This is an addendum to some excellent proposals already made in this discussion. I think it is not in conflict with them.

Summary: My major approach would be to reduce the cost of medical care by promoting health, thus decreasing the number of patient office visits and hospital days because there would be fewer patients–fewer persons sick at any one time.

There are three general areas of health care: public health, which includes activities such as water purification, sewage disposal, pollutant control in the air, food safety, product safety, and crime (especially violent crime) prevention; personal health care, which includes what and how much we eat and drink, our physical activities and non-activities; and medical care, which includes direct care of sick persons by the various medical professionals, immunizations, medicines, and medical devices.

My goal for health care is that each persons lives a longer, healthier, and more productive life–knowing that there is not a necessary trade-off between length of life and good health, knowing that on average those who live the longest have the shortest period of disability at the end. My goal also includes accomplishing that and still being able to have good schools, good basic infrastructure, a good law enforcement system, and a strong national defense. Consistent with these goals, much of my approach is focussed on reducing the number of medical care patients.

As a general principle, I see no way of decreasing the cost of the medical care aspect of health care, while giving the kind of medical care that the vast majority of sick persons will want, without decreasing the number of persons who are medical care patients (sick or injured persons) at any given time. But that goal of diminishing the number of medical care patients coincides completely with the goal of a longer, healthier, and more productive life for everyone.

It is a consensus among health care experts that the greatest factor in the improved health and longevity over the past two centuries has been improvements in public health, especially safe drinking water and sewage disposal. I favor continuing work in this area of health care. There is good evidence, for example, that a lot of pulmonary and cardiovascular disease is caused by micro-scale particles in the atmosphere, those so small that they do not even reduce the clearness of the atmosphere. I favor stronger restrictions on behavior that endangers others. I would incarcerate violent crime perpetrators even longer. (An aside: I would decriminalize recreational drugs, which would decrease greatly the burden on the law enforcement system and decrease drug-distribution violence, even though it may increase some the cost of drug treatment and education.) I would outlaw completely the use of electronic communication devices of all kinds while driving. Even use of the least dangerous of these makes the driver as dangerous as when under the influence of 0.08 level of alcohol, and text messaging by truck drivers increases their accident rate 22 times. On the other hand, I am not in favor of a nanny state that requires seat belts, helmets. Nor would I favor a diet consultant visiting the home and checking the refrigerator to try to promote better eating. (I have read that something like this has been proposed in England–so hard to believe, I am not sure it is true.) I will deal with the question of self-destructive behavior that does injure or endanger others later.

There is also a consensus that poor personal health care accounts for about half of all medical care costs. This area includes what we eat and drink, whether or not we smoke or use recreational drugs, whether we engage in risky sexual behavior, how we drive and whether we wear seat belts, and what we choose for leisure-time activities. As a general principle, I would have persons bear the financial pain of poor personal health care. There is already a lot of information about how much various kinds of bad personal health care increases the cost of medical care. There are two ways I can think of to shift the financial cost of poor personal health care from the general public to the individual who does not care for himself or herself. One would be to charge a higher insurance premium to cover all of the actuarially-determined increased costs that that person’s poor personal health care behavior imposes on the medical care system. Another would be for the insurance company to pay only part of the cost of treatment for those illnesses caused in part by poor personal health care. For example, if a certain behavior or ‘life-style’ doubled the chance of a particular illness, then the patient would be reimbursed for only half of the cost of the treatment for that particular illness. (This is how I would deal with problems like not wearing seat belts.)

This shifting of the costs of medical care onto the persons engaging in poor personal health care would have three benefits. One is that the general public would not have to bear that added medical care financial cost. A second is that is would decrease the impulses to make us more of a nanny state. And a third is that there would be a strong economic incentive to take better care of oneself, which would help achieve the goal of fewer medical care patients. There is certainly the hope that persons would behave in a more healthy way, but it is not the nanny approach of intruding into their lives and nagging them to change. Rather, it is one of holding them responsible for the consequences of their behavior. And if, as we are told, that half of all medical care costs arise from bad personal health care, there is a huge potential for shifting costs away from the public sector and, eventually through the economic incentive, eliminating the extra medical care costs caused by poor personal health care.

Be in good heath,

Jim