Great idea from an unlikely source

I went to my psychiatrist today to have my oil checked. We got talking about things other than my brain, as we often do. Today we discussed the prospects for national health care. He said, "I think there should be universal health care coverage, but it should come with some pre-conditions. If you want to be covered, for example, and you're a smoker, you're going to have to quit smoking. Or if you're fat, you're going to have to lose weight. If you're an alcoholic, you're going to have to quit drinking."

That got me thinking: this is exactly what we did with welfare reform. Public assistance became a two-way street. This was the basic deal: "We'll give you cash, food stamps, and medical care, but you've got to take specific, verifiable steps to improve your life. If we find out you're not taking those steps, we'll reduce your benefits. If we find out that you're STILL not taking those steps, we'll kick you off welfare altogether. We're not trying to be mean here. We're just saying that if you want us to help you, you're going to have to help yourself, too."

I know that a similar regime in the health care field could be a nightmare to administer, and would evoke images of Big Brother in a white lab coat. But it's really not that far-fetched. You could start by focusing on just one issue: obesity. So, here's the deal we strike: "Hey, all you people without health insurance, now you can have it, paid for by the government. You'll start with a routine physical. If your doctor finds that your weight is a potential health issue, he's going to give you a body-mass index value that he wants you to achieve within six months. He'll give you a program to help you get there. If you don't get within 10 percent of that value in six months, though, you'll lose your insurance. You can reapply in another six months, but if you're still not within 10 percent of that value, your application is going to be rejected."

So, there's the idea, free for the taking. Senator Obama, I await your phone call.

Comments

[Thomas]

You didn't see the government doing that from the outset? That has always been obvious to me. Likewise I don't care about abortion as a political issue, it's a medical one. But once government gets involved in how your healthcare treatment how long until that is on the table too. Funny a lot of the same woman who demand the right for abortion are the same ones who demand government run health care, just wait until they find out how that works out.

[Anonymous Mike]

SAJU,

It took me a second to realize that this was a “modest proposal”… well done in my view.

The idea is not far-fetched. In Britain, there have been rumblings among doctors that certain types of care should be restricted for patients who have certain types of characteristics or behaviors, such as obesity or smoking. We’re not talking about booting people off of insurance, we’re talking about prioritizing care in terms of things like transplants and life saving procedures.

For those governments with a history state-provided care, the logic of your proposal is solid. Costs are rising faster and after various cycles of cuts in care and budget increases, these governments are faced with a choice; either reduce care through rationing or some other means below an acceptable minimum for all or target those with socially unacceptable behavior and body characteristics.

3 problems, some of which you mention:

Any measure, even if it is a composite, will be in some ways arbitrary. What about the skinny person who downs bacon and egg sandwiches everyday; they probably have a good BMI but their blood cholesterol is probably a donut away from a heart attack. Can you develop a measure that is seen as fair and therefore accepted? Of course in this proposal only rich people, those who can buy insurance on their own, can be fat… so right up there with luxury cars and fine clothes… obesity will be an excellent display of conspicuous consumption.

Second, will you have the stones to actually boot people off of insurance and then what? The welfare analogy falls part on three parts. It’s a lot easier to get a job than lose weight, a closer analogy would be AIMS and we didn’t have the guts to enforce the standards as they were originally written because we didn’t wants hordes of students who didn’t graduate. Second, welfare was seen as a direct cause of unemployment creating a cycle of dependency; welfare reform wasn’t only seen as breaking a cycle of dependency but restored the status quo ante before welfare programs even existed. Third, if you boot people off health insurance where do they go? The idea of having public health insurance is to not only give poor people help but to avoid all sorts of social costs such as emergency room visits.

Third, since when was it ever a good idea to allow government (and bureaucrats) to decide what is socially acceptable health standards and behavior? The trend in this country is the expansion of government-funded health care (witness the recent debate over S-CHIP)…. You start rationing care to those who are “deserving” how long till you reach the conclusion that it is time to look at “useless eaters”?

[Special Agent Johnny Utah]

Mike: I was quite serious.

[Thomas]

If you were SAJU what does it say about your view of personal freedom and choice? Not judging, just saying if that is your POV on this, what does it mean towards your perspective on freedom...worth the thinking.

[Special Agent Johnny Utah]

I didn't say that this system would apply to everyone. I buy my own insurance, for example, so it wouldn't apply to me. But if you couldn't afford to buy your own and you sought insurance coverage through the government, you would have to agree to the terms I set forth. If you found them unduly restrictive, no one would force you to take the coverage. If you DID take the coverage, though, you would need to recognize that your decision to do so imposed on the freedom of others -- those of us who pay the taxes to finance your care.

If it's sauce for the goose...

[Thomas]

But once the government puts the coverage on the table it's such a big game player, it wouldn't hurt the cost of you or all other outcomes? Thinking about auto insurance where was insurance when AZ did require, where were we after it went manditory.

You must admit the rule of intended consquences and to all that means increased cost.

Once again I am not judging, but you know enough of economics, think it all the way through...

[Thomas]

er unintended consequences

[Special Agent Johnny Utah]

I feel you, dog. I think any universal health care solution is going to be very messy, and involve significant costs of one sort or other. That's probably why we don't have it. I'm just saying that if we're going to have it, what I suggested should be one facet of it.

[Anonymous Mike]

SAJU,

Let’s flesh out your concept; after all obesity is but one of several chronic, and controllable, medical conditions that would affect health costs. BMI is a problematic measure of obesity and there are other health factors easier to measure, simpler for the patient to control, and can have just as much impact on the health care bottom line.

Smoking. We all know smoking has a negative impact on health. Shouldn’t we require those receiving government-supported health care to quit smoking?

Alcoholism. Require those who suffer from it to stop drinking

High blood pressure. Does a number on your body over a period of time Can be controlled either exercise or diet or through medication. Require all patients after a certain period of time to achieve a certain blood pressure level

Diabetics. Major health problems from unbalanced blood sugar levels

HIV. HIV infections can be managed by various drugs in order to prevent the onset of AIDS but such treatments are expensive. Why not require all patients to only engage in protected or monogamous sex?

Drug use. I know there is a growing opinion in the medical community that drug addiction is a medical condition, but people shouldn’t be taking them anyway as they are illegal. After seeing all those wonderful ads about the physical effects of meth use, I wonder if the taxpayer should be held responsible for the physical care let alone the cost of rehabilitation and counseling.

Of course this still leaves unsolved the question of how we check up on patients to make sure they are doing all of the things we want them to… are we going to start making people changing their underwear twice a day and therefore make them wear it on the outside so we can check?

So my question is SAJU, how far down the rabbit hole do you want to go? Your initial idea is a good one, people acting responsibly in order to get public help, but it is incomplete for the reasons I stated above. To fully flesh out personal responsibility would mean the creation of a government bureaucracy that would have a mandate to intrude into people’s personal lives. Your proposed program could not just stop with obesity but has internal logic that would drive it far beyond that.

[Special Agent Johnny Utah]

You guys will have to wait for my think tank piece on this topic, in which I will address all of your concerns, and more...

[Vox]

I don't think people are willing to accept that if the government is funding it, they government has a right to impose standards.

You only need to look as far as the NEA to see that a huge portion of the population believes that the government has a responsibility to fund and support 'art' but no right (or responsibility) to define what that is. There has been much argument that, if our tax dollars support painting a mural in a school in Temecula, by golly they should also be spent to fund a woman who stands on stage and paints herself with chocolate while reciting punk rock lyrics. Who is the government to say which is art and which has greater value to society?

I believe that, should Americans choose to take the path of 'Universal Health Care', there will be no limits, and no stopping the spread of larger and larger socialist programs.

[Special Agent Johnny Utah]

How about No Child Left Behind? The feds said to states, "If you want the money, there are certain things you gotta do. If you don't want to do them, don't take the money."

I know the analogy is far from perfect. I'm just saying that the precedent has been set.

[Michelle]

I finished an interesting book call Better by Atul Gawande.

It's an interesting collection of stories about the author asking the question how can doctors be better at what they do.

There's an interesting section on how much money should a doctor make. He talks to one doctor doesn't take insurance and makes millions. (Why shouldn't he be for profit? The insurance companies are. In 2005, the CEO of Aetna made $10 million.) And the author also talks to a doctor in NH who started essentially a very small HMO in 1971. (It was later taken over by Blue Cross.)

No real point here. But I do recommend the book.

[Special Agent Johnny Utah]

One question, though...was the book interesting?

[Michelle]

Oh, I must have edited that part out!

It was very interesting!

He talks to docs in different situations. Here are a few:

~ doctors on both sides of malpractice suits
~ doctors who attend executions (death penalty)
~the docs in Iraq
~OB-GYNs and discusses the changes in that field

He witnesses WHO attempt to stop an outbreak of polio in India.

He looks at different hospitals and their attempts to prevent the spread of diseases within them.

Also there is a great section on cystic fibrosis.

It's really a good book.

It's on sale at Borders (Buy 1, get another at 1/2 price.) Or you can borrow it when I get back from Mexico.