This may be the last word for now on the idea of using the VA for the uninsured, raised by Dave Moskowitz last week. Let me try to put this in a little context. We’re not likely to have a universal health insurance scheme come out of the next Congress. As I write about elsewhere, the proponents of this year’s version of healthcare reform (California’s Prop 72) which I support because it’s better than nothing, come straight out and say that incremental change is all that we can expect. While I don’t approve, I don’t disagree. So Dave’s idea is an incremental change that’s worth considering and also not to far away from Bush’s idea of spending more money on community health clinics for the poor. I did though have a couple of concerns before I appointed Dave to run the much revamped VA. He replies here (and you may notice him getting into the somewhat cynical but jocular spirit of THCB):

You asked two more questions, which I’d now like to reply to:

Is Congress ready to come up with $100 B for healthcare? Perhaps Congress has grown amnesiac since the 1994 Contract On America. They are spending, after all, our taxpayer money. According to the Constitution, they’re supposed to be working for us, not the other way around. Congress has already spent $180bn for the War in Iraq, and have just been asked by the Administration for another $70bn, bringing the total to $250 B, a project which enjoys less than 50% popularity with their constituents. So it would be only reasonable, in a representational democracy, for them to spend $100 B of our money annually on a need near and dear to 70% of Americans. I understand that using the government to help the people has fallen out of favor as a political concept since Reagan took office in 1980, but perhaps the people will gently remind their elected representatives who’s paying their salary and why.

Why separate but unequal in healthcare when it no longer applies in education? Au contraire, gentle blog-meister. Separate but unequal is no longer supposed to apply in PUBLIC education, but Brown vs. Board of Education of Topeka, KS never struck down the inherent separateness (and demonstrated inequality) between public and private schooling. In the US, roughly 85% of education is public, open to all comers, and 15% is private. We’re all aware of public school districts where daily survival is the most one can pray for, let alone a college-prep education. And we’re all aware of the training ground set up by the power elite that includes prep schools like St. Paul’s, St. Alban’s, and Andover. After all, the Presidential candidates for the past four years have come only from those three high schools. Waterloo is still being fought on the rugby fields of Eton, so to speak. (Ed’s diversionary note: They don’t actually play rugby at Eton; they play this weird sport instead and the correct quote is “playing fields”. Anyway Rugby wasn’t invented till decades after Waterloo! End of history and English elitist culture lesson!) So separate and unequal is in no way un-American.

It’s actually as American and as much a pillar of capitalism as apple pie (not to intimate that the pillars of capitalism are grounded in less than cement). It’s seen, for example, in airplane travel (Business Class vs. Coach), ground transportation (luxury SUV vs. public transportation), housing (4-star hotels vs. economy motels; gated mansions vs. trailer-parks), food (fresh T-bone steaks vs. frozen bulk hamburger), medicines (branded vs. generic), etc., etc., etc. People get what they pay for. The goal of government is to ensure that the cheapest commodity is at least non-toxic. In government as in medicine: primum non nocere (first, do no harm). In the case of healthcare, I’ll let you in on a very well-kept secret: the cheaper public system is very likely to yield better patient outcomes than the more expensive, private alternative.

Here’s why: Modern health plans started with the Blue Cross/Blue Shield plans set up in the 1920’s by surgeons to make sure they got paid for the operations they did. Healthcare reimbursement has kept its close ties to the hospital ever since. For 70% of healthcare dollars to be spent in the last 12 month’s of a patient’s life means that it is spent on surgery and ICU care that is futile but expensive. An excellent example of how the system works is the recent decision by CMS to pay for lung volume-reduction surgery (essentially, popping emphysematous blebs) the week after a study in the New England Journal of Medicine showed that it was useless. Only in America!

Genomics makes it possible (finally!) to prevent diseases from occurring, or at least not to be ambushed by them, as we all currently are. Genomics makes it possible to keep people healthier and out of the hospital. The current hospital-based system, which represents the medical establishment in every country, with its research institutes and medical schools, will not go quietly, as the TB sanitaria did in the 1950’s when streptomycin was discovered. But the dynamism of capitalism will save the private sector. In order to regain market share, the hospital-based system will be forced to adopt preventive molecular medicine. Patient outcomes will begin to improve in the private sector, too. There will be aggressive marketing, encouraging patients to stay with their fancy, branded private sector health plans. If the tobacco and ammunitions industries can survive despite their effect on the public health, then the private healthcare system will do fine, too. But we need both players, because the government by itself simply cannot pay for healthcare at the current level, let alone with double-digit inflation. Healthcare would have to be rationed, as in Canada and the UK.

This is politically unacceptable. Americans like the notion that anybody who can afford a liver transplant can get one, and Mickey Mantle can get two in a week. If the private sector folded, the $100 B annual price tag for 45 million currently uninsured Americans would balloon up to $600 B a year for all 270 million Americans. Getting this Congress to spend an extra $600 B a year on health for the nation will be infinitely harder than getting them to spend six times less. So by all means, let’s keep both systems. But if you happen to find yourself, for a time, in the public sector healthcare system, don’t be upset–you may actually be getting better care!

While I think he’s hit the nail on the head with his analysis of the wasted money spent on end of life care — and the Dartmouth crowd agree — I’m still not quite sure if I follow all Dave’s logic. Surely if Congress is going to spend a lot more on health care for all Americans, private sources (that is employers and individuals) will spend less. However, the idea that health plans have to compete on outcomes is something I like the idea of, even if its mostly fantasy for the near-future. I’ll see if this idea crops up elsewhere, but hopefully this has added something to the debate.

Meanwhile certain wags have pointed out that as a non-natural born citizen I can’t be Preznit and appoint Dave as head of the VA. Even if the Constitution was changed and I could be, I might find a tough opponent in a certain ex-steroid using body-builder. The Guvernator is raising my ire this week by both opposing Prop 72 (which given his business connections I’d expect) and much more so by toadying up to the most appalling union in America, the California Correctional Peace Officers Association, in opposing Prop 66 — the much needed amendment to the nutty three strikes law. You may recall that in the recall race Arnie said he was opposed to special interests. The prison guards have been the most egregious and aggressive special interest group in this state for over a decade. Good one, Guv.