Charles Wheelan, Ph.D. The Naked Economist

Health care is the most difficult public policy problem there is. Substantively, the system has been cobbled together with duct tape for 40 years, so tweaking costs in one area could easily cause another part of the system to fall apart.

Politically, health care is right up there with many other controversial issues, and in some cases it's probably tougher since doctors, hospitals, trial lawyers and insurance companies aren't giving tens of millions of dollars to politicians to affect every particular battle. In the case of health care, that is what's happening.

But unlike flag burning, for example, health care actually affects your life. I don't know if the Obama plan would be an improvement on the status quo, in large part because it's not entirely clear what the Obama plan will turn out to be.

I do know that the current health system is not something that any sane person would have designed from scratch. And if that's true, then it stands to reason that we ought to at least entertain thoughts of how we might make it better.  As the health care debate swirls around us, here are seven questions designed to illuminate that discussion: 

1. How did we get the health care system we have?

By accident.  This is not a system that Ben Franklin and Thomas Jefferson planned over months of meetings in Philadelphia.  This whole system was an unintended consequence of Franklin Roosevelt's attempt to restrain inflation during World War II.  His administration forbade wage increases; clever employers offered workers free health care instead.  Ever after, health insurance was attached to employment in the U.S., making it a complete outlier in the developed world.

Our whole health care system was an unintended consequence.

2. If we had a Canadian-style system (or British or French), would you give it up for what you have now? 

I'm not asking if those systems are perfect. They're not. And I'm not asking whether people in those countries complain about their health care. They do. I'm asking you to do a thought experiment.  Imagine that you were in a country that guaranteed coverage, where health care costs are 25 percent to 40 percent less, where life expectancy is higher; and where the costs of the system are not imposed directly on businesses.

Now suppose that a politician stood up and proposed scrapping all of that (and the admitted flaws of those systems) and replacing it with the U.S. system: No guaranteed access, shockingly mixed health outcomes, a stifling burden imposed on businesses, and all at a higher price.

3. What are your preferred benchmarks for quality in a health care system, and how does the U.S. system stack up?

Any reasonable indicators should measure how healthy we are, not how we get that way. The most pathetic thing about the current health care debate is the ideological obsession with government involvement. That's a means, not an end. 

I doubt we will ever see the following conversation:

Doctor:  "I have good news.  Your daughter's heart surgery was a success.  We expect a complete recovery."

Parent:  "That's wonderful!"

Doctor:  "But wait, there is tragic news as well.  I'm going to be reimbursed for this successful surgery by the government, not by a private insurance plan."

Parent:  "Oh God, no!"

What we should care about is the outcome, not who is paying for it. How healthy are we?  How long are we living?  What is happening to our survival rates for different diseases?  Are we providing patients with the most appropriate and cost-effective care?  Do Americans have access to good care in a timely manner?
 
We shouldn't care about government involvement per se. We should care about whether government involvement improves health outcomes or not.  As far as I'm concerned, we should embrace health care delivered by small green aliens wearing rainbow suits -- if there is evidence that it would produce better results.

4. Where did King Hussein of Jordan fly for cancer treatment?

To the United States. The U.S. is a great place for cutting-edge research and care.  I suspect that the rest of the world is free-riding on that to some extent.  King Hussein didn't fly to France or Canada. In fact, many wealthy Canadians come to the U.S. for care.

But here is the wrinkle in the King Hussein story.  He flew to Minnesota for treatment, not Miami or L.A.  Why is that relevant?  Because Minnesota is one of the places in the U.S. that spends significantly less on health care than the rest of the country, while getting similar outcomes (taking into account the pre-existing health of the population).

And King Hussein flew to the Mayo Clinic, which practices a form of medicine that doesn't look like the rest of the American system.  Physicians are paid a salary, rather than being compensated based on the quantity of procedures and tests they provide. The incentives are different.  The costs are lower.  And the outcomes are excellent.  Good enough for a king, literally.

If we could somehow get the whole system to look like Minnesota or the Mayo Clinic, or to look different but operate just as well, then we'd be done.

5. Should we scrap Medicare?

I'd just like a little more intellectual honesty here.  The same politicians who rail against government involvement in health care almost always extol the virtues of Medicare.  In fact, Republican Sen. Mitch McConnell had the chutzpah to accuse Democrats of cutting Medicare in order to create a massive new government-run health care plan -- which is curious, given that Medicare IS a massive, government-run health care plan.

So if you are ideologically opposed to government-run health care, then I'd like to hear your explanation of how and why America would be better off without Medicare.

If you oppose government-run health care but support Medicare, then you've just left me confused.

6. Can our health care system get worse? 

Yes. Just because the status quo is a mess doesn't mean that Congress can't make it worse. That's what is so scary and difficult about the current reform effort. For all the failings of the system, a large proportion of Americans think that their health care is just fine.

If Democrats believe that any reform is better than no reform, they are dangerously wrong.  That's why whatever happens ought to proceed slowly, deliberately, and with as much Republican support as possible.

7. Do you think the American health care system will be better or worse in 10 years if we do nothing now?

I'll let you answer that.