Comments on July 31 article

I can't comments in the comments section...but just a few brief replies to the thoughtful comments posted.

***economy of scale and public option***
I agree one of the arguments for a single payer or a public option is economies of scale, and a fear of private insurance is that public option would use knowledge gleaned from Medicare to give it competitive advantages. I think most opposition to public option and certainly single payer is based on general notions of 'gov't can't do anything right.' I wrote a few weeks ago about Medicare as a innovator in health insurance. In fact, most health insurance innovations of the past 25 years have come from Medicare. Prospective payment of hospitals which developed DRGs, which are now used by priviate insurers, RBRVS which allowed for attempts at differential payment policy designed to encourage primary care, etc. I suspect that there are innovations that have been developed by private insurers, but they are mostly related to underwriting and trying to not cover bad risks. This is what insurance does. So, culturally, we are stuck in no man's land. We say we don't want gov't (most people say they don't want gov't; you are saying opposite). Then when private insurance does what private insurance does, we say we don't like that. Lets develop regulations, etc. to stop private insurance from doing what private insurance does.

A very coherent argument can be made for single payer. I think if I were the king I might have universal single payer with very high deductibles, esp at younger ages and private insurance on top to fill the gaps. However, that is not going to happen this time around, and I suspect a public option won't either. If you really want single payer, you should probably be for whatever option ends up having indivdiuals do the most themselves for arranging their own health insurance...there will be many pitfalls and the experience may well make folks more ready for single payer later.

**do cross national comparisons include all persons or exclude uninsured**
They include all persons. You are saying that uninsured people are not as healthy as insured people...I agree and it is part of the point. If you add in 47 Million uninsured, the fact we spend twice as much as most is all the more amazing. Also, your general point is why people often look at measures such as healthy life expectancy at age 60 or life expectancy at 60 or 65....these measures mean given you live that long, then what is your experience. Just about all persons in US are covered when they reach age 65, and one of the knocks of other nations is that they don't invest as heavily in tertiary care...these later life measures are therefore comparing insured people across nations. And we still lag behind.

**how can you assess/change intensity without malpractice reform**
I think it is interesting how quiet malpractice has been in the debate. However, I suspect it is the CENTRAL political issue that paves the way for a consensus bill. I am writing about malpractice and patient safety this coming Friday.

**how would you propose to assess intensity?**
I would end or greatly limit the tax exclusion of employer paid insurance for one, which should at least stop insulating heavily insured folks from their decisions.

Key to me is developing a commission that is insulated from Congress to take a comprehensive look. I would start with the 10 most expensive conditions and look closely at what services may have little to no benefit and/or extremely high cost per benefit and perhaps stop paying (Medicare) for certain services or at least changing the current procedure whereby Medicare heavily sets payment rate but does virtually nothing about what can be done and when. This group would need ability to be very comprehsive not only in potentially red lining some stuff, but also proposing payment changes. Congress would then have to vote up or down a la base closing commission.
Note, the CBO said that the commission AS OUTLINED IN THE LETTER wouldn't do anything of consequence to alter costs. We need something consequential. Lessons learned from Medicare can move into private insurance...this is almost always how insurance innovation goes.

Note this will likely incrase admin costs of Medicare, especially if you likely end up with appeals or having to make the case for certain procedures in certain circumstances (like with private insurance) but you could argue Medicare doesn't pay enough in admin in this context.