Tyler Cowen points to some interesting research from Sherry Glied showing that the marginal dollar spent on health care -- which is to say, the dollar spent on experimental treatments and high tech services, not the dollar spent on prevention and flu shots -- isn't very progressive. In other words, rich people use those things more than poor people do, and a progressive system would focus more on the expansion of basic services than new surgeries. Tyler seems more surprised by this finding than I am, but in any case, it's true. And it doesn't change the fact that a universal system would not only be a whole lot more progressive than what we've got today, but it would also make a whole lot more sense. Indeed, that's the implication of the other part of Glied's paper, which makes a fairly important point no matter where you stand on the ideological spectrum. She finds that whether you route money through the government or the private sector isn't a terribly important variable in how much your costs grow, rather "the efficiency of operation of the health care system itself appears to depend much more on how providers are paid and how the delivery of care is organized than on the method used to raise the funds." This is, again, true. At a recent health care conference I was at, one of the panelists was talking about the efficiency of the VA. People get hung up on the fact that the VA is government-run, she said. But what sets the VA apart isn't that it's run by the government. It's that it's an integrated, self-contained system, like the Mayo Clinic. What we have in American health care is a "sector, not a system. And systems work better." That's why I'm always beating this drum on "integration." Creating a health care system that is amenable to reform, experimentation, long-term care management, and all the rest is very important. Where that system is single-payer or hybrid is a secondary concern. Single payer is an easy way to create a single system because it is, by definition, a single system. There are ways to do it in a hybrid context, too. But health savings accounts and consumer driven medicine and all the rest are dead ends in this regard.
