Some observers have suggested that if we tax the gold-plated insurance that some employers offer to their employees, insurance that encourages over-utilization of health care would begin to disappear. To avoid the tax, employees would settle for more basic, less expensive plans. Others propose giving consumers a larger menu of plans to choose from, so that they have an opportunity to pick more modest plans that don’t cover so many unnecessary treatments.
Both ideas suffer from two problems. First, they assume that less expensive insurance plans cover effective care—and eschew unnecessary care. Second, they’re proposing a crude across-the-board solution to a complicated problem. As I have said in the past, the waste and “fat” in our health care system is not hanging out around the edges of the steak. It is marbled through the meat. Eliminating it means using a scalpel to discourage use of specific tests, treatments and products that provide no benefit for patients who fit a particular profile. Simply taking a whack at expensive insurance plans does not do the trick.
Granted, the idea of taxing pricey employer-based health insurance has a certain appeal. Today health benefits are not taxed as income. Since more affluent Americans are most likely to enjoy the most valuable benefits, this seems to be a “regressive tax break”—one that favors the rich.
Moreover, the Congressional Budget Office reckons that if the IRS taxed employee health benefits that cost the employer more than 75 percent of all insurance plans, it could raise $452 billion over the next decade—a nice chunk of change that could be used to help finance health reform. But, as Merrill Goozner points out over at GoozNews,
“As the CBO report [also] noted, those most likely to be hit by the new tax would be workers who live in areas with higher health care costs; who receive more generous benefits; and who work for “firms that had higher premiums because of the age or poor health of their employees.”
“Only one of those categories – taxing people with so-called “Cadillac plans” – can be politically justified,” Goozner observes.
Gold-plated plans may well cover (and thus encourage) many unnecessary and overpriced procedures. If Washington began taxing them, employers might begin taking a closer look at the waste embedded in the coverage, and shop for more sensible plans. Or so the theory goes.
But, Goozner points out: “there are very few plans out there whose high prices are determined by the generosity of their benefits. The vast majority of costs in high price plans are driven by the other two factors: they are either in high-cost areas or they cover costly patients, or both.”
Clearly, it makes little sense to tax my health benefits because I happen to live in Manhattan instead of Vermont. I don’t have any control over the number of unnecessary treatments that New Yorkers receive, or the towering medical bills and spiraling premiums that have become an accepted part of Manhattan’s medical culture. Nor would it be fair to tax my benefits if I worked for a small company that was forced to pay higher premiums because many of its employees were older.
Goozner offers an example: “I spoke briefly last week with a health policy analyst working in a small shop where the average age was 52 and family health care premiums have shot over $21,000 a year, well above the 75th percentile cut off envisioned by CBO. 'Under that proposal, we would be taxed on $8,000 simply because of our average age, not the quality of our plan,’ he said.”
An article in last week’s NEJM, suggests that perhaps employers could “compute an adjustment factor, based on their firm's location or their workers' ages, that could be used to set the cap."
“But wait!, says Goozner, “If employers are allowed to adjust the premiums they report based on local costs, employee age and their overall risk, most plans’ reported costs would gravitate toward the national mean. . .” In order to raise the same $452 billion over ten years, he points out, we would have to begin taxing “surplus benefits in roughly half of all plans.” Now you are talking about taxing middle-class families who are lucky enough to have health benefits. Particularly in a recession, is never going to fly.
Give Consumers Choices—They’ll Choose Less Extravagant Plans
Some argue that employees themselves could reduce overtreatment if they chose less expensive plans that offer less coverage. “Consumers can be given more choice of insurers, creating an incentive for them to sign up for a plan that doesn’t cover wasteful care,” proposes New York Times reporter David Leonhardt . (Thanks to Naomi for calling my attention to Leonhardt’s suggestion.) In this particular story, Leonhardt defines PSA testing and treatment for early-stage prostate cancer as potentially wasteful care.
I am very glad that Leonhardt is throwing a spotlight on the problem, but this is not news. I have written about early stage prostate cancer in the past, here and here. (See also this more recent 2009 article in the New England Journal of Medicine ). Leonhardt is right to say that “No therapy [for early-stage prostate cancer] has been shown superior to another.” He quotes Dr. Michael Rawlins, the chairman of a British medical research institute: “We’re not sure how good any of these treatments are.” Nevertheless, urologists continue to recommend PSA testing and treatments—without any solid evidence that they work.
We may well be squandering health-care dollars on the PSA test (which is not a very good test) and treatments that do not save lives or extend life– while exposing men to serious risks and side effects.
But given the unknowns, can we really expect consumers to choose an insurance plan that doesn’t cover testing and treatment for prostate cancer? How many consumers are in a good position to read the studies and evaluate the evidence themselves?
There is only one reason why an employee would choose less expensive, less comprehensive insurance: because he couldn’t afford the pricier plan.
By shifting the burden to consumers to eliminate the waste in our bloated system, Leonhardt is really calling for a two-tier system: cheaper, less comprehensive care for low and middle-income families, and much pricier, fuller and no doubt more wasteful coverage for the upper-middle class and upper-class. (I am sure this was not Leonhardt’s intention, but this is how giving consumers what some call “a choice to fit every pocketbook” would inevitably work out.) Probably the less comprehensive insurance would cover less wasteful care, but most likely, it would also fail to cover many expensive treatments that we know are effective.
Giving consumers a menu of plans is not the way to eliminate waste from the system. When people talk about “consumer choice,” too often they are talking about leaving everyone “free to choose” (or forced to choose) the care they can afford.
In truth, only a panel of physicians and researchers (like the comparative effectiveness committee that the Institute of Medicine has appointed to set priorities for comparative effectiveness research ) is in a position to oversee this work.
Ultimatly, once we identify ineffective, unnecessary products and treatments they should not be sold in our health care system—just as we wouldn’t allow sale of a treatment for cancer that might be available in Mexico, but that doctors in the U.S. consider quackery. Similarly, when we determine that a drug or device is too dangerous, we insist that manufacturers take it off the market. The waste in our health care system doesn’t just represent a waste of dollars, it exposes patients to needless risks.
Is PSA testing and treatment for early-stage prostate cancer mere quackery? No. We don't have proof that it is effective, but we also don’t have clear medical evidence that it isn’t. I do believe that there is much to be said for “watchful waiting”—keeping an eye on the cancer to see if PSA levels rise. This is such a slow-growing cancer that many men will never experience symptoms. They will die of something else long before the cancer catches up with them.
This is why it would make sense to pay doctors more for the time it takes to give patients all the information they need about side effects, benefits, and uncertainties before going ahead with treatment—and paying physicians less to administer the $100,000 proton radiation therapy that Leonhardt describes—a procedure that involves a proton accelerator that can be as big as a football field.
Given how little we know about the proton radiation therapy, I would suggest that it should be used only on patients enrolled in randomized clinical trials—so that we could gather more information on comparative effectiveness.
This, of course, would be a huge disappointment for the company that makes the equipment, but we really need to spend more time investigating experimental treatments before unleashing them on the marketplace. One might also consider raising co-pays for treatment when we have no firm evidence that they either save or extend life—though if we want to avoid rationing care based on ability to pay, I think we would have to offer subsidies to those who truly could not afford the co-pay.
But what we don’t want to do is create two levels of health insurance, either by taxing richer, more comprehensive benefits, or by giving low-income and middle-income families the “opportunity” to purchase policies that skimp on care.
We need to target the gray areas of medicine, and let head-to-head comparisons begin to narrow the areas of uncertainty. Until then, everyone needs insurance that covers all of the care that you or I would want for our families.
As I’ve said numerous times, I wouldn’t have any problem with taxing all health benefits, not just those above some threshold value. If employees who choose a less expensive option were able to redirect the savings into either higher wages or better benefits like more paid time off, higher 401-K matching contribution, more robust disability insurance, etc., I think most would wind up net better off. Polices could vary based on deductibles, co-pays, out-of-pocket maximum exposure, and whether the network of providers is relatively narrow as in HMO’s or broader like in PPO’s. The scope of procedures that are covered could be comparable for all coverage options.
One aspect of the current health insurance system that troubles me is that be insulating people from so much of the cost, we seem to have developed a culture of: If my doctor and I think a given test, procedure, service or drug might benefit me, I want it and I expect someone else to pay for it. The more extreme version is: Even if my doctor disagrees, if I want it, I should be able to get it and someone else should pay for it. Taxpayer financing would be great as long as the tax burden falls mainly on someone else, especially the rich, but it should be free or very low cost to me.
With respect to healthcare costs here vs. those in Western Europe, there are several important cultural differences that deserve more attention. First, Europeans are less litigious than we are in the U.S., while the legal system in much of Europe uses a loser pays rule which generally results in far fewer non-meritorious claims and less defensive medicine than we find in the U.S. Second, as we have discussed before, Europeans are more accepting of death than we are which means there is a lot less futile care at the end of life than in the U.S. system. Doctors in Europe are probably quicker than doctors in the U.S. to tell a dying patient: “There is nothing more (aside from palliative or hospice care) that we can do for you.” Third, doctors in Europe are apparently willing to work for significantly less compensation compared to their U.S. counterparts, a difference well beyond what could be attributed to differences in how medical education is financed. Finally, prices for drugs and hospital based care, including surgeons’ fees and imaging, are substantially higher in the U.S, even at Medicare rates. If we layered U.S. prices on European utilization, the gap between their healthcare spending as a percentage of GDP and ours would probably be much narrower.
Thanks, Maggie, for pointing people toward my column and understanding the pernicious side effects of taxing benefits. If properly adjusted to account for those side effects, it would merely be a tax on the upper middle class to support health benefits for the lower class, and while liberals may find that politically palatable, most Americans in the current economic environment would not, especially when there are more progressive tax subsidies for the well-to-do to go after.
I was deeply saddened to see Ezra Klein endorse the concept by praising Len Burman’s column in yesterday’s Washington Post, whose editorial pages are galloping to the right. Newspapers are oppositional by nature, and the change at the White House and on Capitol Hill made that shift inevitable. But in our new media environment, where paper-hired bloggers have the freedom to express opinions once only reserved for columnists, it becomes a real test for papers to see if they encourage political diversity in their in-house entries to the blogosphere. I suspect there will be tremendous pressure on bloggers to toe the company line. I wonder if that is happening to Ezra. At least Dan Froomkin had the intellectual courage to stay true to his liberal beliefs once Obama joined the White House.
The whole reason that “gold plated” healthcare plans exist, in corporate america and in union contracts is to pass a tax benefit to particular workers with the subsidy paid by taxpayers at large.
Tax all benefits, not just health, but also retirement benefits as the income that they are. The current system disadvantages the self employed and those without generous tax-payer subsidized benefits.
Barry, Merrill, Christopher
Barry-The biggest difference between European and U.S. spending on health care is not prices (though that is a major factor), but, rather, our over-use of advanced medical technologies.
Hospital staya are longer in Europe–but a lot less happens to you while you are there (fewer tests and treatments. In Europe, it’s not an unregulated for-profit system. )
Merill–
Thank you for pointing out that many expensive health care plans don’t’ provide more benefits. The greater expense is a function of
geography and/or the size of the company and the number of older employees.
I agree that WaPo does seem to be moving to the right on health care issues–along with the NYT and others.
My sense is that they are responding to their readers’ concerns that if everyone has health care coverage, and we really restructure the system, the upper-middle class will be the losers in order to provide care for low-income Americans.
This isn’t true. The administration is not talking about cutting back on effective or needed care for anyone. AS you know, its goal is to weed out the innecessary care that exposes well-insured and more affluent people to risk without benefit.
But many people still don’t understand this (including many in the mainstream media.)
Re: Ezra Klein writing for WaPo. Often I agree with Ezra, somtimes I don’t. (On this issue, for instance.)
But I don’ty see any signs that he is being pressured by the Post’s editors to say things that he doesn’t believe.
Ezra Klein strikes me as too bright and too proud to do that.
Thanks again for inspiring me on the problems inherent in taxing health insurance.
Christopher–
I would hate to see a tax on pensions.
Employer-sponsored pensions are a social good–that’s why the IRS doesn’t tax them.
IMO, the 401-k was a terrible idea. Most people are not nimble, well-informed money managers.
They should not be asked to manage the money that they will rely on when they retire.
Employer pensions, run by conservative pension fund managers (as they were in the past) was far and away the best way to provide
savings for employees in their old age.
We can always make laws to balance things out for the self-employed.
During the six years that I was self-employed while writing two books, I found the deduction for health care premiums and the deductions for self-employment expenses to be extremely helpful.
Paying both the employer’s and the employee’s share of Medicare and SS contributions was expensive, but some of the deductions helped to make up for that.
If we raised the cap on SS taxes to cover all income–not just income up to X–
we could provide tax relief for the self-employed.
I agree that pensions are a social good. The self employed are heavily taxed for retirement savings. We would like a little more of that social good, too! Let the self-employed save enough to cover up to 75% of their income tax free, as we would recieve in a corporate or government setting! Like the health insurance benefit, pensions favor those employed by a large corporation to the detriment of the self employed.
In order to compare apples to apples, total salary ought to include the value of all the benefits..health, pensions, perks etc. Just about every concievable perk has been wrung out of medical practice, so lets at least let the rest of society enjoying perks pay taxes on them!
The public doesn’t believe that only effective care will be denied.
As I have said before, I want a low standard of care so that we don’t break the bank with healthcare and have no resourses to do all of the other things we as a society should be doing.
I think this would better allow for the very large gray area in medical treatment.
Effectiveness research is a good idea, and it has been going on since Osler. It often raises more questions than it answers.
People are very irrational when it comes to risk. Chain smokers are often squeemish about the risk of radiation from a chest radiograph. A surgeon colleague of mine has been threatened with litigation three times this WEEK if she doesn’t order a breast MR for three different anxious patients.
Utilization is the big problem, and if it were set to only what is actually effective, it could be drastically reduced.
Christopher–
These days, very few corporations still provided defined-benefit pensions.
Gov’t workers have them–becaused they have unions.
Gov’t workers also typically earn significantly less than their peers in the private sector. (Compare, for instance, what Medicare officials earn vs. insurance executives. Even clerks and secretaries working for Fortune 500 companies usually earn more than those working for government–but their benefits are not as good.
Will the middle class (average household income around $50,000 a year) agree to pay taxes to help support self-employed doctors earning over $175,000 save for retirement? Dream on.
“These days, very few corporations still provided defined-benefit pensions.”
That’s correct. In round numbers, approximately 20% of private sectors workers are covered by a defined benefit pension plan today as compared to roughly 40% in the late 1960’s and early 1970’s. My own employer shut its defined benefit plan to employees hired after July 1, 2003 and shifted them into a defined contribution (401-K) plan. Many companies have done this in recent years for two main reasons. First, the long term cost of defined benefit plans is highly unpredictable and can be quite large relative to other costs of doing business. Second, the rules around keeping corporate pension funds adequately funded are increasingly complex while companies can find that they need to make substantial contributions to their pension funds during times of economic stress when they can least afford to do so. Defined contribution plans, by contrast, are completely predictable. You contribute some percentage of payroll, sometimes depending on seniority, to each employee’s account each year, give them a reasonable number of mutual funds, including fixed income and money market funds, to invest the money in and that’s it.
I’ve said before that I think taxing health insurance benefits is a good idea, but I don’t see much evidence of thinking collectively among union leaders, their members and others who have generous, high cost insurance plans. Democrats only seem capable of raising taxes on the top couple of percent of the income distribution. The top income tax rate is already slated to go back to 39.6% in 2011 after the Bush tax cuts expire. The House Ways and Means Committee wants to impose a 1%-3% surcharge beginning in 2011 on incomes above $280K (single) and $350K (couple) which would rise to a 3%-5% surcharge in 2013 if healthcare cost reduction targets aren’t met. On top of that, Maggie thinks it would be a good idea if Social Security taxes were extended to all wages. That’s another 12.4% including the share nominally paid by the employer. Those who would like to see health insurance paid for via a payroll tax instead of the current premium based system don’t realize that it would probably take a tax equal to 15% of payroll to get the job done. Finally, high tax states like NJ and NY are looking to the same high income people to pay still higher rates than the 8.97% rate that taxpayers in NJ are already paying. Meanwhile, people who are fortunate enough to earn much of their income from capital gains and qualified dividends would continue to pay only a 15% federal rate on those earnings. For a high income taxpayer in NJ, if all of these provisions were in place, the top marginal combined federal income, payroll (including the employer share) and state income tax rates would add up to 85%.
California politicians have already learned that trying to extract 50% of state income taxes from 144,000 wealthy people in a state with a population of 38 million is not sustainable because (1) incomes are extremely volatile at the high end, especially with respect to capital gains but dividends and interest as well, and (2) they can move to a more tax friendly locale as quite a few have.
Finally, as to whether or not younger people should pay less than older folks for health insurance, I think it is impossible to design a health insurance system that will treat every single individual in the population with the liberal consensus definition of fairness and social justice. Some people are going to feel put upon no matter what we do and rightly so. At the same time, any healthcare system we design can be gamed by providers. A certain amount of that will probably just have to be viewed as coming with the territory.
Barry–
You are right ” the long term cost of defined benefit plans is highly unpredictable . . ”
By moving to “defined contribution” plans (i.e. 401ks ) corporations have been very successful in shifting this risk to their empoloyees –few of whom have the skills and knowledge that the people who managed old-fashioned pension fund (defined benefit plans) possessed.
So now, employees are told: you are your own money manager. Good luck!
Regarding taxing those at the top: the 1% of the nation with the highest incomes now take home 20% of all income.
As for taxing the wealthiest: As I am sure you know the wealthiest 5% of the population own 60% of the wealth in this nation.
They also pay lower taxes than they have in years. (Even in the late 80s–at the end of the Reagan administration, the wealthy pay more. This lopsided situations needs to be addresed.)
“They also pay lower taxes than they have in years. (Even in the late 80s–at the end of the Reagan administration, the wealthy pay more. This lopsided situations needs to be addressed.)”
Maggie,
The wealthy are paying considerably lower tax rates on capital gains and qualified dividends than they did under Reagan but considerably higher rates on ordinary income. When the 1986 Tax Reform Act was fully phased in starting in 1988, all income was taxed the same at a top rate of 28%.
I agree with you that current tax rates on capital gains are too low, and I didn’t support the Bush era reduction in the tax rate on qualified dividends even though I personally benefit from it. I’m very uncomfortable with subjecting more of wage and salary income to the Social Security (FICA) tax, and I’m not enthusiastic about a payroll tax to fund health insurance as an alternative to the current system because it puts all of the burden on the wage earner, which includes bonus income and, believe it or not, income from the exercise of stock options, but leaves investment income from capital gains, interest, dividends and rent unscathed. I just don’t think that’s fair.
If we could have an income tax system that integrated the payroll and income taxes which would ensure that high income people paid at least 28%-30% of gross income in combined federal income and payroll taxes plus the state and local taxes they pay now, it would be fine by me.
Separately, on the investment of 401-K funds, the larger employers are offering employees plenty of help through the big mutual fund firms like Fidelity. In many cases, they are also offering default choices for employees who don’t want to make a decision themselves. Most typically, this would probably be 50% in a broad based stock index fund and 50% in some combination of fixed income and money funds or guaranteed investment contracts. At the end of the day, it does, as you say, shift the risk from the employer to the employee. However, when you look at all the firms that have gone broke in the last 10 years including many of the large airlines, steel manufacturers, and more recently, GM and Chrysler, lots of employees, especially among the higher paid, have taken huge hits to their pensions as the PBGC only pays a maximum of $45K per year for one life and about 20% less for two lives assuming both spouses are at least 65 years old. If they are younger, the payments are reduced. So, the guaranteed employer defined benefit pension is only as good as the long term economic viability and sustainability of its business. This is why it’s important to have Social Security as a basic safety net and is why I consistently opposed the Bush Administration efforts to privatize Social Security even though it was (and still is) a minority view in the industry I work in.
Barry–
I appreciate what you are saying about supporting higher taxes on capital gains and dividends.
(I actually wouldn’t tax dividends at the same rate as capital gains. I think we want to encourage companies to pay dividends–and encourage to investors to invest for dividends rather than chasing higher capital gains.)
On the other hand, I would raise income taxes on incomes over $250,00–and hike them further on incomes over, say $600,000.
I think we want to discourage the exorbitant salaries that encourage short-term thinking, and, well, just plain greed.
I really don’t believe that anyone earning $600,000 would do a better job if he were earning $1.2 million. But I do think that such a high salary sets the wrong tone–and sense of priorities–for any organization.
On 401-k’s, you write: “Separately, on the investment of 401-K funds, the larger employers are offering employees plenty of help through the big mutual fund firms like Fidelity. In many cases, they are also offering default choices for employees who don’t want to make a decision themselves. Most typically, this would probably be 50% in a broad based stock index fund and 50% in some combination of fixed income and money funds or guaranteed investment contracts.”
I’m afraid that “help through big mutual fund firms like Fidelity” means help from a company that has a vested interest in seeing employees invest in stock mutual funds (which means profits for Fidelty as they move in out, plus management fees (if they are Fidelity funds). A great many of these investors- would be better off investing in Treasuries (as end-users, waiting until they mature) that they could buy directly from the government with no transaction costs.(Who at Fidelity is going to advise that? But I suspect interest rates will be going up, making medium-term Treasuries potentially attracive. In the meantime, short-term govt-insured CD’s are attractive and safe– far safer than virtually any stocks in a market that is still falling.
While I was at Barron’s, I kept all of my retirmeent money in GICs. I didn’t want the potential conflict of interest of being in stocks or mutual funds–and, more importantly, the GICs paid the steady modernate return I was looking for. (Alan Abelson had advised Dow Jones on the GIC offering.)
I think that if we could all make5% to 8% a year (more when inflation is higher, less when it is lower) savers would be well-rewarded for saving and we could be spared the extremes of boom and bust cycles.
Before the 1980s, old-fashioned pension fund managers who managed funds for the country’s largest corporations understood this.
But in the 1980s, everyone became hooked on the idea of “growth stocks,” “growth funds” and double-digit returns.
This led to bubbles–and where we are now.
Wealthy wage earners should be very angry. Instead of congress eliminating the insurance middleman waste to pay for health care reform, as they should, they are proposing sending rich guys the bill in the form of new payroll taxes.
Aren’t these politicians just great? The rich guys obviously did not put enough in the kitty. Rather than eliminating the insurance waste, they’ll just have you pay for it.
And as well, this whole concept of “cheap” and “expensive” policies escapes me. In my mind there should be just one: you get sick, you get care and the caregiver gets paid. To forecast that someone in your family is going to have this or that disease before the fact, has obviously not had a child diagnosed with diabetes or polio or other genetic disease.
Admittedly some policies might have riders to cover dental or vision, but by and large we should have just one basic policy.
Related to the idea of “gold plated” insurance plans is an article that appeared in the Baltimore Sun on 7/12 written by Marc Kilmer. The article can be seen online at: (http://www.mdpolicy.org/research/detail/best-medicine-competition)
In it, he makes the point that many insurance plans are expensive because they have been forced by state mandates to include treatments that people would not have chosen if left to their own devices; chiropractic, fertility treatments, acupuncture, etc. Obviously, including these benefits in all insurance plans causes insurance companies to raise their rates and pass along the cost to those do not and will not use these treatments. He suggests that these mandates should be eliminated or “end run” by allowing people to purchase insurance across state lines. I agree.
Maggie says: “Until then, everyone needs insurance that covers all of the care that you or I would WANT (emphasis added) for our families.”
To further analyze the above statement, I suggest that we substitute other basic needs such as education, food, housing and transportation in the above statement.
1) Education: “Until then, everyone needs access to education as good as what you or I would WANT for our families”
2) Food: “Until then, everyone needs food as tasty and nutritious as what you or I would WANT for our families”
3) Housing: “Until then, everyone needs housing equal to what you or I would WANT for our families
4) Transportation: “Until then, everyone needs transportation as comfortable and efficient as what you or I would WANT for our families”
By this logic, everyone should be “covered” to go to Harvard, have Julia Child as their chef, live in the Hamptons and be chauffeured in a Mercedes.
Maggie’s thinking – everyone should have access to all the health care you “you or I would want” is one of the fundamental problems underlying our current Health Care Crisis. Instead, we should be listening to the Rolling Stones: “You can’t always get what you want ….”
Legacy Flyer –
You are missing one of the key concepts of health insurance. You don’t buy the health care you want, you participate in a pool that provides coverage of the health care you want/need, and includes others who get coverage of care they want/need. A twenty five year old may prefer to buy a policy that excludes care for heart disease, but would like to get acupuncture to deal with bad tension headaches. You may have no use for chiropractic care, but want coverage of expensive anti-lipid drugs. With insurance, you all buy the whole coverage package, and the different levels of use are what keeps the insurance program in the black. State mandates assure that this playing field is kept level, not just a popularity contest. You may be paying for someone else’s fertility treatments, while they pay for your pacemaker.
That said, I do completely favor limiting payment to management that is proven efficacious. However, if we do that, the big money is not in chiropractic or acupuncture, but rather in more mainstream overuse of surgery, diagnostic treatments, and expensive drugs. It is fair to ask that “alternative” medicine be put to the test of efficacy and efficiency, but only if mainstream care is put to that test as well.
I continue to maintain, and can cite bales of data to back this position, that we can afford to give everyone the care they want/need at the same level if we get rid of the approximately one third of conventional medical management that is not useful, or is useful but could be accomplished using much less expensive approaches. The Western European nations are doing that; the Dartmouth Atlas all-stars are doing that. The key problem is to get us all to do that, and then we can easily provide high quality care for everyone, high income to low income, because we will have an extra $800 billion a year to play with.
The simple fact is that no one, rich or poor, needs a lot of what is being done today. The rich will be better off if they get coverage that improves management, and the poor will be better off if they get coverage, period.
Legacy,
I was using “you and I would want” addressing the readers of this blog.
By and large they are intelligent people; some are medical professionals.
Anyone who reads this blog understands that there is a lot of ineffective care out there that puts people at risk without providing benefit.
Obviously that is not what you and I want for our famliies. We want medically effective care-and everyone should have access to medically effective care.
Everyone also should have access to first-rate education, healthy food and safe clean housing.
Harvard has begun a broader scholarship program, recognizing that it is draw students from a too-narrow pool.
Finally, see Pat S’s reponse to your comment.
Pat S–
Yes– thanks.
Jack– I agree, there should be one basic very comprehensive plan. See Zeke Emanuel’s Healthcare Guaranteed– he argues that
coverage under this plan should be better than 80% of the employer-based insurance that we have today.
Emanuel would have private sector insurers provide this insurance, but they would be tightly regulated, and all plans would have to at least meet that standard.
There would be no premiums–and so no high-dedutible plans.