Wednesday, February 21, 2007


Following an exchange in which I argued my case that we would not see Medicare for all, Peter Kilborn, retired Boston attorney and friend from early Boston days, responded as below. It struck me as very likely typical of what many are thinking. I will respond to his questions, but perhaps others would like to, as well.

If not Medicare for all, what is your answer? I suppose there are really two questions: (1) what would be the right solution and (2) is there a politically possible solution.

The various problems you describe are, I think, relevant to any sensible solution and are what lead me to think we will not in your and my lifetimes see anything more than small bites at the problem.

To filigree what you said: we cannot afford to pay for everything that everyone wants, both in the realm of what is covered and how the system operates.

On what is covered. At one point Oregon had (maybe still has, for all I know) a list of cures, procedures etc., ranked in order of priority. Somewhere near the top of the list would be something like "antibiotics for a sick child" . Somewhere near the bottom would be "viagra for ninety-year olds." Somehere in the list a line would be drawn, below which the system would not pay. This requires a policy decision which - as you suggest - our system just won't make. We will not countenance rationing of medical care, but without rationing, the cost, as a fraction of our GDP, becomes unsupportable.

I remember from our days on the hospital scene various and sundry saying "We cannot have a two tier health care system." But, as long as there are some more affluent than others, we have to. If we ration, as we must, the affluent must be able to insure against things not covered by the system.

How the system operates. By that I mean the Harry and Louise problem. It may well be that a system which covers everyone will require that not everyone will be guaranteed access to the physician of his/her choice. That, again, is apparently politically a non-starter. And it bleeds into the two/tier problem. In England, the rich - by paying - in effect jump the line and also get the MD of their choice.

All of the above is very elementary but it leads me to throw up my hands. We will never get the purists to agree to partial solutions, but partial solutions are the only ones which will work in our democracy.

So, if you were advising the leaders of the Democratic party in Washington, what would you advise them to do?

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