America set up a single-payer health plan a long time ago. It’s what the Democrat Party wants for the country. It’s called the Veteran’s Administration. While some VA offices worked well, the system as a whole was a train wreck. I don’t think that there is anyone in Washington that would dispute it.
Reform of the VA (and its labor unions) has become a cliche for a lot of politicians. The current move is to allow patients who need care immediately to step out of the system and go to healthcare providers in the open market. 
However if all healthcare in America was a much larger version of the VA, there would not be an open market to resort to. Sure, there’d be some independent providers catering to elites and those wealthy enough to pay for them. But the really good healthcare would be far beyond the means of 95% of the nation.
Is that what we want?
I realize that the “free cheese”/”Obamaphone” crowd want somebody else to pay for their needs, and they ALL want Cadillac care, but that won’t be happening in a country of 330 million people where 48% pay no federal income tax. 
The Market
The market for health insurance should look like the market for auto insurance or homeowner’s insurance: coverage you buy on your own, instead of depending on the government or your employer to buy it for you. Supplement that market with financial assistance for the poor and the chronically ill, and you’ll have achieved market-based universal coverage, along the lines of Switzerland’s health care system.
In order to make the U.S. health care system as free and efficient as Switzerland’s, we’d need to do four things: (1) establish a functioning individual health insurance market by replacing Obamacare’s exchanges; (2) gradually raise Medicare’s eligibility age for future retirees so that more people in their sixties would buy individual coverage that is subsidized where needed; (3) gradually migrate certain populations out of Medicaid and into the individual market; (4) address the grab-bag of other health-reform problems like medical malpractice, hospital consolidation, drug pricing, and veterans’ health care.
The American Health Care Act passed by the House was focused on problems (1) and (3). Legislative rules bar Republicans from using the reconciliation process to change Medicare. 
The Onion
Medicare is the elephant in the room that nobody wants to talk about. It’s a $600 billion/year problem that is headed toward a trillion (see figures below). Because old people tend to vote, politicians don’t want to bite the onion and change the eligibility age. But it needs to be nudged upward – possibly to 70, to make room for all of the younger (newly entitled) sick, those chronically dependent on others for their sustenance and so forth.

Ideally any government insurance/welfare program would deal with chronic and catastrophic problems, requiring patients to cover the cost of incidental doctor’s visits and elective care. Catastrophic plans are far less expensive but that’s where the greatest need is.

Though it may seem impossibly unfair to some of this blog’s readers, discounts and preferential treatment for federally subsidized healthcare should be given to people who don’t voluntarily engage in activities (smoking, abuse of alcohol and drugs, obesity, etc) that put themselves more at risk. This may sound cruel, but incentivizing good habits may increase lifespan, the quality of that life and the expense of medical care paid for by public dime.

At least that’s how I see it.


  1. It's not a good plan, Linda. (1) There is not enough pork for the insurance companies, who insist on that. (2) Touching Medicare creates HOWLS of anguish from people, but it's the only way to save the program for everyone. (3) Obamacare changed the entitlement culture and people want more free stuff. And while nothing is free, there are a lot of identity politics tied up in wanting something that you don't pay for.

    I don't know if anyone could create a plan that is fiscally responsible and compassionate at the same time. There are a lot of really irresponsible people in America. The government check has become a way of life instead of a safety net for the weakest, dumbest, sickest and most needy among us.

  2. LL,

    Subsidize the poor so you get more of them and more pretending to be poor (ie black market workers declaring no/low income to game the system) When was the last time there were people dying in the street(unless lead poisoning counts) The old system worked for almost two hundred years. One incentive to get a job was to pay for medical and not be a leech on society.
    So quit subsidizing leeches, that's what charities do best.

  3. You're getting soft in your dotage there, LL. Maybe stay in California, just move closer to the old folks home so you don't have as far to relocate.

  4. LL,
    Folks who live longer lives due to healthy living practices tend to be healthier to the end. Yes their last days maybe expensive but they weren't sucking at the teat for years. (Except milking social security)

  5. The drug pricing you have in #4 is a very large piece of the pie. I have had many patients who go to their doctor, paying out of their pocket for the visit, but then can't afford to buy the meds they need to manage the medical problem that is the problem. Some docs will do samples, but those tend to be limited long term. Or folks come out of the hospital with all their meds changed all around, many times they are the more expensive ones as the cheaper ones didn't work, which was what lead to the hospitalization in the first place.

    Incentivization will only work well if you incentivize the younger set, the older you are, the more accumulated damage has been done. So, to avoid the accumulation, don't smoke, drink, or sit for hours and hours. Do drink water, eat your veggies, and move on a regular basis. Avoid the first 3, and do the second 3 things to help prevent heart disease, congestive heart failure, COPD, diabetes, liver failure, kidney failure, and high blood pressure. Which are the most common diagnoses, along with dementia, for being hospitalized, and for frequent medical appointments.

    Now we just have to figure out a way to make water, veggies, and movin' to be as cool as freebies…

  6. > discounts and preferential treatment for federally subsidized healthcare should be given to people who don't voluntarily engage in activities (smoking, abuse of alcohol and drugs, obesity, etc) that put themselves more at risk.

    In general, a hearty AMEN from me (and probably most people who actually take care of patients*). The devil of course is in the details. Who do we let define what is "risky"? (God forbid we actually use evidence from observational cohort studies and intervention trials, you know, actual epidemiology and science, when GOV and special interests can use it to push particular agendas having little if anything to do with actual health.) As an example, I know medical professionals who take me to task for my 1-2 drinks nightly as "too much alcohol" even though it is totally in accord with guidelines, because they personally have some problem with people drinking, period.

    *most actual caregivers (which I am not these days) really hate dealing with obese people. I'm not talking 20, 30 even 50 lbs overweight. I mean like twice the size of a normal human being, or more. Nurses and aides get physically injured trying to horse around (sic) someone like that, everything is worse: anesthesia is more difficult and risky, surgical wounds don't heal right, etc etc etc.) Narcotics seekers are much disfavored as well, gotta admit.

  7. Good luck with fixing healthcare and the debt. Smart people are building compounds in the mountains.

  8. how about making the Medicare/Medicaid pay on time vs the USG floating a loan through the doctors for months on end.

    In re the drugs, what about the oncology patient that doesn't show up on the correct day for the infusion and that days drug cocktail expires (having been fedex'ed in on dry ice for that day, now there is a few thousand flushed, who pays for that?

  9. LL,

    With your subsidies (and necessarily entitlement) the responsibility is transferred to the provider of payment for services and the doctor.

  10. The only moral, ethical and logical method is for the government, at all levels, to but out. Charities will fill in as they did before. The USG can "subsidize" by encouraging saving for care, ie HSA.
    Additionally, the VA system would need to be closed or be responsible for their inaction

  11. Keith – I may have struck a cord. The REALITY is that people will vote themselves other people's money. Bernie Sanders came close to winning the Democrat Party's nomination and if it hadn't been rigged for Hillary, he might have.

    Any practical approach to government subsidized healthcare in America has to take into account that there are a vast number of legislators who will help them vote money from your pocket – because of income inequality or some other buzz at the moment.

  12. Yes, but it won't happen. I've read what you wrote and I hear you. However the free cheese genie is out of the bottle and following your lead on this, while desirable, is not workable. There is a 51/49 split in the US Senate. Trying to make something work needs to take all of that in account.

    The Democrats want 100% government managed healthcare – they want the VA. And the 48% who pay no federal income tax want free healthcare. It's a tippy thing.

  13. There was a thing on the news about evil people who have suggested that some lose a few pounds. Lord knows that I could stand to lose a few pounds. But my point is that if you are getting FREE MONEY for healthcare, you should be held to a standard and the standard can be debated – but should those of us who pay for their bad choices continue to subsidize those bad choices?

  14. My suggestions are a token of what I consider to be common sense direction for healthcare. Kieth Moore wants to shut it down, but you can't do it in a democracy where you've already shown people they can vote for it and get it. Prevention is the key to good health, but we see how that works.

  15. What we may get in the end is an nice uncivil civil war to correct the path that we are currently going down. We might be able to rid this part of the world of Progressives and get rid of income taxes. And if we don't get rid of income taxes, at least a spread that makes everyone pay something into the treasury instead of 48% getting out of it.

  16. I find it irritating Social Security is included as part of the national budget.

  17. Everyone needs 'skin in the game'. It's the only fair way to operate. I can't see us going to something like a 40% VAT to pay the bills. It would be more hated than graduated income tax.

  18. You mean, that it wasn't sequestered, invested and that it's nothing more than a massive ponzie scheme?

    And while illegal aliens aren't technically eligible to receive Social Security benefits (unless they steal somebody's identity…), they can receive Supplemental Security Income (SSI), a program with Social Security. SSI is a federal welfare program that is paid out of the Social Security funding.

  19. LL,

    With the use of fentanyl (from China) to "cut" heroin, both in Mexico and all the way to street level, the problem is taking care of itself in a way. The lack of knowledge inherent even in your average tapeworm, is hurting the dealers also. It is rarely a good idea to kill off your customer base.

  20. LL,

    I agree with you, the parasite learned about the ballot box and the politicians tie enough little but disparate groups together to get elected. I guess we just have to wait for the acknowledgement that the money has run out

  21. LL,
    If you follow the government's own predictions as to the solvency of the Medicare, Social Security and the SS disability funds, every year we get more than a year closer to the end.

  22. The snake can only eat its tail for so long. But the public has very short and selfish sight. They want everything for themselves and they want it now. There will come a time when the age needs to be increased for both SS and Medicare. 70 makes more sense than 65. It's a place to start.

    People should have alternate plans to Social Security for retirement but many do not. The same should be said for medicare. But it's in the same boat as SS.

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