Mon Dieu! If only policy was informed by French philosophy these days (or any philosophy, for that matter). The closest we seem to get to this recently is David Cameron embracing libertarian paternalism, and then his health spokesperson dismissing it a few weeks later (the philosophy of the inconsistent). Reading Hazel Blears sometimes makes me think that the intellectual content of British politics can't really get any worse (I guess I shouldn't really say this to Americans, after 8 years of Bush), but the Conservatives seem determined to prove me wrong.
Still, I read somewhere that Obama is surrounding himself with more top minds than any President since 1800 (or so). So, you can sleep easier now, Alan.
________________________________
From: Maynard, A. [mailto:[log in to unmask]]
Sent: Tue 2/17/2009 10:55 AM
To: Oliver,AJ
Cc: [log in to unmask]
Subject: Medicaid and NHI - NEJM piece
Thanks for this homework Adam
I read Michael's article with interest when it appeared last month. It
is a logical and pragmatic approach As ever we have to apply evaluative
criteria in relation to the conflicting policy goals being pursued
i) equity: expansion/equalisation of the income ceilings offers coverage
of the uninsured by stealth but challenges State's "autonomy".Dragging
Arizona to New Jersey levels may be difficult! Some nice politics
ensues! Medicaid could grow into a public insurer which competes with
the inefficient private insurers (they are poor purchasers who condone
inefficiency) in some ways like what Tom Rice is advocating (Health
Economics's Editorial available in electronic form and in printed
version soon)
2) efficiency: increasing access and expenditure does not tackle the
gross inefficiencies of the US health care system. These inefficiencies
are well chronicled e.g clinical practice variations from Wennberg to
Fisher, avoidable medical errors which kill more Americans annually than
Vietnam/Iraq/Afghanistan, the lack of regard for measuring success i.e.
outcome measurement, despite Codman's advocacy over 100 years ago, and
perverse incentives! The Brits are little better of course but to ignore
these issues is to court disaster from.....
3) expenditure inflation. I have always been a keen supporter of high
levels of expenditure inflation in the US health care system as this
constrains, admittedly inadequately, our cousins spending on the
military and foreign policy!!. However, semantics apart, we are now in a
depression, and the incentives inherent in the US health care systems
make inflation a major risk. Before more loot is pumped into the system
the cartels have to be constrained by technology appraisal which shows
that often the pharmaceutical emperor has scanty clothes (i.e. some of
the new drugs are not cost effective) and by patient level data that
shows that doctors are poor managers who need comparative data and
better incentives to be "healed"!
As Fuchs and others have written in the NEJM and elsewhere, we know what
to do in principle. However the practice is difficult due the founding
rebels adopting too much French philosophy in creating their political
institutions!
Best wishes
Alan
Professor Alan Maynard, University of York, England
Chairman, York Hospitals NHS Foundation Trust
Founding Editor, Health Economics
Adam Oliver wrote:
> Hi
>
> Attached is a short piece by Michael Sparer on the possibility of expanding Medicaid to achieve universal insurance. Michael would appreciate your comments - his email address is [log in to unmask]
>
> All best,
> Adam
>
> Please access the attached hyperlink for an important electronic communications disclaimer: http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm
Please access the attached hyperlink for an important electronic communications disclaimer: http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm
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