Thursday, September 17, 2009

Obama's Marketplace Plan

Even the famous Ewe Reinhardt agrees with me. Obama's proposed marketplace, where private insurers would compete with a public plan to provide customer-friendly health insurance, is going to be costly. If you're going to give so much care to people, ban rescission, allow pre-existing conditions, and put a low cap on out-of-pocket expenses, then you're going to have an expensive insurance plan.

To keep costs practical, one thing you have to be aggressive about is the chronic diseases that make up the bulk of costs. Encourage and demand more personal responsibility, and be able to cut people off from expensive care caused by their irresponsibility. For example: diabetes is widespread and totally manageable. It is far cheaper to help diabetics follow their treatment regimen than to pay for all the ER visits resulting from improper self-management. Many hospitals offer services that help slower diabetics keep track of their medication, plan their diets, get regular check-ups, and so forth. Not everyone uses those services, though. Some people insist on doing whatever they feel like, and make six trips to the ER each year. That hurts the rest of us. When New York City began a program to call every diabetic regularly to remind them to get check-ups, there was a big outcry about violating their privacy. Well, they violate everyone else each time they avoidably use expensive health care resources. Should everyone pay for a smoker's expensive lung cancer treatment? For a head injury of a motorcyclist who refused to wear a helmet?

We are all part of a system. If a person is going to renounce their responsibility to the system, their responsibility to take care of themselves so costs to the rest of us are manageable, then they renounce their membership in the system. The system should help those who make good faith efforts to support the system in return, but should not be obligated to help those who selfishly and irresponsibly hurt the system. An arrangement like England's that refuses to pay more than a set amount to keep a person alive for a short time would also be appropriate. We have finite resources to be spread out among everyone in the system. If we focus on an individual at the expense of the group, we cause far more damage that we prevent. In health care matters, we need a teleological utilitarian ethic. Even some modern deontologists allow for a 'Principle of Permissible Harm'. Spend our finite resources first where they will cause the greatest increase in quality-adjusted life-years working. That will make the system much stronger and sustainable for the future. Our current system is not sustainable, and is killing more future life-years than it saves now.

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