A Modest Proposal on Vouchers

I have a “modest proposal.” http://en.wikipedia.org/wiki/A_Modest_Proposal.  Rather than creating a voucher system in education, as some have suggested, why not convert Medicare — which is a voucher system — into something that works like the public schools?

Under the Medicare program, the federal government pays for health care, but the elderly are allowed to choose any health care provider they please.  If the nearest public clinic isn’t good enough, they are allowed to use other non-profit, for-profit, and public health facilities elsewhere, and still have Medicare pay.  Moreover, the level of Medicare reimbursement is the about same (with an adjustment for the cost of living) whether the patients were dishwashers or doctors in their working lives, and whether they live in Scarsdale or the South Bronx. 

Health care workers also have choices.  The states license them to ensure a minimum level of quality, but beyond that they run their practices as they please.  If they can’t get a job at a public hospital, they can get one at a private or non-profit hospital, and Medicare will still help fund their wages.  Or, they can start their own health care practice, and still bill Medicare.  As a result, doctors and nurses are paid as much in private hospitals and clinics as in their public counterparts.  Even HMOs give patients a choice of doctors and hospitals, and doctors and hospitals still have a choice of which HMOs they can choose to join.

How can Medicare become more like the school system? 

First, Medicare patients would be forced to go to the single doctor or hospital they were assigned to.  If the care wasn’t good enough in their opinion, they could move, or go to a private health care provider.  Even though they paid the same taxes as everyone else, however, those going to private health care providers would not receive Medicare funds. 

And the level of Medicare reimbursement would be adjusted based on the affluence and influence of each community.  It would be higher in affluent suburbs, but lower in areas with many low income or minority residents.  To limit political opposition, there would be special “magnet hospitals” for “gifted” patients in areas with otherwise terrible health care.  Elected officials could get their health care there.

For their part, doctors and nurses would have to get a job at the single Medicare agency, or settle for much lower wages in private hospitals and practices.  On the other hand, their wages would not vary based on the quality or quantity of their work.  Once they received tenure, they would be paid even if they barely made an effort, and the patients would have nothing to say about it.  In poor communities, many of the doctors and nurses would be uncertified.

That may seem like a big change, but we can get there through a slow evolution.  As a first step, all public employees could be required to use public hospitals and clinics.  Here in New York, that would do wonders for the finances of the Health and Hospitals Corporation, and might even save the city money compared with its health insurance payments, since it could provide a lower level of health care spending for city workers living within the city than for those commuting in from the suburbs.

Then,  HMOs could be encouraged to merge until there is just one big HMO in every community, which every doctor and hospital is obligated to work for and every patient is obligated to join, and that assigns each patient one primary care doctor and hospital without consulting them.

Finally, the government could either take over the one HMO, or control it through regulation, with an additional bureaucracy approving its every decision.  Here in New York, that could also save money if the elderly who are sufficiently affluent to have choices move out or pay for health care on their own, the way parents do.

Politically impossible?  Perhaps.  But here in New York, we should take the position that if it’s good enough for the kids, it’s good enough for the seniors and public employees.