Verified by 
In his Presidential campaign, Barack Obama repeatedly assured voters that under his reform plan, "if you like your current health insurance, nothing changes, except your costs will go down by as much as $2,500 per year." That position is probably untenable. In the long run, it is hard to expand coverage to the tens of millions of Americans who lack it without decreasing benefits for those already inside the tent. If you have a top-of-the-line package now, its name may stay the same, but the services you receive when you seek care will shrink.
The front page of today's New York Times features a report on the British method for containing health care costs through constraining benefits. Through a government agency called the National Institute for Health and Clinical Excellence, or NICE, the UK tries to exclude from their payment system any treatment with a high cost-to-benefit ratio. In particular, the system seems to value a year of life at about $45,000. The National Health Service will not pay for a cancer drug that promises, on average, six months extra survival at a cost of over $50,000. In contrast, in the US, Medicare would probably cover the intervention.
Whether it should is another matter. For the moment, Medicare is just about the best health insurance in the world. If you live in Tennessee and decide to get your cancer treatment at Sloan-Kettering in New York, you can go ahead and do that, and you'll get technically up-to-date care, without respect to cost.
In a prior posting, I implicity recommended the Medicare-for-all approach to universal health care. My belief is that if you don't recapture the profits and indirect costs of the private insurance system, you can't expand coverage by much. But although liberals, and here I include myself, want to add subscribers through simplifying plan administration, the skeptics are probably right: the savings won't go far enough.
There is an enormous reservoir of unmet need, such as postponed care for chronic illnesses. To meet that cost, we'll be tempted to make care less generous. The first phase of the NICE approach is the easy part - squeeze drug companies. But along the way, some patients will miss out on interventions that would have extended their lives. And the needed cutbacks extend beyond medications, to "elective" treatments and to matters of convenience. A financially efficient system would have fewer hospitals, longer waits, and less quality-of-life coverage, for procedures like hip replacement in the elderly. If we move in that direction, you may have insurance with the same name, but it won't be the same insurance. Some sorts of care simply won't exist - the infrastructure, from the operating suite to the surgical team - will have disappeared.
Actually, very few people favor constraining care when it comes to themselves. I have experience in this arena. In the early 1980s, when Ira Magaziner proposed the Greenhouse Compact in Rhode Island, I served on the health care panel, and in particular a subgroup dealing with questions of ethics.
The Compact was an ill-fated plan to bring business to Rhode Island through having the state help create academic and technical centers of excellence. Both political parties, all the labor unions, the churches, and every other official organization favored the Compact, and the voters turned it down by a margin of about four to one, out of mistrust of government. For odd reasons, the plan extended to the shaping of a Medicare waiver that would have allowed the elderly to forgo end-of-life care (along the British model) in exchange for prior quality-of-life services, such as better transportation and nursing home accommodations.
There was one problem with hammering out the waiver: no one was willing to give up anything. The unions in particular would not agree to any constraint in coverage - and this was a case in which any savings would go to pay for new services for the very people who had forgone the health care benefit. As I recall, the Catholic Church representative was uncomfortable with limitations on terminal care. It did not matter what the academic philosophers said, the members of the ethics panel simply could not see their way to cutting life support, surgeries, or medications for the elderly. (As it happened, at about that time, the New England Journal of Medicine published a study showing that in North Carolina, families tended to try to undo end-of-life care limitations that patients who were relatives had set in place.) A transition to the British model, where the privileged forgo benefits to provide coverage to the less privileged, will be harder to sell.
We do need to find a way to provide health insurance for all citizens, and probably many non-citizens as well. But the politics of the transition to broader care will be difficult in ways that the recent Presidential campaign did not suggest. Any substantial growth in subscribership will lead to a cut in benefits - and if the recession we're in is deep and long enough, we may get the cuts without the growth.
