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I think you understand the over-arching economics models better than I do... but here's a stab at your questions...
1. There are public options in the form of MedX, VA, etc. In the case of MedX, as the sole insurer of a pretty large portion of the population it wields some significant negotiating clout. But here are some market distorting factors:
- The health care infrastructure that it draws from doesn't exist as a result of the rates that it sets. MedX benefits from doctors, hospitals, drugs, etc. that exist in spite of the business it sends their way. How?
- Because MedX says to doctor, we'll reimburse you X. Doc says, okay, but I can't live the life style I want on X and pay for everything I need to pay for (malpractice insurance, capital investment in equipment, etc) so I will charge my non MedX patients X+Y to subsidize the difference. This same market distorting effect carries over to drugs, hospitals, etc.
- MedX has incredible opaque finances because it's back-stopped by the govt, and therefore heavily politicized. Worst case, the govt will likely print money before they'll reneg on services under the option. This has broad implications for the economy at large, and an option not available to any public insurer.
- MedX doesn't have to adhere to the same regulatory and market fracturing regulations that the govt holds private insurers to. Therefore it's actually more of a "free market" option than the supposed free market one in terms of regulatory burden.
And there are many others. The problem is you can't look at any of the public programs (all of which have horrendous administrative flaws... just talk to any doctor about their experiences billing and collecting through MedX) and extrapolate it to being a universal insurer. It won't work. You eliminate all the private-side business that makes the health care infrastructure possible, and they'll be nobody for MedX to send people to. (Ask any hospital administrator if they could survive based solely on MedX reimbursement rates.)
Bottom line - changing from private to public is a huge undertaking... no less than if the UK said "screw the NHS, tomorrow we're all moving to private insurance". It's a dramatic infrastructure shift that proponents are severely underestimating. And going halfsies (a "competitive public option") just exacerbates the existing market distortions.
2. France as got fabulous health care. So does Japan. Both are suffering from the same greying of the population problem that we are. The difference is, the govt has backed the healthcare entitlement. And governments aren't very good at delivering bad news. Ever been in Paris during a strike? One of those where the farmers park their tractors blocking all the in-roads to protest even modest reductions in subsidies? Yeah... that's the mentality your dealing with. The recent switch in ruling party after 50 odd years in Japan was in part because their economy is a disaster. Sarkozy tried valiently to reign in the French entitlement culture (of which the healthcare system is a significant part of the economic burden) when he first came in to office, but has retreated since in the face of rabid opposition. Merkel has tried the same thing w/ Germany -- same response. The problem hasn't been fixed, and it's only getting worse... it's just once a govt has given a level of entitlement to people, it's damn hard to take it away. So they're just kicking the can down the road like we are with Social Security.
But goddamn the free healthcare is dope while it lasts...
3. Here's the fundamental problem that nobody likes to think about. Health care costs money. Finding new options for treatment costs money. And just because someone is sick and something may help, doesn't mean there's the means to pay for it. A couple of examples that might help this not come off as completely cold-hearted corporate apologism...
- Think about Lipitor. Something like over 70% of the US population is obese, with most having the symptom of high cholesterol. That means a large portion of these people could benefit from Lipitor because a) they have high cholesterol and b) Lipitor exists. That doesn't mean that the resources exist to pay for all 240 million of those people to receive Lipitor. So you ration.
- "Personalized Medicine" is the emergine practice of recognizing that drugs react differently to people because, well, we're all unique. This is especially true in therapeutic categories such as oncology, where classes of chemo have very different efficacy levels for, in many cases, unknown reasons. You COULD apply the broadest range of treatment options to all patients to give them a shot a the, in many cases, <5% efficacy rates that just MIGHT save them. Moral? Don't know. Economically sustainable? No way in hell.
- We're living significantly longer in large part to expanded treatment options. The last 10-15 years of an individual's life are now dramatically more expensive from a health care consumption standpoint than they ever were. Well... people aren't saving that much more to offset these costs. They're not even working that much longer. So how exactly do we cover these costs?
- Finally, let's say I ask you for $100. I tell you that you're guaranteed to get $105 back by the end of the week. Would you do it? How about 90% chance you'll get $110 back by the end of the month? What about you won't see anything for 2-3 years and even then there's a 98+% chance you'll lose it all? How much would you want then? $300? $1,000? Well, if you like the latter scenario, you'd do well at a drug company trying to find new treatments. For every blockbuster there are literally hundreds of drugs that have 9 figure investments to get to clinical trials and then fail, resulting in a complete loss of investment. Right now, the private investment community bears that risk. You really want to shift that to the taxpayers? Bottom line -- drug discovery is expensive, and the global model of consumption is changing faster than the companies can adapt. Ever wonder why it's "big pharma"? That's 'cause they're the only ones who can afford the necessary economies to bring therapeutics to market. The dirty secret is that pipelines are empty... they're just not finding the broad-based breakthroughs. The discoveries that are proving out are much more likely to be highly focused therapies or orphan treatments that have a very narrow market -- meaning Economics 101 has to recover cost + risk from a lot less people, meaning much higher costs per treatment.
I think the fundamental problem is that sustained health requires medical care. Medical care fueled by continued innovation is expensive and risky. However distasteful it may be to equate life and health with money, you cannot separate the two. Well, you can and become a Christian Scientist or adopt some other sect that chooses not to partake in modern medicine. But outside of that, it costs to create, it costs to distribute and costs to treat. Every potential cure has to be countered by someone willing and able to pay for it. And there's no rule of nature that says those two will perpetually be aligned.
As to whether all ntaions' care involves insurance... by definition insurance is nothing more than a "promise of reimbursement in the case of loss." It's the guarantee that someone other than you will pay for the medical services you consume when you need them. So universal care IS insurance - the burden of risk is just transferred to the tax payer. In a perfect world of streamlined government efficiency that would result in some cost savings, but also creates a whole host of other issues in the transition. And unless the government is going to pay all the doctors, run all the hospitals, operate all the pharmacies, manage all the supply chains, research and create all the drugs, arbitrate and insure against all malpractice, etc. you're still just f-king at the fringes while the rest of the machine plods along.
To really fix the real problem - long-term cost containment - we're going to have to make major structural changes that will require EVERYONE to leave their own sacred cows at the door. So far nobody has solved that problem, and although the govt sponsored plans to better at hiding the issue (just like we do... do you really know how depleted the Social Security trust fund is?) and our private sector brings a degree of transparency that puts it all front and center, the issue's the same everywhere. And kinda like climate change, nobody wants to make the hard decisions that tell people they can't have what they're used to and to which they think they're entitled.
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