I’ll end my comments with two quick thoughts. The first is that as Michael Cannon, I, and some others bickered over health care “transparency” at a conference yesterday and today, somehow (OK, it was my fault) the idea emerged that doing a kitchen renovation is damn complicated and expensive. And even if you think you know what appliances and cabinets you want and know what things (especially labor and appliances) cost, you don’t. And after you’ve managed one renovation (as Michael and I both just have) you’re only an expert on how to do your own again – so it’s a non-transferable skill! So the need for full transparency of cost, quality, etc. in health care is in my view strong, so long as the person who (unlike me doing my kitchen) has that view knows what to do about it. For the expensive part of medical care (i.e., the care of the low number of high-cost people), someone who is not the patient has to take the role of decision-maker, or the provider system will roll all over the purchaser – as they have for 6,000 years and especially the last 60.
It may be that the U.S. government is culturally incapable of performing that role (although some government agencies like the U.S. Marine Corps seem to be pretty effective). It may also be that, for quality reasons, we see a growth of high-end health advocates who perform this role for the well-to-do. (Concierge primary care is heading this way). But we should be able to create a system in which purchasers care about that cost, and the “agents” managing the process signal to the end-consumers by price, quality, and other measures that they are providing a better service. The only rational way for that to happen is, in my view, (as Michael says) to have those agents compete on a level playing field. That’s Enthoven style managed competition, and frankly all proper markets are managed – there’s a reason we have an SEC and a CFTC. You can’t sell the same bushels of corn on the Chicago futures market to different people at different prices, or make your bushel bigger or smaller than the markets’. The rules need to be the same for everyone. If Clark’s view of managed competition comes true, the sick will be paying more for their health care bushels.
And, as I said in somewhat more flippant tones to an emailer from the NCPA complaining about my Spot-on article today, if you don’t manage the insurance market by providing incentives to the insurers, or the intermediaries, to compete on providing the most cost-effective care at a rational and visible level (which in my view is a population-average rate charged per month for all care), then the private insurance market will continue to disintegrate. It’s been held together this long only by the “social insurance” provided by large employers, and that’s going away fast. For sure, that may be the intention of some of the Grover Norquist ilk, but I fear that the end result of all of that will be an increasingly elderly and uninsurable segment of middle class America.
Which is why I still believe the most likely outcome (assuming that we don’t have national Arnie-care any time soon) is a continued decline of private insurance and insulation, increased middle class insecurity, and an eventual populist rallying cry making “Medicare for all” the law of the land. And, frankly, it’s the polices of the right that are encouraging the “go it alone” attitude in an unreformed individual insurance market that make that outcome most likely.
You guys don’t want that to happen. Do you?