Diverting funds seems unlikely. We have a government that pays cost-plus for “rebuilding Iraq” but pays cost-minus for Medicaid. The likelihood of seeing adequate payment from government coffers approaches zero since the opposite (increasingly inadequate payment) has occurred historically. Alternate “out-of-the-box” ideas might include: requiring patients to pay their bills, requiring 10% of all charitable contributions be sent to a national pool of funds distributed proportionately to uncompensated providers, requiring patients who can’t pay to work for their providers until their debt is repaid, or reconsidering debtors prisons. All of these are politically unlikely, which leaves us with requiring individual coverage.

As many have noted, individual mandates are unlikely to be perfect. There is no such thing as perfect. Because everything has a cost, including enforcement, we should stop pretending that we can ever get something for nothing. It is more important to identify how we can improve our dysfunctional healthcare system toward something which we can actually afford. To this end, individual mandates become one of the pieces of the solution. Rather than reiterate the pros and refute the cons, I will simply say that we should emulate what has worked best elsewhere and accept that if even 60% of individuals participated it would be a huge benefit for our system as a whole. With proper incentives to participate and disincentives for violators, I believe that we can reach 90% or better.

As to what constitutes a basic plan, I agree with others, including California’s Governor, that preventive services carved out from a high deductible plan provides the needed coverage at an affordable price. Those who meet low income criteria should get government subsidies on a sliding scale and no one should be exempted. The increases that those not receiving subsidies pay would be less than what we currently pay now. How? Healthy people who “wing it” under the current system would pay premiums rather than paying nothing when they are seriously ill unexpectedly and can’t afford to pay. In addition, there would be long term cost reduction from preventive services for those who currently wait until a crisis exists causing them to obtain more services that are less effective at higher cost. Preventive services enable earlier detection and more effective treatment at an earlier stage of disease at lower cost.

We desperately need popular support for an individual mandate. When businesses realize that their healthcare costs will drop significantly with an individual mandate, perhaps we will see a strong PR campaign set in motion.

Of course the odds of aligning all these factors are microscopic.

But before we even get to that point, we have to decide WHAT is being mandated (“basic” coverage, “comprehensive” coverage, “catastrophic” coverage? and what exactly do we mean by each of those?), and WHO is being mandated (the poor? the wealthy? the disabled? the homeless? immigrants legal or not?). Then we have to ensure that what is being mandated is actually available in all areas at all times. And we have to make sure that the mandated coverage pays providers well enough that they will accept it (unlike Medicaid), but not so well that we encourage over-utilization. And we have to ensure that the insurance providers don’t undercharge or overcharge for the coverage.

Are we having fun yet?

And then we should really spend a minute or two thinking about the effects on families of requiring they pay insurance premiums BEFORE they can buy food, or housing, or clothing for the kids, or transportation so they can get to work.

And we have to do all this in a highly political atmosphere where each side is trying to discredit the other, not just in academic journals and op-ed pieces.

No problemo.

Greg Scandlen

Welcome to the final edition of Health Wonk Review for 2007. HWR is a biweekly compendium of the best of the health policy blogs, hosted in rotation by — you guessed it — health wonks who blog. Given the plethora