Comment of the Week: Another View on Healthcare

Regular commenter weboy takes on the public option in the healthcare debate, and makes some good points:

Just to be (slightly) contrary, I do know people who are quite satisfied with their healthcare - young office workers, mainly, who are largely healthy and who are comfortably insured by their employers. They are the people insurers want - people who go to the doctor occasionally, whose biggest concern is an allergy pill or birth control, whose basic relationship with the system is a copay at the doctor and another at the drugstore. Remember, some 85% of the population is insured, and many may favor a public plan... even though they'll never need it. The "it's nice... for someone else" may mean that the vague support for a "public plan" lowers when you get into specifics.

I like Gawande well enough, and he's got some good observations... but he's a doctor, with a doctor-centered notion of how we fix healthcare... and the real fixes we need - changes in the way doctors practice, changes in the way people access care, and even more fundamental changes to patient expectations - don't favor the status quo. And they're not easy. We shouldn't oversell what's under discussion just now - at best, we're creating a new system where some percentage (though not all) of the uninsured will be able to get insurance... whether that means they get better, affordable care remains to be seen... but the possibility that we'll simply expand the insured without bringing down costs is also very real - that's been the basic unfolding of the situation in Massachusetts.

A "public plan" is not necessarily the "hill to die on" about what's under discussion; it's a key piece, yes, but it will be less than meaningful if, for instance, the subsidies for the working poor aren't in place to make it possible for people just over the poverty line to pay for it. Similarly, no one has examined the real elephant in the room - Medicaid, which, has enormous funding problems, and 50 different operations across the states, which are not delivering equivalent operations, or care, to the most needy.

A public plan that "looks like Medicare" is as much a kind of hazy propaganda as the kind of opposition the right is giving - it's taking some nice hot button words and stringing them together, without examining the reality in detail. Medicare has problems - reimbursement rates for one thing, are an enormous issue that's being deliberately ignored, and Medicare has not, really, shown itself able to incentivize "best practices" or really question poor care (remember those "low administrative costs"? That's because Medicare doesn't have a large operation to question the billing of procedures). A public plan, really, is a vehicle to getting closer to a 100% insured population. Without it, we have no realistic hope of achieving that goal... but the rest of what it can or might do... is really very debatable.