More on healthcare — “Medicaid for all”?

Last updated on: July 24, 2013 at 2:41 pm by Jane the Actuary

More on healthcare — “Medicaid for all”? 2013-07-24T14:41:00-06:00 Jane the Actuary

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OK, so I’ve gotten some pushback from my modest number of readers (small gripe about the BlogSpot platform: I can’t get it to register the instruction to not track my own pageviews, so I don’t know how many real people actually read my writing — but I suppose any number, however small, is enough to keep me honest and focused on writing for an audience) about whether the state has any responsibility with respect to its citizens basic needs. But I’m going to bracket that for the moment; maybe I’ll return to that topic and work through that later.

For the time being, let’s take it as a given that the state should be concerned with its citizens access to and ability to purchase healthcare services.

What’s the best way to do it?

The easiest approach, and the one chosen by most countries, is some variant of “Medicaid for all” on a single-payer or provider reimbursement model. I use “Medicaid for all” deliberately rather than the usual formulation of “Medicare for all” since in practice, there end up being two types of providers: those who accept the fixed reimbursement levels as payment in full and those who either require supplemental payments or who operate outside the national healthcare system entirely, with patients paying privately or via private insurance. As far as hospitals go, there are ward (or 3- or 4-bed rooms) for national health insurance participants, and private rooms for privately-insured payments. And there are private hospitals/clinics which only accept private-pay/privately-insured patients. The waiting lists for procedures, the horror stories of poor treatment, and the “Liverpool Pathway” in which the terminally ill (or maybe those who are just elderly) are put on a fast-track to death, are all a part of the national healthcare system — in such countries, the private system (which can be entirely separate, where you pay full costs, or just require upgrades at additional cost) gets you to a much more pleasant and civilized healthcare system.

This system has advantages — everyone has at least a minimum level of healthcare in a cost-controlled fashion, with the limitations and undesirability of the national healthcare system motivating people to move into the private system. It is, I suppose, like the difference between Cook County (now Stroger) Hospital and the amenity-laden all-private-room new hospitals through the area. It would be similar to a “beans and rice dispensary” approach to providing food to the poor: get all the beans and rice you want free, and pay for your New York strip steak.

With respect to doctors, the system wouldn’t be that difficult to implement: set a reimbursement level that keeps enough providers in the Medicaid-for-all system to handle the inflow of patients, but low enough to produce wait times and other access limitations as well as ensuring that the providers’ offices are just a little dingy and the receptionists a bit grumpy, so that anyone that can afford the private system chooses to pay for it. For hospitals, the answer isn’t as clear — far too many hospitals have been on a building spree, and I’m not really sure what would happen if “MfA” were to be implemented, with smaller reimbursement rates and an expectation that they would have to pare down the amenities rather than expect private-pay patients to cover the gap, in the way that now happens with Medicare. Of course, part of the “MfA” hospital cost control would be restrictions on availability of procedures in the first place. Oh, and medications? Generic only.

Regardless of whether this is a good idea or not, ould this work? I don’t know. Would Americans accept it? — that is, would Americans accept a system of free deliberately-minimal healthcare provision for all? I don’t know that either. Readers, what do you think?

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