National health care might be a disaster, due to the cost and the complexity. A government-controlled system also creates agonizing moral dilemmas (read about the eye treatment ruling covered further down). Still, despite my opposition to it, I can see it's a real possibility, and soon. Keeping that in mind, here is what we can do to solve some of the inherent problems and make the system work better.



What's Your QUALYs Score?

Who gets what health care? That would be a tricky decision for any of us, but some might argue that the bureaucrats in the National Institute for Clinical Excellence (NICE) are pretty good at it. They are evaluate and approve treatments for the National Health Services administration in Britain (their national health care bureaucracy). After all, the life expectancy in Britain is about the same as in the United States, and the government spends less on health care while covering ALL citizens.

Making such decisions, of course, does lead to some interesting problems. One example: In 2002 NICE recommended that a certain treatment for macular degeneration be used only in one eye - the one less affected by the disease. What about the other eye? It is presumably allowed to go blind. They arrived at this decision by using "QUALYs," or Quality-Adjusted Life Years.

How does this methodology for measuring the value of treatments work? Let's look at a couple examples. A surgery that gives you an average of ten years of life is better than one that gives you five, and so scores higher on the QUALYs scale. Years added to life matter, but so does quality of those years. Suppose you could be saved by a treatment but be in a coma for six years, while another person could be saved and healthy for six years by some other treatment. If funds are limited (aren't they always?), the latter would be approved.

Now let's look again at the case of the eye treatment. The score for QUALYs is high for the first eye, since seeing presumably greatly increases the quality of life over blindness. But seeing with the second eye doesn't boost the quality of life nearly as much, right?

We don't need to get into the complexities of the system to understand the logic. Life matters, but quality of life also matters, an idea most of us can agree to. But it leads to some uncomfortable conclusions, doesn't it?. For example a person with a debilitating disease or handicap presumably scores lower in QUALYs when considered for a life-prolonging heart operation. We might pass her over in favor of a healthier person who would benefit more according to the QUALYs score.

The real truth, normally ignored, is that there a financial limit to any national health care plan. As a result, we have to make decisions that can certainly be uncomfortable, and sometimes downright disturbing. What if a million dollars could prevent ten thousand people from getting a deadly disease, or that same million could be used to treat and possibly cure twenty people who already have the disease. Should we allow the twenty to die in order to prevent the deaths of ten thousand?

Of course, it's easy to say we should cure the twenty AND run the prevention program. This may even be possible, and we certainly could pay for both eyes to be treated in the case of macular degeneration. On the other hand, we really can't do everything. Honesty compels us to admit that perhaps going blind in one eye isn't nearly so tragic as losing sight in both, and if treating just one eye for one patient saves enough money to treat another patient's heart problem with a new procedure that saves his life, maybe we need to make that kind of decision.

Whatever utopian theorizing we do, tough choices will have to be made at some point if we decide on national health care. We'll need to put a value on life, or on various qualities of life at least. Yes, we may even have to put a value on one eye versus two, or on eyesight versus saved limbs that might be amputated otherwise. In a market system medical providers compete to provide better treatments for your diabetes, but this will be, in part, a system where your diabetes competes with somebody's migraine headaches or broken nose.

National Health Care - Some Suggestions

If we allow a market system of health care to exist alongside a government system, we could at least pay to have the other eye fixed. The rich will obviously get better care, but I don't think we are such a petty envious people that we would vote against such a dual-system just because of this. The healthiness of the wealthy doesn't hurt the rest of us. Also, we all would at least have the hope of raising money for whatever additional health care we desire. So let the market still exists.

There will also be the problem of demand. Free means higher demand, of course. At the moment I have a few teeth that I might have a dentist look at this week if the examination and treatment was free, but since it isn't I'll wait a bit. People often delay treatment because of the expense, but they also look for and find cheaper alternatives. That would change if we had free national health care.

There will be a big increase in demand. Naturally, cuts that might be bandaged will be more often be stitched if the service is without cost. A headache or sore throat that would normally be endured might mean a trip to the free hospital or clinic. Sadly, this would use government health care money that might otherwise pay for research or treatment for life-threatening illnesses, meaning more tough decisions.

How do we alleviate this problem of excessive demand? Design a system that isn't free. After all, the problem isn't that we have to pay for health care, since we find a way to pay for groceries, clothing and cable television without government handouts. The problem is the high price and unpredictability of health care expenses. An occasional surprise is one thing if it's a few hundred dollars, but a few weeks in a hospital can eat up a lifetime of savings.

Address THIS issue, instead of encouraging people's unwillingness to budget for unexpected, but affordable surprises? How? One way is to have national health insurance for all, but with a $500 annual deductible. When a person can't afford this (it amounts to $42 per month) it usually suggests a budgeting problem, not a problem of over-priced care.

Have each person pay 20% of all costs beyond that deductible as well, up to $1,000 ($5,000 in costs). This would keep people from running to the doctor or hospital for every little thing. This also encourages them to look for cheaper effective treatments, so the system doesn't destroy the usual incentive (money) for this creative process of health care improvement.

Prescription drugs shouldn't be covered until the cost goes beyond that $500 annual deductible, and even then the patient should pay his or her 20%. People (even poor people in this country) find a way to pay for bigger expenses in life, and this would keep the system from being abused. What if some people really are too poor to afford even this? Address that problem through general welfare programs, rather than paying for prescriptions for tens of millions who can easily afford them.

I am not thrilled with the idea of a national health care system. On the other hand, if it is going to happen in any case, we at least make it sustainable and leave open more options for all of us. That's what the system outlined above would hopefully accomplish.