We cannot discuss healthcare without addressing the larger issue of social justice. We cannot separate social justice from the broader context of economics. In other words, capitalism vs. socialism. Providing for the common good, must entail redistributing wealth. Redistributing wealth leads to all sorts of distortions in the efficient allocation of capital. Government is the mechanism- however imperfect- we employ to balance these two competing values.
We asked people who live in countries with universal healthcare, as well as those of us who struggle with access to medicine here in the U.S., to comment on their personal experiences within each system. What we found, is that there isn't a great deal of difference either way. Access is limited and/or rationed based largely on the relative age of the population- not on a philosophy of justice. The younger the population, which is to say, more paying into the system than benefitting from the system, the more access to, and quality of, healthcare in general.
The joke about the restaurant serving lousy food and not enough of it, seems apt in this case. We know that any product that is price-fixed, inevitably leads to a shortage of that product, and what is available, is of shoddy quality. On the other hand, capitalist medicine would likely result in the wealthy eating truffle jello on satin sheets, while the rest of us splint our broken legs with grandma's picket fence slats.
It is inevitable, therefore, that even the most doughty capitalist must accept a certain amount of redistribution, while the most ardent socialist must acknowledge the need to rationalize the cost. So how do we, in the U.S., find the right ratio?
There are really only two options. Either we ration life-saving, life-prolonging, but expensive medicine, as Dr. Berwick has suggested, or we ration the relatively inexpensive, and largely elective areas, by requiring copays on commonly prescribed drugs and unnecessary visits to primary care physicians. Assuming we choose the latter course, we then calculate the contribution required to meet our social obligations.
An inexact science, by the way. Two separate articles floating around recently are, in fact, related. One article suggesting that non-profit insurance companies in Washington are sitting on truckloads of profit, and the other citing decreased spending on healthcare as a result of higher out-of-pocket costs to consumers. Insurers base their premiums on expected future claims. When those claims drop precipitously, insurers find themselves with a short-term windfall, which they are, by law, required to rebate in the form of lower premiums in subsequent years.
Clearly, this is not always the case and requires government diligence, which is, after all, the proper role of government in any case. For perspective, if we extrapolate the fraud, waste and abuse within Medicare, to the total spent on healthcare in the U.S., we can estimate that something like a half a trillion dollars a year goes to no good purpose. Enough to pay for every single currently uninsured American (approx. 50 million people).
We have written many times in the past, that the role of government is to act as the referee- not one of the players. Healthcare is a perfect example of how government could do good by doing its job well. We would all feel much better if they did.
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