Should health care operate more like public schools?

Posted in Uncategorized

In the New Yorker, Atul Gawande implies that the problem with our health care system is that it isn’t like our K-12 education system:

During the next two centuries, we relied on government to establish a system of compulsory public education, infrastructure for everything from running water to the electric grid, and old-age pensions, along with tax systems to pay for it all. As in other countries, these programs were designed to be universal. For the most part, we didn’t divide families between those who qualified and those who didn’t, between participants and patrons. This inclusiveness is likely a major reason that these policies have garnered such enduring support.

So let’s imagine a world in which the health care system is like our system of public education:

(1) There are local “health care districts” administered by elected politicians.

(2) The HC districts establishes a “local clinic” in each neighborhood.  You’re asssigned to your local clinic and required by law to submit to care.

(3) You’re allowed to “apply” for access to clinics outside your neighborhood, if those clinics “have space.”

(4) Most of the best doctors choose to work at the clinics in the wealthier, whiter neighborhoods.

(5) Therefore, the clinics in the wealthier, whiter neighborhoods provide better care.  They are also full-up with wealthy, white patients.  They’re required by law to turn away the poor, brown folks from other neighborhoods who try to gain access to their doctors.

(6) Each clinic is given an “allocation” of doctor positions, so that the ratio of doctors-to-patients is the same across all clinics.  Salaries, however, are determined by seniority.  The doctors in the upscale clinics make more money, because they typically stick around longer, because the upscale clinics are quite nice places to work.  So the upscale clinics actually have larger budgets for doctor salaries, despite the fact that their patient base is healthier.  It’s redistribution in reverse!

(7) It’s virtually impossible to fire a doctor.  Because they’re doctors!  You can’t fire someone who is a doctor.  He/she needs to be protected.

To his credit, Gawande identifies the root of all our health-care problems: the moment when the federal government made employer-provided health insurance tax deductible.  This whole mess springs from that decision.

But please don’t use K12 education as the model for reforming health care.

 

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