Friday, June 01, 2007

Krugman: 2006 article on health care reform

Brad DeLong pulled a post from his archives about a Krugman and Wells 2006 essay on health care reform. It's a great summary. For example:
The Health Care Crisis and What to Do About It - The New York Review of Books

...Employer-based insurance is a peculiarly American institution. As Julius Richmond and Rashi Fein tell us in The Health Care Mess, the dominant role of such insurance is the result of historical accident rather than deliberate policy. World War II caused a labor shortage, but employers were subject to controls that prevented them from attracting workers by offering higher wages. Health benefits, however, weren't controlled, and so became a way for employers to compete for workers. Once employers began offering medical benefits, they also realized that it was a form of compensation workers valued highly because it protected them from risk. Moreover, the tax law favored employer-based insurance, because employers' contributions weren't considered part of workers' taxable income. Today, the value of the tax subsidy for employer-based insurance is estimated at around $150 billion a year....
Never fails. If you want to understand strange behavior, begin with the tax laws. The entire article is worth reading and tucking away for future reference.

In a similar vein DeLong joins the discussion about whether Hilary's plan was "right" after all (but see how a comment catches him out) and Gawande finishes his NYT series with an outline of the road ahead (emphases mine):

... This is what that road looks like. It is not single-payer. It instead follows the lead of European countries ranging from the Netherlands to Switzerland to Germany that provide universal coverage (and more doctors, hospitals and access to primary care) through multiple private insurers while spending less money than we do. The proposals all define basic benefits that insurers must offer without penalty for pre-existing conditions. They cover not just expensive sickness care, but also preventive care and cost-saving programs to give patients better control of chronic illnesses like diabetes and asthma.

We’d have a choice of competing private plans, and, with Edwards and Obama, a Medicare-like public option, too. An income-related federal subsidy or voucher would help individuals pay for that coverage. And the proposals also embrace what’s been called shared responsibility — requiring that individuals buy health insurance (at minimum for their children) and that employers bigger than 10 or 15 employees either provide health benefits or pay into a subsidy fund.

It is a coherent approach. And it seems to be our one politically viable approach, too. No question, proponents have crucial differences — like what the individual versus employer payments should be. And attacks are certain to label this as tax-and-spend liberalism and government-controlled health care. But these are not what will sabotage success.

Instead, the crucial matter is our reaction as a country when the attacks come. If we as consumers, health professionals and business leaders sit on our hands, unwilling to compromise and defend change, we will be doomed to our sliding global competitiveness and self-defeating system. Avoiding this will take extraordinary political leadership. So we should not even consider a candidate without a plan capable of producing agreement.

I studied the Clinton I plan reasonably carefully, and I spoke on it to community groups in my prior home of Escanaba, Michigan (in the UP!). I remember it as very clever, but paternalistically dishonest. We were told nobody would lose anything, but that didn't make sense. One man's 'adverse selection' is another man's bargain -- so eliminating adverse selection means some people lose out on their personal bargain. I suppose that's simply the way politics works -- the public has a limited appetite for the truth. Even so, it rankled. Maybe this time we should try the truth for a change.

I'm curious to see what we'll do. I'm with Gawande, who says elsewhere in his article:
.... whether as a doctor or as a citizen, I would take almost any system — from Medicare-for-all to a private insurance voucher system — over the one we now have. Job-based insurance is bleeding away the viability of American businesses — even doctors complain about the cost of insuring employees. And it has left large numbers of patients without adequate coverage when they need it. In the last two years, for example, 51 percent of Americans surveyed did not fill a prescription or visit a doctor for a known medical issue because of cost....

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