Why should one have health care just because they have money and I don't? It's just another discrimination against another group in a country that prides itself on not discriminating against anyone.

Right on, my friend. I'm sick and tired of this pussy-footing around the issue. And the issue is that Americans are under-covered to the point of not obtaining the health care they need until it's too late. I'm done with the fear-mongering and misconception that to take care of the least of us is socialism. Would that our society was more social and valued each of our members instead of putting a shiny coating on a corrupt system and calling it "free enterprise."

Michael, good points. Gives me an idea for another post sometime.

Coyote, I'm not anti-capitalism, but I do think sometimes capitalism is the wrong tool for the job, and this is such a place. I think the reason some people like it isn't that people think it's the right tool but rather that they think it's nicer to say “I support free markets” or “I support capitalism” than to say “I just care about me. Others can fend for themselves and if they don't they deserve to die.”

rated a million times (if I could).

myopia, I appreciate the thought. :)

Health care isn't free. Somebody has to pay for it. Yet, you think it is a moral issue, that if the nation cannot afford for everyone to have access to some procedure, that even those who are willing to pay for it out of their own pockets, should be prevented from using the service?

Is this different from food? Why not propose that no person is allowed to buy food, of a higher quality than the food provided for free to the worst-off citizen?

You say that the comfortable have plenty of voice. But they're also the ones paying for it, for everybody. It makes sense to me that they have a bit more say in the outcome, than those who simply accept the charity, but don't contribute to paying for even their own care (much less that of everybody else).

(P.S. @Stever: Good to see you! Been a few years since Gompers Secondary School, no?)

Don, I made an edit subsequent to initial publication to clarify that I don't know if you saw (if you read this on RSS, it's possible your reader didn't grab the update): I meant the non-purchase of additional insurance, etc. to apply only to our leaders, not to the citizenry at large. Your responses looks like you might have inferred the reading that I worried people might, that I was intending this for everyone.

(Of course, you and I have had a great many hypothetical arguments not visible here, and I may in one of those have even suggested that the rule could apply to everyone. Such is the nature of hypotheticals... one wants to consider all options. But that concept is not in play here, so don't get it confused.)

Read the yellow box in the web page to make sure you're rsponding to the most up-to-date wording. If you are reading me correctly, I'm not sure why you're so worried about this. Taking office is voluntary and presumably there would be people willing to serve under those restrictions. The regular populace, under this proposal at least, can do as they like.

I intended this proposal to be the most Libertarian of cures for health care, at least to the first order. That is, it doesn't cost anything to make the amendment above, and having made it, it doesn't bind any leader to a solution of any particular kind. The singular effect of the proposal is to raise the stakes for our leaders so that finding a workable solution—any workable solution—really matters to them. Quite honestly, I think it does not really matter to them right now. It's just an intellectual game to be played by people who are “above all this” but who are trying to do something for the “little people.” But we are a government of, by, and for the people, and on this matter I want leaders who are in the game, not above it. I think a lot of people do. A lot of people might not want this particular proposal, but I think this particular proposal crystalizes the essence of what people think is wrong with the debate right now.

That is, the discussion point was this: How can people lead on this matter when they consider the matter already a solved problem?

If these were the mere ravings of a single individual, you'd have nothing to fear from this discussion. No one would be at risk of putting it into action. It's just a random person's free speech.

But if there were enough people to pass this, for example, in a national referendum (if such were possible—I've heard of them by state but I think we have no such national mechanism) over the objection of our elected leaders, then almost by definition it would imply that this was a serious matter that a great many people saw as unaddressed.

We the populace can elect only from the people who run for offce, so unless a proper control is created on the “free market” of candidates, a tax on holdnig office if you will, then the wrong candidates will succeed in the market. Or, at least, that's a way to look at it. It's not quite what I was thinking as I was writing this, but as the expression goes, it's “good enough for government work.”

The food analogy is interesting, by the way, but we in fact don't have a problem where people go bankrupt trying to get food, so this isn't needed. We do, in fact, pretty much have food for all.

Housing would have been a trickier choice. Requiring our leaders to be homeless until everyone is housed might be interesting, but not very practical. Here I will plead that not every politically fair solution is a practical one. I do think the health care under discussion here, though, is practical, in the sense of implementable without risk to the proper functioning of government.

Right: food, housing. After I posted, I was thinking of expanding your idea to the limit. Namely, you can work as hard as you want, and make as much money as you want. But the money isn't good for anything. You're never allowed to buy anything. Instead, all items that you might want to purchase (food, medical care, housing, luxuries) are only available from government stores, and only for free. You aren't allowed to have an iPod or cell phone, unless every citizen can be provided with one for free.

I realize that your actual proposal was only for elected officials, not for everyone. And that you're only suggesting health care (insurance?), not all items. But I still think it's instructive to consider the extreme case, and to compare your intuitions there, with those in the case you've actually suggested.

Don, I don't see the point of such an absurdity. The goal is not (as commonly parodied by the Right) to randomly perturb people's lives. The specific proposal here (not easily implementable even, so mostly a thought exercise anyway) is highly targeted to surgically addressing a specific problem presently vexing a lot of people in the US and at the forefront of all political discussion. Let's suppose you had some medical problem and I proposed cutting into your body to address it. Would the right discussion be to say that we should engage a discussion of cutting arbitrarily into the body? What would that serve? The question is whether this proposal would work. You might say “should be legislation, not Constitutional” and I'd disagree but it would be a valid criticism. You might say that because you thought it was overkill for the provision to last past its time of usefulness. My concern is not that it endure forever, but that it not be subject to ordinary legislation for at least the near term, or the first order of business would be Congress voting it out. You might say you thought $5,000 was the wrong amount and we could discuss another amount, but I picked that number as a number that would not bankrupt most people, in order to indicate my understanding that people might need to pay out-of-pocket for at least some issues (something you commonly suggest). You might argue that other policies are useful vehicles, but the problem is that becomes a backdoor to people going bankrupt if such policies can be afforded by some and not others; I don't oppose them in principle but I don't know a way to codify which are ok and which are not without getting back into the mire where legislators can buy their way out of caring about others, and since I figured this would not be a show-stopper for at least some competent people taking office, I figured it was acceptable to lose some other would-be office-holders who thought this was a show-stopper, especially since those are likely to be the people who think they're protected and yet are indifferent about others being protected. People who really wanted to stay in office could decline their care for a while, and would be well-motivated to strike down any notion of pre-existing condition restrictions—that was a calculated part of my offering this. And so on. That's the kind of targeted discussion I'd like to have. But instead, in this case, I think you're ranging needlessly far afield and blurring matters. I'm not proposing this should be the health care all have. I'm saying that the claim implicit in Congress not taking action is "what people have is livable". This is not the high end of what people have, but it is something that is purported to be livable. My discussion point here is: What if we tested that claim?

So, fine. If you just want to stick to your actual proposal, then it's obvious that you think representatives want more health coverage for themselves, than they intend to vote for in order to cover all citizens. You think, almost certainly correctly, that if you forced the representatives to themselves have only as good health coverage as the worst of their fellow citizens, then they would choose to vote for more generous coverage than otherwise, basically for selfish reasons. They certainly want more generous coverage for themselves, and they'll accept spendng for the whole country to get more generous coverage, in order for them to get a better deal as well.

So, the intent is clear, and the effect is clear. The only problem: I see no reason why this outcome should be expected to be a better choice for society as a whole. You're almost certainly right that it would lead to more generous coverage for the average citizen, but the line won't be being drawn for cost/benefit reasons; it'll be drawn for selfish reasons (since your amendment merges the selfish with the national).

I suspect the result would be a health care plan that is too expensive for the nation's good.

But Don, won't it be a way to force discussion of how much we can and should afford? I feel right now the problem is that people are evading that. Even you are. You make allusions to us not being able to pay for things that are “more generous” but you don't say what is and is not an acceptable line.

Also, if you take as a given that Obama won't sign a bill that doesn't pay for itself, I think it's not true that they'll just vote themselves largesse. Of course, you may question whether this is really going to happen, too, but then let's have an open debate on precisely what we can afford and precisely what counts as a payment.

The problem is that everyone is mixing a lot of undefined terms and a lot of stuff is falling through the cracks. And by that I don't just mean people and their health, which is definitely falling through the cracks, but procedure, terminology, quality assurance. The tools that any decent engineer would use in the crafting of a properly functioning machine.

It's fair to question all of these things, but do it cards on the table exposing what you want to do and that you have a specific concrete plan that is better. At the end of the day, the only plan we'll pass is concrete. You have a lot of interesting criticisms of what I offer, and indeed this particular plan is unworkable not because I think it wouldn't work but because implementing it would be hard (you'd have to teleport the words onto the Constitution since the Congress isn't going to put them there and the People have no mechanism for getting them there otherwise). But nonetheless, I am exposing myself to criticism and ridicule by trying to make things specifically concrete in order to elicit conversation on points that are not being discussed, and I'd like it if my critics exposed themselves to at least the equivalent risk. :) How much can we afford? I am fighting phantoms here—I can't tell you how we should address an issue if I don't know what you're fearing. Fearing mere overspending is a little vague. That doesn't make it wrong. Just not constructive to discuss.

Kent says: "let's have an open debate on precisely what we can afford and precisely what counts as a payment."

Yes! Exactly. But I don't think your post was trying to do that. Your post was suggesting and end-around process, that would change the incentives for how the decision gets made. But it doesn't directly discuss what decision would be a good choice for the nation.

"I am exposing myself to criticism and ridicule"

I agree completely. You deserve enormous credit for submitting regular blog posts on these difficult topics. I'm well aware that I don't have your courage to regularly publish opinions. That I just sit back and criticize. I completely accept your point here. In fact, I agree so much that I used the famous Teddy Roosevelt quote in my high school valedictorian speech (long ago...).

"what you want to do and that you have a specific concrete plan that is better"

I think I mentioned the outlines in a comment on some other post of yours. (1) break the connection between employment and insurance (by eliminating tax breaks); (2) correct medical rescission and adverse selection and preexisting conditions by having government-provided single-payer catastrophic coverage; (3) correct the growth in health care costs by: (3a) compensating doctors based on hours or patient outcomes, rather than procedures, and (3b) having most people pay cash (or very high deductibles) for ordinary typical expected everyday medical procedures (along with a social safety net for the very poorest citizens).

That's what I would do. I think it all comes down to the incentives in the system. I think most people (doctors, patients, even insurance companies) want to do the right thing, but the overall structure of the system has perverse incentives that result in a bad outcome overall.

What does people paying cash accomplish? People are all of different means. In the case of a car, people of greater means buy better cars and people of lesser means buy junkers or walk. Is that your model for how health care should work?

Cash, and capitalism in general, is a method for allocating scarce resources. And health care is a scarce resource: not everyone can get all the care they can possibly dream of wanting, if it were all free.

So you must have some way of limiting the care you provide. Market mechanisms, where prices float until supply and demand come into balance, is one method. There are others: rationing, long lines, etc. But what you don't get is the fantasy where everybody has all the care they could possibly want. That is not a realistic world. If you don't allow the market price to settle the tension between supply and demand, that doesn't make the pressure disappear. It will come out in some other (generally worse) way. Black market sales, corruption, under the table kickbacks, rationing, long lines, etc.

The point is that you need the patients to say: yes this procedure might help me a tiny little bit, but it is very expensive, and so I'll choose to keep the money and not spend it on the procedure. Patients themselves need to participate in cost/benefit analysis.

Otherwise, patients have no incentive for forgoing any care, no matter how expensive, no matter how low the utility. Once the government is the one paying for things, it becomes a political question about what is covered, not a medical question. And any time anyone suggests cutting back expenditures, the argument devolves into class warfare between the haves and have nots.

Having the patient (partially) pay for each choice, is a way of bringing medical cost/benefit analysis back into the overall health care question. And it opens up the topic of health to a much greater array of options than just insurance, e.g. lifestyle changes (lose weight, exercise, stop smoking/drinking).

Those are never part of the debate, when all you're talking about is spending other people's money.

And, as a concrete example to think of, consider that the bulk of US health care costs come at the end of life. Let's say that there is a procedure which can grant an extra six months of life at age 85, but costs $1 million. Is that procedure a good use of the nation's wealth? You'll get one answer if you say to the patient: "the procedure is free to you: do you want it, or not?" But you'll get a very different answer if you just give the very same patient the $1M, and ask them whether they want to spend it on the procedure. Many would prefer to pass it on to their kids or grandkids in their estate, rather than "waste" it on a few extra low-quality months at the end of a happy and fulfilling life. They might even rather pass on $500K or $100K, than get the $1M procedure.

How do you get the correct allocation of the nation's limited wealth, in such situations? Keep in mind that the 85-year-old patient themselves would not choose to spend the wealth that way, but they are only choosing it because you only offer them the single choice of either getting the procedure, or not. They get no benefit in turning down the procedure. So of course they'll ask for any procedure, no matter how marginal, no matter how expensive.

This is why I'm concerned about the incentives in the overall system. Bad incentives make even people who want to do the "right thing", instead make choices that are bad for all of us.

But Don, the whole point is that what I thought we agreed upon is that there is some level of care that ought not be scarce and some level beyond which it is too expensive. If the low-end of health care is not scarce, that is, band-aids and cough medicine, then the question is why people should pay out of pocket for that. I thought it was the high end of health care that we're worried we can't afford for everyone—that is, iron lungs and heart transplants and MRI's. It seems to me that the amount of good caused by having people pay for a band-aid is marginal, while the nuisance value is high and there is a serious chance that those of little means will find, on a day to day basis, that they cannot afford even that which you do not (I think) intend to begrudge them. Meanwhile, the truly scarce resources, the heavy machinery of medicine, certainly we don't want to use money as the arbitrator, merely saving those who are of means, or we have what we have now. So I still don't get it.

Also, I don't agree with some assumptions you've built into your commentary. You hypothesize a patient being given the ultimate say on whether they get treatment, but I don't know that this has to be organized that way. Maybe doctors would get the final say. Maybe doctors would have a budget. Maybe doctors would get more money if they optimize patient wellness. There is, in the end, no substitute for society deciding it will give less importance to some issues than others. No one wants to say it, but whether it's said or not, it will be true in any of these systems. The only choice will be where that information is hidden. Your shying away from public options as if they will have this problem worse than others therefore seems to miss that somehow. Capitalism and the free market are not magic bullets, they're just tools. Capitalism guarantees to bound the amount of money spent but not to do so fairly. You fear that this will overspend and that the overspending will be damaging; that is not the outcome in other socialized systems anywhere in the world, so the burden is on you to show why the US will abuse things worse than not only the other most successful societies around us but also the most corrupt and poor.

Either way, I am taking notes for a next post to refocus the discussion on some of this, which I don't want to get lost on the tail end of a discussion that many might not get to. Feel free to continue commenting here ... or to take a breather and wait for me to follow up with a full new article.

Kent, re: cost. I think your examples miss the great middle ground. You're probably right, that band-aids are too cheap to matter much. Meanwhile, heart transplants are rare enough that, although they are expensive, they aren't a big part of overall cost either.

MRIs are a much better example. An expensive technology, that has a small chance of helping a large variety of cases. You're playing basketball, and twist your ankle, so you go to your doctor and ask for an MRI. Is that procedure worth spending the money for, or not? Who decides? On what basis? You must make this tradeoff somehow. My suggestion is, there is benefit in the patient himself making some financial calculations as well.

And I note, that I talked mostly about reducing demand, but there's a supply side too. If a lot of patients choose to spend their money on a procedure that would not otherwise make the cut (cosmetic surgery?), then market forces allow more providers to appear, over time. It's hard to duplicate that benefit of the market (resource allocation) when using more centralized decisionmaking.

You also say that I'm "shying away from public options" ... am I? I recommended single-payer government insurance for catastrophic care. Isn't that even better than the "public option" currently being debated in Congress?

I vote for less pontificating immediately and more immediate legislative reform - especially the exact reform I am hoping for: coverage for all at an affordable rate, removal of all exclusions for pre-existing conditions, a public option to make all the other pieces work.

Perhaps health care isn't a right. Perhaps it is a privilege, but we need to allow this privilege to be granted to all and we need it now.

I would propose deleting the 2nd Amendment, and replacing it with your amendment.

Don Geddis pointed me at this interesting piece, which suggests someone is actually attempting something vaguely like this... perhaps not the least good health care, but the health care of last resort to be sure.