The American system of medical-care delivery has no name. It is neither single payer nor based on private enterprise. It is a patchwork of cockamamie carrots and sticks, agencies and incentives, exceptions and accounting tricks, cajoles and punishments, cobbled together over some 50-100 years of legislation that itself was a product of pressure-group pushes, graft, loopholes, mandates, and subsidies.
It’s not even a clean public-private partnership. It’s a public-private-nonprofit-grifter-payola regulatory cacophony of confusion and chaos over which pharmaceutical companies and professional lobbyists exercise the dominant influence.
Still it quasi-functions. It hobbles along year after year with ever more expense and administrators, with ever worse results. Absolutely no one would design such a thing from the ground up. No one is particularly happy with it but neither is there much push to change it fundamentally.
The Covid years devastated trust or, perhaps, just pulled back the veil. Every poll confirms it, e.g. a Harvard/Northwestern poll showed that trust fell from 71.5% in April 2020 to 40.1% by January 2024 across all groups. The reality is likely far worse. Everyone is asking how to restore trust.
The last time centralized reform was attempted was 15 years ago. The debates about Obamacare minted a healthcare expert daily and generated think-tank blueprints reflecting every ideological bias. The final product of a thousand pages, in which no one group got its way, was shoved through with great huzzahs on one side and boos on the other. It resulted in more coverage, yes, but also cost increases anywhere between 50 and 500 percent depending on how one chooses to measure it.
No one can produce evidence that it has made America more healthy. A statistical tour through chronic disease data, or a casual walk through a mall or airport, proves that.
The debate over the Affordable Care Act pretty well exhausted the appetite for far-reaching reform. And maybe that is a good thing because the drive today is not for one system for everyone but a realization that the needs are so diverse and diffuse that it would likely have more success with a series of parallel systems that emerge from the ground up.
Thus has most of the Make America Healthy Again (MAHA) agenda focused on matters that individuals and families can do themselves. They include being more scrupulous about diet, exercise, sleep, sunshine, and caution about prescription medications, whether for mental or physical maladies. The movement against mandates is at the core simply because it now (versus a few years ago) pertains to children and relates directly to the grave concern about ill-health and the rise of autism.
Again, this is a more productive conversation than going back to the drawing board to reform a system that has no name and hardly anyone understands in its totality. It recognizes something crucial, namely that health is not granted by a system of government or a large insurer but rather emerges from individual decisions and habits. In large part and with the exception of unpredictable twists of fate, much of what we call health is mainly within our own control.
Given that insight, we have a better starting point in which to discuss real policy reforms that can give people a greater degree of control than they currently have under the existing bureaucratic patchwork of programs, mandates, agencies, and bureaucratized systems. Here are eight examples that can make a massive difference and should be favored regardless of ideological bias.
- Liberalize generic therapeutics from prescription control and make them over the counter. People are not idiots, though the US’s prescription system presumes they are. Fourteen states are working toward making Ivermectin and other common medicines like Hydroxychloroquine more available, thus liberating people from dependency on medical services. With the ubiquity of AI and quality medical information everywhere at our fingertips – no longer monopolized by the lab coats – we are better positioned to care for ourselves in our own interest. Probably hundreds of generics that people take routinely could be so regarded.
- In many countries, pharmacies have nurses and doctors available for diagnostics, which seems like a much better system than ours. It is far easier to get routine medical care in Mexico than it is in the US. This should not be the case, but regulatory barriers limit pharmacists’ roles in diagnostics or prescribing. Liberalizing the system and breaking down professional barriers and regulated buckets could better serve the healthcare consumer.
- Allow employers to offer employees an opt-out of mandated health insurance. The mandates are hugely expensive for employers. Every employer with more than 50 employees must comply. We don’t even have to change the mandate but simply permit options for the workers. Allowing their workers an extra $5-10 thousand or so in salary and wages would be accepted by many and give the direct primary care industry a boost. This would lower costs and boost job options.
- Permit anyone to make contributions toward a Health Savings Account, not just people with high-deductible health plans (as it stands today). The HSA is a bit of an annoyance – its troubling how government uses the tax system to direct spending choices – but it at least allows some tax-free choice that can otherwise earn money in financial markets. It makes no sense why these should not be open to anyone, even and especially people who elect against expensive coverage. It would serve as a substitute for insurance and add to the country’s store of savings and capital.
- Permit insurers to offer catastrophic-only plans to people of all ages. For that matter, health insurers need to be free from the shackles of predefined plans that are inclusive of services that most people do not want or need. A catastrophic-only plan would be selected by many. This might be the worst aspect of Obamacare, and it needs to go. We should be able to buy health insurance the way we buy any other good or service, which is to say, according to our own perceived needs, risk aversion, and willingness to pay.
- Put actuaries to work not just on large groups of people but on individuals, and allow premiums to adjust based on actual individualized health risks. This would strongly incentivize better living. For example, there could be discounts for people who join and use gyms, follow a keto diet, don’t abuse substances, and so on. Reward them and many more will join in better practices. It’s possible that this could happen even without repealing the non-discrimination for pre-existing conditions. Simply reward people with lower premiums for being less likely to use medical services.
- Eliminate legal indemnifications from pharmaceutical harm. The rest would take care of itself.
- Permit non-allopathic services providers such as naturopaths and homeopaths to enlist to be paid with insurance money. This would save insurance companies millions if not billions of dollars. Such doctors rely on supplements and alternatives, not drugs, that cost far less. And they help people fix their lifestyle choices. This fits where the market is going in any case, as people are seeking out a greater range of opinion.
None of these eight reforms rub hard on ideological wounds. All are about respecting individual choice, which is the essence of health. They can all be pursued without touching existing entitlement systems and legacy welfare provision. They would amount to the first major steps toward creating parallel systems of experimentation, all within the framework of the existing system. It seems like they should earn bipartisan support.
