Gezondheids-zorg, reactie op Amerikaanse = Nederlandse
Stemming: ja 1, nee 0, onbekend 0, onthouding 0, afgehandeld ja
Aan: de mensen. In reactie op - (engels).
I've thought some time about the health-care system from a fundamental
economic perspective, because it is the most difficult subsystem.
Infrastructure, Police, Justice, Government are easy: nationalize it.
Simple productivity like backeries and farming: free market.
Health care has fundamental economic problems:
[-] Buyers don't wish to buy, they are forced to buy because of an
[-] Buyers don't know beforehand they will get sick.
[-] Cost of treatment beforehand is often unknown.
[-] Serious hospitals contain so much equipment and skills that if they
go bankrupt, it could disrupt society seriously.
[-] Small hospital like services can go bankrupt.
[-] Patients often visit only a few or even one hospital in their entire
life, and therefore are not in a position to judge services from
direct experience. They have to find the best one based on hear say.
[-] Hospitals are such complicated operations that while one department
may be of world class perfection, another might be substandard in
[-] Hospital visits will often be decades apart, in which time a hospital
could change its competence drastically up or down wards.
[-] When patients can choose their hospital, the hospital has a reason to
do well in case the payment structure is such that healing is rewarded
and incompetence punished. Because of the insurance situation this
link is not a given like it is in any other market: an insurer has
for example a financial interest in terminating an expensive patient,
and has a financial interest in rewarding hospitals who terminate
expensive patients on its behalf.
[-] Hospitals can be places where many volunteers work, which is also
technically not the logic of the free market (which doesn't mean I'm
against volunteer labor!).
[-] The technicalities of the treatment are so difficult that only the
professionals themselves understand it; and even they often don't.
In other words: I don't see a bigger economic challange then health
care. Finance ? Finance is not difficult at all: it must be
democratized, socialized, and nationalized. Finance is a piece of
cake compared to health care.
So I thought this scheme might work, comments appreciated.
These ideas are to work in a DAVID economy, which is an economy
where business finance is socialized, land is distributed, companies
become democracies after starter leaves, and the government is a true
[-] Small hospital/clinic operations can be free market, like backeries
and shops. But, of course, they need to comply with quality standards
because the public is in no position to judge quality. The public
must be protected from malpractices, and so does the honorable
competition who do make all the necessary costs. Health care is too
final and definite to a person its life, it is a lot worse then
having a bad cup of coffee for once when it goes wrong (after which
one can still casually switch to a better service).
I'm not going to argue each point, takes too long, it shouldn't be hard
to see why:
[-] Big hospitals could *rent* all the equipment from the Government.
[-] Big hospitals could be divided into smaller money flow independent
management units (idea already done somewhere in Holland, said to work).
[-] Big hospitals are run by internal and/or state democracy.
[-] Nationalized, minimum services mandatory to be insured. Hospital does
not look at who is insured but treats all patients regardless.
Technically a non-insured person is someone who hasn't payed its state
taxes ("state" mean country/nation Government here).
[-] Insurance (state) pays hospitals for treatments.
[-] Patients can choose freely to whatever hospital they want to go within
the nation. It may be necessary to avoid insurance fraud to have a
case by case examination by a state agency. For example: a fraudster
and a private doctor and surgeon pretend a heart problem, pretend an
operation for 80.000,-, then split the insurence money. It might also
work that the examination is made afterwards, if possible (for example
in case of a heart-transplant it could probably be detected that it
took place ?). As things are with law enforcement: you only have to
investigate a certain percentage, and punish hard. If you only test
20% of all cases, and close hospitals and throw the guilty in jail
in case of frauds, then the other 80% are probably going to be ok
because of fear.
Then I thought the following might work, because you run the risk that
hospitals that are most expensive will attract most patients, so that
can spiral out of control. Although you could limit that problem by
direct management. Maybe that is sufficient already, probably is.
[-] Insurance pays, say, 99% of all medical bills, and 100% of all bills
above a sum that all people should be able to afford easily (or pay
back easily), say 1 month of average wages (or 2 weeks).
That way the public will also weigh in the cost of treatments, and
choose a hospital that has a better cost/quality balance. They won't
always want to go to the most expensive for the insurence because
they don't pay the direct bills anyway. They'd be paying a small
amount, if done right just enough to make the people choose cheaper
if the price difference doesn't buy anything worthwhile for them.
A bit of payment for hospital visits also keep the number of visits
down, although some specialists say that is something that should
*not* be done because people stay home with serious illnesses too
long. In that case examinations should be made 100% insured.
It remains to be seen if this set up with its additional bureaucratic
cost is worth the trouble - perhaps not (probably not?). But it
brings in some structural market pressures to produce cheaper from
the side of the public, which seems to be a good principle at least.
I don't guarantee that this is the best way, but it seems to me it
is a reasonable attempt given the complexity of the field. We should
listen closely to what the medical specialists say and how they want
things to improve quality. People in the field tend to have the best
I think that very simple nationalized health-care tends to work
historically, and that privatized health care (big hospitals, big
insurence) tends not to work. That said, small time private dentists
and other specialist practices also clearly work very well.
So the answer is probably at least the nationalization of insurence
and big hospitals, and free market for small operations, and good
quality control. There can then still be a market for luxury health
One important point is, I think: internal hospital democracy. The
nurses and support staff also know what they are doing, and should
have more of a say in how they do things. As long as there is adequate
quality research/control, it should be OK. Hospitals can be steered
both by state quality control demands (revoking license), and the
amount of money they get from state insurence for a service (finance),
and the willingness of the state to purchase/hire to that hospital group
equipment (finance), and the preference of partially money motivated
patients (market pressures).
One might note that the state can then
make the decision as to whether hospitals will provide extremely
high cost treatments, using moneys which might also save or improve
suffering / life elsewhere. That seems to be the proper platform to
make that decision. (Compare: private health care providing extremely
high cost treatments only for the super-rich, who often stole their
money in the first place.)
Reasonable ? Too complicated ? Wrong ? Let's see how it works ?
Doing = knowing. It won't be perfect in every instance, but I think it
could more or less be a stable system. Then finally politics can get
out of health care and quit their eternal re-organizations. Hospitals
and medical people can then concentrate finally on their work (provided
it is a functioning system). If it works in one nation it can be
replicated to the others.