My friend works for the National Health, Doctor Robert; Don't pay money just to see yourself with Doctor Robert

I know tonight is the big Iraq speech, but until we have a serious President willing to treat us like adults, I'm not going to waste my time on half-baked recyclings of quarter-baked plans that will fail again for the same reasons they've failed before, dooming countless more American troops and Lord knows how many Iraqi civilians to blatantly unnecessary deaths. If I was even vaguely religious, I'd say God have mercy on the souls of all of us poor bastards, but I'm not. If you happen to be, you may want to consider including humanity in your prayers. We need it desperately.

Instead, let's go over a topic where the situation is just as fucked on the ground, but we can at least maintain some hope: healthcare. Just to set some parameters, people in the US spend more per capita on healthcare than any country in the world. From the Kaiser Family Foundation:

It is reasonably well known that for some time the United States has spent more per capita on health care than other countries. What may be less well known is that the United States has had one of the highest growth rates in per capita health care spending since 1980 among higher income countries. Health care spending around the world generally is rising at a faster rate than overall economic growth, so almost all countries have seen health care spending increase as a percentage of their gross domestic product (GDP) over time. In the United States, which has had both a high level of health spending per capita and a relatively high rate of real growth in that spending, the share of GDP devoted to health grew from 8.8% of GDP in 1980 to 15.2% of GDP in 2003 (Exhibit 5). This almost 7 percentage-point increase in the health share of GDP is larger than increases seen in other high-income countries.

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Despite this higher level of spending, the United States does not achieve better outcomes on many important health measures.

Let's be clear here: since we are the only major Westernized nation without some kind of national healthcare system, Americans spend vastly more money privately on healthcare than anyone in the world by a vast margin. On top of this, our government also spends more money than any other government in the world. The total amount ends up nearly double that of any other country, as this table shows (BTW, a side note: this link goes to Ezra Klein's blog. He's one of the writers at The American Prospect, with a focus on healthcare and labor issues, and nearly everything I say here can be found in much greater detail over there).

There is some progress on the state government front, with the Governator proposing a statewide private universal healthcare plan in Cali, which is generally but weakly supported by Kevin Drum and Ezra Klein, but knocked by Atrios for being a half-assed vehicle toward the eventual goal. Both sides make some important points about what really is no more than a halfway-measure toward an eventual solution, but I may have to steal some insight from the gay marriage debate and suggest that getting the ball rolling anywhere is important, and there is plenty of time to improve the system as you go. Let's go over the good and bad:

Good: Universal mandates are good. Some people worry about being "forced" to pay for insurance, but Ezra rightly points out that under ordinary circumstances, we call these payments "taxes":

In fact, there is absolutely no universal health care system that wouldn't include a mandate of some kind -- that's how you make it universal. Indeed, without a mandate, you can't have a decent health system: If the healthy can opt-out until they get sick, coverage will be unaffordable for everyone. For a risk pool to work, it needs members at low risk.

The secret is to do what we do with taxes: exempt those whose incomes fall below a given level. California wants to use 250% of the poverty line. Ron Wyden has a plan in Congress with a more attractive and expensive 400% (soak the rich!), but at least we're on the right track, and everyone is covered.

Community Rating: This means that they can't just boot you for having a pre-existing condition or a "dangerous" job. In California, they deny all coverage to firefighters, athletes, and people taking Celebrex and any number of other medications. This is rather obviously a crucial bit of a universal system, and one of the main weaknesses of the current system, which punishes people for proactively discovering and treating medical conditions.

Bad: Private insurance companies are horrifically inefficient. Their goal, as corporations, is to make money, primarily by insuring young and healthy people who will have low medical expenses, and denying coverage to older and sicker people, who actually need the insurance in the first place. Healthcare costs are incredibly unevenly distributed, with costs concentrated amongst small populations. Insurers can ditch these people, insure the rest, and make huge profits, all while defeating the purpose of the system treated as a whole, For a more recent example, consider the fact that insurers pay hundreds of dollars, if not thousands, to find each new Medicare plan signee. The money they make must be greater than this amount, and it comes from taxpayers and the Medicare clients themselves.

Employer-based insurance is no longer viable. I am at my third job in my twenties, with a new one coming up in the not-too-distant future. Each time I move, I need a new insurance company. God forbid I ever have a pre-existing condition. In fact, there is a huge incentive for me not to find one until I get a permanent job. This is not a good medical incentive. Even worse, academics have among the most stable career paths out there. In today's more transient working society, the old employer-based model doesn't work (it's also killing off a few American companies, like GM). This is the key to the Wyden plan, which would eliminate employer-based insurance. For this reason, it is currently considered fanciful, and will eventually be considered so obvious that our children will wonder how their parents ever managed to tie their shoes or feed themselves.

The obvious solution is single-payer, in which everyone pays into a central pool, and the national system pays out to doctors (like Medicare or the VA system). At this point it's damn near inevitable, but for the fact that it would put insurance companies out of business. Someday, the outcry against the ridiculous system will force us into change, but at least a few big states passing half-assed measures have made this a respectable debate again, a decade after the Clinton plan was unfairly savaged by the insurance industry. We'll close with Paul Krugman, to whom one is wise to listen, but for the fact all his columns in the NYTimes now require a subscription. From the NY Review of Books:

So what will really happen to American health care? Many people in this field believe that in the end America will end up with national health insurance, and perhaps with a lot of direct government provision of health care, simply because nothing else works. But things may have to get much worse before reality can break through the combination of powerful interest groups and free-market ideology.

In a nutshell, we currently do everything wrong. We eliminate economies of scale by having too many companies provide the same service to their own smaller client bases, and in doing so manage to unpool the risk from the population back onto smaller groups, which defeats the whole purpose of insurance in the first place. The future can't arrive soon enough.