Primary Care: Time to Reboot

April 8th, 2008 by DrRich

American primary care medicine has entered into a period of change. “Change” is perhaps too mild a term; many - especially the primary care practitioners (PCPs) themselves - might call it a period of crisis. In any case it is change so profound that one might be forgiven for thinking Senator Obama is already president.

Consider. PCPs have been hogtied to a dysfunctional reimbursement system that (thanks to the government, the insurers, the AMA, and their own specialist colleagues) has drastically and systematically devalued their training, expertise, and time. The very concept of what a PCP is and does (and indeed, what they should be called - whether PCP, family doctor, general practitioner, gatekeeper, or medical homemaker) seems in constant flux.

Whatever it is PCPs do, the government, the insurance industry, and experts on medical policy have spent years making the primary care job seem, well, easy. Their practices have been reduced to a series of discrete, easily cookbookified tasks. Each of these tasks can be directed by “guidelines” (devised, of course, by non-PCP “experts”), compliance to which can be easily tabulated and monitored, thereby to determine the adequacy of the individual PCP’s performance. And, because their job is now so codified, they are expected to perform it accurately and reproducibly in a matter of minutes (some say 7.5 minutes per patient encounter, though others will allow up to 12.5), just like any other rote industrial process.

To make matters worse, PCPs are slowly awakening to the realization that they are being squeezed out from the bottom. Some of what they do (the really easy stuff) is being corporatized into mini-clinics by the large drug store chains, and the rest is being threatened by newly assertive nurse practitioners and doctor-nurses, who are at least tacitly supported by the insurance industry. (Thanks to Dr. Poses for pointing out the relationship between doctor-nurses and big insurance.)

No wonder PCPs have become so terminally frustrated.

It is natural for PCPs to want to fight the changes that are destroying their profession, and causing their numbers to dwindle. Many have offered ideas. Gain the public’s support by alerting them to the impending and dangerous shortage of PCPs. Improve PCP payment schedules. Forgive the student loans of young doctors who choose primary care. Lobby congress for pro-PCP legislation. Offer novenas.

Some of this (DrRich is thinking the novenas) might hold off the inevitable for a time. But PCPs are fighting more here than just the government, the insurers, their specialist colleagues, and nurses filled with thoughts of vengeance (for 150 years of having to give unquestioning obedience to arrogant, clueless and unfeeling doctors, if you care to ask them). The PCPs are fighting history.

What is happening to PCPs is what happens to many experts whose jobs are fundamentally based on knowledge and/or technology. That is, as knowledge and technology advance, some (and perhaps a lot) of what the experts do can be sufficiently simplified and “democratized” that less well-trained individuals become enabled (or believe they are enabled, which amounts to the same thing) to do it themselves.

This is what the market is telling PCPs has happened to them. A substantial part of what they do indeed has been reduced to guidelines and cookbooks (thanks to remarkable advances in clinical studies and medical technology). The typical patient (note: DrRich said “typical”) with hypertension, diabetes, cholesterol abnormalities, and common infections can be relied upon to respond reasonably well to reasonably standardized therapy. And the market is saying to the PCP: “We can find ways of doing this without you.”

The same thing has happened countless times in history. The 1500-year monopoly enjoyed by the clergy in interpreting the Word of God was completely disrupted by the printing press and by the upstarts who translated scripture into the vernacular. The music industry has been fundamentally disrupted by digital recording software, which enables anyone with a PC to do things that had always required multi-million dollar studios. Ditto for book publishing. Ditto for real estate agents, accountants, car dealers, teachers, newspapers. All are wrestling to one degree or another with the “creative destruction” that is produced by advancing knowledge and/or technology.

For the most part, of course, nobody (except, perhaps, the doctor-nurses) will come right out and tell the PCPs to go away altogether. Instead, they’re telling them to dumb down, to just follow the rules, to stick to the guidelines and be paid to perform (one thinks of trained seals), to become like the lesser-trained practitioners who inevitably will be replacing them over the next decade or so. That’s where the profession is going, they’re being told. Get with the program, adapt to reality - or don’t let the door hit you where you keep your wallet.

Looking at the situation from this more historical perspective, one can see why it seems futile for PCPs to respond by railing and complaining, by lobbying for the public and the legislatures to understand that they’re actually quite important, by appealing to their specialist colleagues for more than lip-service support, or by trying to convince more medical students to choose a disintegrating profession such as this.

PCPs are in the path of a tidal wave of disruption, triggered by economic realities and enabled by technology. They are unlikely to prevail by a’wishing, and a’hoping, and a’singing, and a’praying.

From the perspective of history, it becomes apparent that what PCPs need to do is reboot. They need to reinvent themselves in a way that is compatible with the new reality. So far, they seem to be seeing only the disruption part of the creative disruption now tearing their profession apart. They need to find the creative part.

From a simple examination of history, two possibilities will immediately come to mind.

1) Just as advancing medical knowledge and technology has made it possible for lesser-trained individuals to encroach on their turf, so have the same advances made it feasible for PCPs to encroach on the turf of their snugger (and smugger) colleagues - the specialists. Observing how some of the bread-and-butter skills of the PCP have been sufficiently reduced to the point that nurses can do it, one finds it inconceivable that similar basic skills now monopolized by specialists haven’t been similarly reduced. It is undeniably true that for a lot of what specialists do, one doesn’t actually need a specialist anymore to do it. (As a cardiologist, DrRich knows for a fact that this is the case, but unfortunately he is bound by blood-oaths extracted by the high priests of his guild - oaths which mortgaged the immortal souls of his progeny down through 10 generations - not to mention the specifics. Sorry.) But look around. You’ll find examples easily enough.

Fundamentally, advancing technology allows individuals to migrate upwards into areas formerly occupied only by more specialized individuals. This is a law of technologically progressive societies. That nurses are aggressively migrating upwards onto the turf of PCPs is merely a case in point. So, rather than fighting a doomed-by-history rear guard action against the advancing army of nurses, why should PCPs not instead launch a blessed-by-history invasion of their own, against the smugocracy (the people whose jobs end in -ologist)? Heck, they’ll even have the insurers and the feds on their side for once (for the same reason the doctor-nurses now do). Wouldn’t that be novel?

2)Another law of technologically progressive societies is that, whenever specialists are displaced by upwardly mobile, technology-enabled non-specialists, there will always be a portion of the customer base that is likewise displaced. That is, the new, less-sophisticated service providers will be able to provide useful services to a majority of customers - but not to all customers. The customers with high-end needs, who are left out under the new regime, present a new business opportunity.

PCPs operate in a world where the majority of their patients probably have relatively common, relatively easily cookbooked medical problems, and most of these patients will do just fine with their new doctor-nurses. But a substantial minority will have high-end needs, either in terms of complex medical problems that cannot be reduced to simple treatment pathways, or in terms of atypical medical problems that are not easily diagnosed.

DB has discussed at some length this “long tail” in the patient population, as defined by some aspect of material complexity in their medical conditions. The long tail simply cannot be served by guideline-directed care, whether administered by doctor-nurses, or by those more malleable (or complexity-averse) PCPs who will simply allow themselves to be absorbed by the new, dumbed-down primary care regime. Long-tail patients, the outliers, will not be small in number. They will comprise an important new business opportunity, “new” because it is a niche that is not recognized today, as it will be when these patients are being systematically (instead of randomly) culled out.

That business opportunity can be filled by many of today’s PCPs. These will be doctors who enjoy puzzling through complex diagnostic problems, and dealing with complex management issues, and have been trained to do so. To DrRich, this spells “internist.” Doctor-nurses can’t do this job. Specialists can’t do it either. This will be a specific niche for internists.

The best part is that the feds and the insurers, in selling us on the dumbed-down PCP model, are busily assuring us that there is no substantial need for sophisticated PCPs (hence, the appropriateness of doctor-nurses). And in proving the point they’ll be able to rely on carefully constructed, population-based outcome measures (which, since they speak to the average patient, will look very favorable) to marginalize the complaints of the outlying patients. Having refused to acknowledge the existence of complex patients, they’ll hardly be able to make special provisions for their care.

This leaves the door wide open for internists to establish practices to provide healthcare services to patients with difficult diagnostic or management problems, who are being neglected and mishandled by the “official” healthcare system. (These patients know who they are, and are desperately looking even today for somebody to help them.) And since to insurance companies and the feds these patients don’t exist, these practices will have the opportunity to operate outside the system, as private-pay practices, which will eliminate the demeaning checklists, the one-size-fits all guidelines, and the stifling time limits under which PCPs now must operate. And, like plumbers and electricians, they can get paid for what their time and expertise is worth.

(To those of you who immediately object to such a thing because asking patients to pay themselves for medical care is unethical, DrRich asserts it is indeed possible to do this entirely fairly and ethically, while allowing almost anyone who wants this kind of service to have it, and some day he will describe how. But for now, just celebrate the right of people to spend their own money on their own healthcare even when it’s provided by actual physicians, just as [DrRich suspects] you celebrate their right to spend money on chelationists, homeopaths, or reiki practitioners.)

The bottom line, as DrRich sees it, is that the identity crisis now being experienced by American PCPs, while certainly catalyzed by healthcare economics and politics, is a manifestation of the natural and inevitable disruption produced by advancing knowledge and technology. PCPs may be the first, but all physicians will soon face similar challenges as long as medicine continues to advance.

If the PCPs respond logically to this crisis - that is, instead of fighting it, recognizing the opportunities it presents - their specialist colleagues will soon experience their own “encroachment from below,” which is the hallmark of a mobile, technologically progressive society.

Posted in New business models for healthcare, Primary Care in America | 20 Comments »

Should We Aim For Equality or Autonomy in Healthcare?

March 31st, 2008 by DrRich

In a previous post we considered the first of three questions we must resolve before we can decide on any plan to fix American healthcare, namely, the question of whether the healthcare system should be universal.

In this post we will take up the second question: Should our healthcare system be designed to enforce equality, or should it instead permit Americans to exercise their autonomy as individuals?

Note that this question becomes relevant only because the answer to the first question (should the healthcare system be universal?) is “yes.” If we don’t have a universal healthcare system, then by definition we won’t have the option, much less the means, of trying to enforce equality. But once we decide on a universal system (i.e., a publicly-funded system of providing healthcare to everybody), then equality - equal access to healthcare services for everybody - seems not only the fair and logical next step, but also at first glance a very good thing.

The very fact that equality of access seems so naturally desirable - and thus will be very difficult to turn aside - is what makes the notion of a universal healthcare system so disagreeable to DrRich and many others, and is what makes the necessity of a universal system so fundamentally distressing. As it happens, the mere fact that this issue will have to be debated threatens the very nature of the American compact.

We should note right away that there is nothing inherent about a publicly-funded system of healthcare that demands equal access to all healthcare services. The only equal access demanded by such a system is equal access to whichever healthcare services are publicly-funded. That is, universal healthcare does not necessarily preclude individuals from supplementing publicly-funded services with their own resources. To achieve equal access to all healthcare services (and not just the services that are publicly-funded), we would have to actively restrict individuals from exercising their rights of individual autonomy.

To say this another way, ensuring the overall equality of access to healthcare services turns out to be not a positive good (i.e., granting the populace a boon they otherwise might not have), but instead turns out to be a negative restriction of rights.

The right that will have to be restricted is not a trivial one, like, for instance, the right to board an airplane without undergoing a body search. Let’s be clear on what we would be restricting here: We would be denying individuals the right to spend their own money on their own health.

Health - avoiding illness, disability and death - itself has a high intrinsic value, and restricting an individual’s right to use their available resources to maintain their health will have a high personal cost. But the cost will be much higher than just to individuals.

If We the People cede to our government the power to restrict us in this way, we will be abrogating the very foundation of our culture. We will be saying we no longer hold as self-evident our unalienable rights to life, liberty and the pursuit of happiness.

Our founders, recognizing the human condition, consciously tried to establish a system of government that would guarantee individuals the liberty necessary to pursue for themselves the best achievable outcomes, and that would maintain a reasonably level playing field (i.e., as level as practicable) on which they could pursue it. As imperfectly realized as it may be, this effort has made the United States everything that it has become.

It is beyond disturbing that we seem ready to abandon our foundational principle, especially since it will be for no good reason. We would be empowering our government to abridge our personal liberties, all in a vain attempt to achieve something that our founders recognized could never be achieved and should not be sought - an equality of outcomes

Why an equality in outcomes is not achievable.

Achieving equality in healthcare services is simply not feasible; it can’t be done. At least not in America.

Any healthcare system we devise will simply fail if we try to restrain people of means from exercising their fiscal freedom. Restraining this freedom does not work in Canada (whose efforts to enforce a universal system has created a powerful flow of wealthier Canadian patients to healthcare facilities in American border states), nor in Britain (which has given up altogether its attempts to restrict people from seeking healthcare outside the National Health Service, and has allowed a shadow self-pay healthcare system to develop). It certainly won’t work in America.

If we were to attempt to enforce equal healthcare across the population (and at the same time achieve the necessary limits on public spending), the demand among many Americans for more healthcare than the bureaucracy allows will inevitably stimulate a response from creative entrepreneurs. Some of the offerings one could imagine might include black market healthcare, overseas medical tourism, converting mothballed Soviet aircraft carriers to off-shore healthcare Meccas, or (following the example of the gaming industry) building Mayo Clinic equivalents on Native American reservations. (DrRich assumes here that retainer practices will long since have been declared illegal, fraudulent, and heretical, and will no longer be an option for American patients.)

Why an equality in outcomes should not be sought.

It is axiomatic that whenever a society becomes dedicated to achieving a perfect equality of outcomes (any outcome), the power of the individual is greatly diminished and the power of the central authority is greatly strengthened. This, simply, is because achieving equal outcomes demands that the central authority must have the power to take whatever commodity is being equalized from individuals whom it deems undeserving, and give to other individuals whom it deems more deserving. While actually achieving equal outcomes is never really possible, societies that doggedly pursue this end ultimately become tyrannical. This axiom our founders understood perfectly.

If we insist on perfect equality under our universal healthcare system, and forcibly prevent individuals from pursuing their own medical happiness, we will fundamentally redefine what it means to be an American. We will change the essential character of our culture - and of our government.

We should not take this path without careful reflection on what it actually means, both for us and for the generations that follow us.

What should we seek to do, then?

Since insisting on enforced equality in healthcare will undermine the founding principles of our culture, and won’t work besides, a better solution would be to first acknowledge that fact, and then to devise a system that - while incorporating universal access to publicly-funded healthcare - honors the autonomy of individuals to provide for their own well-being, in a way that maintains an acceptable degree of social equity. Such solutions can be imagined.

They will never even be imagined though, let alone achieved, if we allow our political leaders to lure us down the “obvious” path of enforced equality in healthcare, at the cost of individual autonomy. If this is the kind of change we opt for, we’ll be changing America in much more fundamental ways than by just altering our healthcare system.

In a later post we will take up the third and final question we must answer before figuring out how to fix American healthcare: Where’s the rationing?

Note: This is the fourth in a series of posts that discuss healthcare economics, and the three basic questions we will have to answer before we can devise a way to fix American healthcare. The first post in this series can be found here.

Posted in Fixing American Healthcare, Healthcare economics | 1 Comment »

Should the Healthcare System be Universal?

March 26th, 2008 by DrRich

As noted in a previous post, there are three basic principles we are going to have to resolve before we can decide on any plan to fix American healthcare. The first of these is: Should the healthcare system be universal? That is, should our reformed healthcare system apply to every individual legally residing in the United States?

DrRich is truly distressed to report that the answer to this question can only be: Yes.

DrRich is constitutionally predisposed against a universal healthcare system. By “constitutional” he refers not only to his own inherent biases, but also to the document produced by our nation’s founders. In that document our founders took pains to preserve individual liberties against the opposite extremes of anarchy and tyranny, and recognized that an indispensable component of personal liberty is personal responsibility.

The personal responsibility that makes personal liberty feasible includes the responsibility to provide for oneself the necessities of life, as well as those nonessential things one typically consumes during the course of one’s lifetime. A society founded on liberty and economic freedom, for instance, requires that products and services consumed by individuals, such as Caribbean cruises, ice cream, food, clothing and healthcare, should be provided by the individuals who are consuming them.

To be sure, in a compassionate society arrangements can and should be made on occasion to support individuals whose circumstances prevent them from supplying themselves with certain necessities of life, such as food and shelter. Healthcare will also often fall into this “necessities of life” category, and therefore a compassionate society will find it salutary to provide such care to some of its citizens on occasion. (Some of what we now deem “healthcare” has aspects more in common with Caribbean cruises than food and shelter, and we seem to have an increasingly difficult time differentiating the essential from nonessential varieties; we will leave this problem aside for purposes of the present discussion, and instead take it up later.) But the desire to help certain of its citizens who are unable to gather some of life’s necessities - a charitable desire that redounds to the civility and well-being of the whole - is a far cry from the duty, or even the desirability, of providing the necessities of life to all people, or even to certain categories of people defined by some arbitrary characteristic (such as age).

There are, of course, philosophical problems in taking what ought to be the responsibility of individuals and handing that responsibility off to society. You can find discussions of these problems by reading the founders. But DrRich is no philosopher, and besides, it appears to him that roughly half of America believes today that society ought to provide the necessities of life to all its citizens. Not wanting to cause unnecessary turmoil among his readership (DrRich being a lover and not a fighter), he will leave philosophy aside and instead rely on the economic question. For, while bad philosophy often smolders for many generations before bringing down a culture, bad economics will do it much quicker.

We have detailed in a previous post the astoundingly dysfunctional economics of American healthcare, and how the fiscal obligations to which we have already agreed are leading us inexorably to destruction. The idea of a further expansion of those fiscal obligations at this point is beyond absurd. (”Beyond absurd,” that is, in the sense that it’s beyond absurd to shoot yourself in the head while falling to your death after jumping off a cliff. Putting a bullet in your brain might normally be considered absurd, but actually it adds very little net harm once you’ve already leapt off a cliff; that is, it’s beyond absurd.)

So, you may be asking, if making the provision of healthcare a societal obligation is morally, philosophically and economically undesirable, then why would DrRich assert that any reform of the healthcare system should be universal?

It’s not because healthcare is necessary for life (since necessities of life ought to be the responsibility of individuals), nor because healthcare is a right (since there is no such thing as a right that requires forcibly reducing the rights of others; such a thing is properly labeled not a right but a tyranny), nor even because healthcare is very desirable (since, after all, so are Caribbean cruises). No - our reformed healthcare system will have to be universal not because of any positive attribute of healthcare itself (not because healthcare, being good, ought to be provided for everybody), but rather because of the negative character of our current healthcare economics.

Because the healthcare obligations we have already signed up for promise fiscal ruin in the foreseeable future, the one non-negotiable requirement of any meaningful healthcare reform we may undertake will be (must be) to restore some real hope of economic stability. (Anything else we may do, including insuring the uninsured, sending men to Mars, defeating terrorism, or achieving energy independence won’t matter if society collapses under the weight of its accumulated healthcare debt.) And saving our society from economic collapse requires a solution that applies to everybody.

In a previous post we saw that the underlying cause of our impending healthcare fiscal crisis is our systematic failure to establish limits. That failure derives directly from our decision - taken over the past 60 years - to collectivize healthcare expenditures. Whether directly (through Medicare and Medicaid), or indirectly (through tax-deductible “private” insurance premiums), the taxpayer is subsidizing virtually all healthcare spending in the U.S. While this arrangement might be fiscally acceptable if we were on a pay-as-you-go basis, the fact that our present unfunded obligation for Medicare alone reaches $34 trillion demonstrates that we are not. By saddling future taxpayers with an enormous fiscal burden that guarantees societal disruption - slapping away that small hand that reaches up for ours - we reveal ourselves as being something other than compassionate conservatives, or compassionate liberals, or compassionate anything. If we fail to limit our appetite for healthcare expenditures that benefit only ourselves, we will be revealed in a decade or two to our own children and grandchildren (not to mention to future historians) as among the most morally repugnant generations in history.

Any real healthcare reform will have to be universal not in order to spread the benefits of healthcare evenly. It will have to be universal because real healthcare reform, fundamentally, will have to be an assertion of limits on publicly-subsidized healthcare. Anyone whose healthcare is subsidized by present or future taxpayers will have to receive their healthcare benefits under this new system of limits. Since it is difficult to imagine anybody today whose healthcare is not so subsidized, any meaningful healthcare reform will have to apply to everybody; it will have to be universal.

Stated another way, healthcare reform must be universal in order to accomplish the one thing that such reform absolutely must accomplish - setting the limits that will allow rising generations of Americans a fair chance at maintaining societal stability. Universality is not required by a concern over healthcare benefits; it’s required by the need to establish real limits.

In future posts we will look at the Fuchs/Emanuel universal voucher system (DrRich’s original assignment), to see how well it meets the “universality” criterion herein defined.

But first we need to consider the second principle that must be resolved before we can effectively reform American healthcare - should our healthcare system be designed to enforce equality, or should it instead permit Americans to exercise their autonomy as individuals?

Note: This is the third in a series of posts that discuss healthcare economics, and the three basic questions we will have to answer before we can devise a way to fix American healthcare. The fourth post in this series, “Should We Aim For Equality or Autonomy in Healthcare?” can be found here. The first post in this series can be found here.

Posted in Fixing American Healthcare, Healthcare economics | 4 Comments »

Can a Voucher System Fix American Healthcare?

March 21st, 2008 by DrRich

A previous post considered the main problem with current healthcare financing as described by Drs. Fuchs and Emanuel, namely, that individuals are actually paying for their own healthcare today, but are led to believe that the cost is actually “shared” by businesses and government. Since they believe they are getting something for nothing, there is no incentive for Americans to limit their demands for healthcare.

It should be no surprise, therefore, that the solution proposed by Fuchs and Emanuel offers to make individual Americans aware of how much of their own money is being spent.

Under their plan, every American will be given vouchers by the government to purchase health insurance from private companies. The vouchers will be paid for from a Value Added Tax (VAT) on purchased goods. Insurance companies would be required to sell a basic insurance plan (fully covered by the vouchers) to any individual American, regardless of any underlying medical conditions.

Furthermore, individuals would not be limited to the insurance they receive under the voucher plan. Instead they would be free to purchase whatever additional healthcare coverage they choose.

The Fuchs/Emanuel plan is therefore universal, but also intends to preserve Americans’ freedom of choice. In DrRich’s estimation, it is the explicit nod to freedom of choice that makes this proposal interesting.

The “basic health services” that would be required under this plan (i.e., the services that insurance companies would have to provide to anybody with a voucher) would be determined by a federal health board, specifically modeled after the Federal Reserve Board.

Notably, Senator Tom Daschle has recently published a book that also recommends a federal health board modeled after the Federal Reserve Board. How much of this idea he may have received from Fuchs/Emanuel (who have been writing about this for a number of years) is not known to DrRich. But Daschle’s call for a federal health board has been endorsed - at least to the extent of supplying “blurbs” to spur book sales - by several disparate political figures including Senator Bob Dole and Senator Barack Obama. So, apparently, the “federal health board” may be an idea that is gaining in popularity. (It is perhaps unfortunate that both the Fuchs/Emanuel proposal and the Daschle proposal were advanced well before the current credit crisis made the Federal Reserve Board seem far less omniscient and sure-footed than in happier days, and perhaps less welcome as a role model than it might have been a few short months ago.)

In any case, the fact that a federal health board has been championed by a noted American progressive makes DrRich suspicious that the idea of such a board is not inextricably tied to the notion of individual autonomy, as it is under the Fuchs/Emanuel plan. In the Daschle plan, the federal health board is the centerpiece; it is the whole idea, and is the means by which a centralized authority will control American healthcare. In the Fuchs/Emanuel plan, the voucher-supported basic coverage supplemented by individually purchased insurance is the centerpiece; the federal health board is “merely” the mechanism that will define what we mean by “basic coverage.” At least, that’s how DrRich understands it. And understanding it this way, DrRich will formally reject the Dasche plan as simply another way of turning the American healthcare system over to the feds, (so there, Tom!) and will consider the Fuchs/Emanuel plan more closely.

Will a scheme based on the Fuchs/Emanuel universal voucher plan work?

Now, DrRich has advanced his own plan for fixing American healthcare, thus joining the not-so-exclusive ranks of Fuchs, Emanuel, Daschle, Clinton, Obama, (maybe McCain - DrRich is not really sure), and thousands of others. And it would be all too easy and all too unproductive to dive into a long tract comparing the particulars of these many plans (possibly designed to show why none of them would work as well as DrRich’s).

But in truth, DrRich does not pretend to really know what the “best” plan for solving our healthcare problems might look like, and does not wish to try to drag his readers through the mud in a vain attempt to find out.

There are, however, some basic principles that will need to be decided upon - whether implicitly or explicitly - in any plan that offers to fix American healthcare. These principles will determine not only what kind of healthcare system we are to have, but also what sort of society we will become.

So in evaluating the Fuchs/Emanuel voucher plan (which was DrRich’s original assignment), he will do so within the framework of three basic ideas that must be addressed in any system that proposes to fix American healthcare. These ideas are:

1) Should the healthcare system be universal?

2) Should the healthcare system be designed to enforce equality, or should it instead permit Americans to exercise their autonomy as individuals?

3) Where’s the rationing?

We will explore each of these three questions in subsequent posts.

Note: This is the second in a series of posts that discuss healthcare economics, and the three basic questions we will have to answer before we can devise a way to fix American healthcare. The third post in this series, “Should the Healthcare System Be Universal?” can be found here. The first post in this series can be found here.

Posted in Fixing American Healthcare, Healthcare economics, New business models for healthcare | 3 Comments »