France economic and medical system:While Clinton was trying to sell his medical plan, there was another factor that temporarily relieved people: the mid-1990s was the golden age of the health maintenance organization (HMO). The original intention of the health maintenance organization is that in the traditional “pay for service” insurance, any medical measures taken by doctors within the scope of insurance can be paid by the insurance company, which leads to excessive expenditure: doctors will recommend any measures that may have curative effect, and patients will let it go, because others pay.
It is envisaged to replace it with “managed care” of the health maintenance organization, because in managed care, doctors belonging to the health maintenance organization network have the incentive to take costs into account, so as to abandon medical measures with mediocre curative effect but high price.
The assumption is that people will accept such restrictions because it will greatly reduce insurance premiums. The basic idea of taking cost into account in medical decision-making is very reasonable. Britain’s “national health service system” (NHS) is an example of the real implementation of public health care in major developed countries, and the budget of the system is limited.
The medical experts who manage this system rank the medical measures according to the medical effect brought by each pound of expenditure, so as to limit the expenditure with low curative effect and make the best use of the limited budget. In the United States, the Veterans’ health administration, which is a concrete embodiment of the national medical service, is doing roughly the same thing.
Moreover, despite the limited resources available to the NHS and the Veterans Health Administration, both systems provide excellent and efficient health care. However, the health maintenance organization is a private organization run by businessmen, not a public organization in charge of doctors.
At first, they seem to have the expected effect of saving expenses: with the popularization of health maintenance organization in the 1990s, the long-term growth of medical costs has been suspended, which is obvious in table 11-2. Throughout the 1990s, due to the cost savings of the health maintenance organization and the prosperity of the economy, the situation of medical insurance was greatly improved, but it did not last for a long time, as can be seen from table 11-3.
But in the end, the health maintenance organization failed to bring sustained cost savings for a simple reason – lack of trust. In general, patients in the NHS are willing to accept a certain degree of medical expenditure limit because they understand that the budget of the NHS is limited and the doctors running the system try to make the best use of it.
Members of the American health maintenance organization are reluctant to accept limited medical treatment because they know that the health maintenance organization is operated by accountants who try to maximize the company’s revenue. Due to this distrust and dissatisfaction, although the membership rate of the health maintenance organization peaked in the mid-1990s, other more relaxed “managed medical” institutions continued to develop.
Moreover, strong public protests and congressional hearings forced insurance companies not to take drastic action to reduce costs. As a result, medical expenses in the United States soared again, and employment based insurance declined again. All this means that the probability of success of the current medical reform is higher than that in 1993.
That year, Clinton had a short time to implement reform before the public turned its attention to other issues. This time, it is hard to imagine anything that can weaken the public’s desire for change and make anti reformers claim that the crisis does not exist. But even in 1993, if Clinton had not made a few key mistakes, he might have achieved health care reform. Don’t repeat the mistake. Others have written a lot about the personal attacks and disadvantages involved in Clinton’s medical plan. I have no intention to talk more about it.
Instead, I want to focus on two things Clinton clearly did wrong. First, he started too slowly. Matthew Holt is a medical analyst. His articles on health policy blog have become a must read in this field. Holt compared Clinton’s reform with Johnson’s success in implementing federal health insurance, and found a strong contrast between the two. Johnson signed the law on July 30, 1965 to make federal medical insurance effective, less than nine months after his victory in 1964; Clinton did not make his first national speech on health care until September 23, 1993. There are several reasons for the painful consequences of his long delay.
By the autumn of 1993, the political residual prestige of the 1992 election had completely dissipated, and the Clinton administration was also entangled in some trivial matters, such as the role of homosexuality in the army and various scandals fabricated by the propaganda agencies of the conservative movement. At the same time, due to the economic recovery, people’s need for health care reform has also decreased.
Why didn’t Clinton act early? This has something to do with decision-making: he first focused on budget affairs. The formulation of Clinton’s medical plan is also a troublesome process. There is a huge and secret special working group involved, and its leaders have offended many natural allies. And most importantly, Clinton is not ready. Federal health insurance was established after years of discussion, while Clinton acted rashly with little planning.
He did not mention the details of health care reform in the election, nor did he have a preparatory national debate on this issue. Second, Clinton’s final plan exposed another problem: it is easy for others to portray it as a plan that will deprive Americans of their medical choice. The Clinton plan accepted the implicit theory of “managed care”, that is, limiting expenditure on expensive medical measures with questionable medical effects will greatly save costs.
The program pursues universal coverage, but will actually introduce everyone into health maintenance organizations that follow the guidelines of “controlled competition”. Opponents of the plan quickly seized on the point of “managed medicine”. The earliest and most destructive “Harry and Louise” advertisement warned that “the government will force us to choose from several medical plans designed by government officials”. In order not to repeat this unfortunate history, today’s health care reformers must avoid these mistakes.
They must act at full speed: if a progressive president enters the White House, if progressive lawmakers occupy a majority in Congress and take office, at least they must have determined the basic elements of a universal health care plan through extensive discussion.
Therefore, it is a good thing that health care reform has become a central issue in the current presidential campaign. Their proposal should also reassure Americans that people will still have a certain choice, and those who currently enjoy good insurance will not be forced to accept poor results. When Roosevelt founded the social security and unemployment insurance system, he stepped into an unknown territory.
The United States has never had such a system, and the welfare state systems of Germany and Britain are limited, and Americans know very little. No one is sure how effective the new deal will be in protecting Americans from risks. On the contrary, universal health care has existed in the western world for decades, and we already know how it will work.
Ezra Klein conducted a good survey of the medical systems of other developed countries, and his opening remarks are worth quoting in the full text: medicine may be difficult, but medical insurance is very simple. Other industrialized countries in the world have found a way, and this process has not allowed 45 million people to lose insurance, insufficient national insurance of about 16 million people, and soaring medical expenses, which has seriously threatened the national economy.
Even better, none of these successes is a secret, and the mechanism is not unknown. Ask medical researchers what to do, and they will sigh a little impatiently and make suggestions similar to those in France or Germany. However, if they are asked what they think they can do, they will only hesitate to squeeze out some fashionable empty words and evasions, such as “regional purchase alliance” and “medical savings account”, so as to try their best to avoid offending people in the insurance industry, pharmaceutical industry, conservatives, manufacturers and so on.
This topic is famous for its complexity, but it is only the forces protecting the status quo that complicate it, not the problem itself. Look at the French system. The World Health Organization rated it the first in the world. France maintains a basic insurance system covering all people, which is funded by taxes.
This is similar to Medicare. People are also encouraged to buy additional insurance to cover more medical expenses – similar to the supplementary insurance purchased by many elderly Americans outside the federal health insurance. The poor in France receive subsidies to help them buy additional insurance – similar to the public medical assistance in the United States, which helps millions of elderly people out of trouble.