On average, Americans spend about twice as much on medical care as do Europeans and with poorer results. About half of that cost is paid for by government. If we could get the cost of medical care down to European levels either the government (i.e., tax payers) could stop paying for any of it with no change in the cost to patients, or patients could stop paying anything with no change in the cost to government. Of course it wouldn’t work like that and is much more complicated but it does focus the mind about the issues concerned.
Both the Affordable Care Act of Obama and the current drafts of its replacement by the Republicans are limited to what can be considered budget authorizations so that they can be passed with simple majorities. In June 2015, when the Supreme Court rejected challenges to the constitutionality of parts of the ACA (the insurance mandate), Chief Justice Roberts complained that: “Congress wrote key parts of the Act behind closed doors. . . . Congress passed much of the Act using a complicated budgetary procedure known as ‘reconciliation,’ which limited opportunities for debate and amendment, and bypassed the Senate’s normal 60-vote filibuster requirement. . . . As a result, the Act does not reflect the type of care and deliberation that one might expect of such significant legislation.” Now the Republicans are doing the same thing. Once again George Will is right on target: Why-repeal-and-replace-will-become-tweak-and-move-on/2017/06/27/
This means that the most important elements of health care reform in America—reducing supply side costs—must await other legislation. However, limited market forces are already eating away slowly at the American Medical Association’s (the doctors’ union) self protective strangle hold on the delivery of medical services. The information technology now exists to dramatically improve the quality of service while lowering its cost. Nurse practitioners have already taken over some routine functions previously preserved for MDs. With a growing shortage of doctors, more restrictive practices are likely to be relaxed such as phone consultations, etc.
The focus of the ACA and the current Republic efforts to “repeal and replace” it, has been how best to finance these costs for those financially unable to pay them. The two overriding challenges for this effort should be to adequately target those who need such assistance and in the process to avoid undermining to the extent possible the incentives for both doctors and their patients to provide and to seek the most cost effective care.
There are many small and large details in ACA and proposed Republican replacements that could be changed to improve targeting of financial assistance and the incentives for seeking and delivery cost effective care. See my earlier discussion: A-mistitled-tax-proposal. The largest issues are how best to remove the unfair tax treatment of employer provided health insurance vs. the “private” market and how to insure that the risk pools in the private insurance market include both healthy and sick premium payers.
The point of insurance is to pool the cost of the risk of bad things happening, like breaking a leg or getting sick. Thus the lucky (healthy) share the costs of the unlucky (sick or injured). The group as a whole must pay the total medical costs of all members of the group. It follows that health insurance should be mandatory for every one in a properly defined group. The risk pool of employer provided health insurance consists of the company’s employees, and premiums are set on the basis of the average medical costs of that group. There is no such predefined risk pool for those who buy insurance in the “private” market. The logic of insurance suggests that everyone within each age group should be required to buy insurance at a cost to each that reflects the total medical costs of the full group. The-individual-health-insurance-mandate.
The simplest, cleanest, and most comprehensive way to insure that those unable to pay for whatever medical care they need can do so is to require that all people in their group buy insurance so that those who later don’t need it finance those who do. I have earlier advocated that this approach be integrated as part of a guaranteed minimum income (GMI). A GMI would provide the basis for eliminating most government welfare programs from Social Security and food stamps, to disability and unemployment insurance. But first a brief word about minimum wage laws.
Charles Lane has proposed a sensible approach to balancing the political attraction for legal minimum wages with the economic case against them. He proposes that the issue be removed from the political arena by legislating an automatically adjusting formula for a legal minimum wage that closely matches actual historical wage experience so as to minimize the harm to low skilled and inexperienced (teenagers) workers that would be hurt by higher minimum wages. Forget the $15 minimum wage–here’s what a sensible compromise would look like/2017/06/28
A legal minimum wage does not help the unemployed. A Guaranteed Minimum Income would. It should be paid to every man, woman, and child but the amount might vary with age (but not with income). It could be administered by the Social Security Administration, which it would replace. Saving-social-security. Fixed shares of the GMI would be placed in an individual health insurance account, a pension account, and an education account (school tuition or college fund). The amount deposited to the health savings account would be required to be used to purchase general health insurance and would be sufficient to do so.
The GMI would be paid for from general tax revenue. Clearly our existing, hole riddled income tax laws (both personal and business) are a mess and need to be cleaned up. As I have argued earlier the fairest, least distorting and easiest to administer tax is a consumption tax. I should replace all income taxes, wage taxes and existing sales taxes with one uniform Value Added Tax (VAT). My-political-platform-for-the-nation-2017.
Let’s try for better health care that costs less for both patients and tax payers.
Warren's space 
I like how you ended, by identifying the tax system is the basic problem. Who pays, of course, is the central issue with income redistribution schemes, such as “needed” health services. The basic ethic requires this not be rationed by “ability” but somehow rationally distributed, since providers are not slaves (thus it is not “a right to medical care”). I suspect overhead costs are being allocated by politics instead of measured by marginal value. But the growth of large health care “groups” under the Abominable Care Act hasn’t helped. Overhead costs (“allocated; negotiated”) are growing.
The basic poison was the WW2 price-wage controls, and the IRS rulings exempting medical. The tax system is the culprit, of course. Why should anything relating to medical costs be included in the income tax morass? But your utopian proposal, which I endorse, seems too far to hope for. It is a foolish idea to “measure” social well being by “[annual] income,” when clearly it depends on what one consumes.
Warren, Thanks, always a pleasure to read your reflections. So clearly written that one need not agree with every point to feel enriched by the experience. My utopia would include VAT, GMI, and a single-payer public health system, wiping out layers of intermediaries. All would mean big changes in fiscal federalism but those seem to happen anyway these days, with little forethought or game plan.
Several Basic Points Might Help Thinking about the issue:
Pre-existing conditions: everyone has lots of them. What we really mean to address are catastrophically expensive care of a few pre-existing conditions. Anything “pre-existing” cannot be part of “insurance” which is about future possibilities and group schemes to pay for those.
Some portion of those would make more sense as part of a safety net at state or federal level.
Health, care when in poor health, and payment for that health care need to be kept distinct.
Good health: depends on genes, habits, diet, exercise, accident/luck, etc. A good portion of this should be made an individual’s responsibility, but apportioning this is very complicated.
Health Care: The “supply” side comprises hospitals, clinics, doctors, nurse, medicines, equipment, knowledge. Other than encouraging doctors in poor countries to come to the U.S. and taxing medical equipment, very little is addressed in the laws under discussion.
Payment for Health Care: insurance, co-pays, deductibles, philanthropy, government subsidies
Employers often pay insurance premiums for employees; this should be considered as compensation, and probably taxed —
Costs are very often opaque; precluding serious competition.