One of the things that really soured me on the Clintons–or perhaps better stated, the first–was the botched Hillarycare mess. Instead of fixing what was broken, she tried to remake the entire system, resulting in a bureaucratic mess. Ditto Obamacare’s 2700 page monstrosity that would have spawned tens of thousands of pages of regulations. And that is why the American people rejected the plan.

But once the beast is slain–let us hope it is its death throes–the problem remains. A good column by Robert Samuelson casts light on the conundrum we face. From “Missed Opportunity on Health Care:”

Already, health care represents one-quarter of federal outlays. In 2008, Medicare and Medicaid, the two biggest programs, cost $657 billion, or 22 percent of the budget. By 2020, the CBO puts their spending at $1.5 trillion, about 28 percent. And these estimates don’t include the costs of Obama’s proposals. Before spending more, we need to spend better. If we don’t, all possible outcomes are bad: high deficits or higher taxes; stunted take-home pay (squeezed by insurance premiums and taxes); lower spending on other programs; or meat-cleaver cuts in health spending. The vast medical-industrial complex — doctors, hospitals, drug companies and more — should be forced to change, just as other industries (autos, media, airlines) have had to adjust. The changes need not involve the mass layoffs of other industries, but they must alter how medical care is financed and delivered.

Agreed, to a point. But health care isn’t manufacturing.  How it is delivered and the ethics it follows materially impacts our cultural values and the foundation of human exceptionalism.  As a consequence, what it can’t do is push the expensive for which to care out of the lifeboat through rationing or presume the horrific notion of the life not worth living, at least not if we wish to maintain our morality as a society.

Samuelson makes a suggestion:

Hospitals and outside doctors often don’t coordinate. One study found that two-thirds of patients leave the hospital without proper “discharge summaries” detailing tests and drug treatments. In early 2008, fewer than 20 percent of doctors used “electronic medical records” in their offices. High start-up costs were a major obstacle.

To counter all this disarray, Mongan and Lee would restructure the health care sector. Hospitals, doctors and clinics would consolidate into networks that embraced electronic record-keeping, the sharing of information and the search for “best practices.”…Their improved health care system would require a shift from fee-for-service reimbursement, which sustains fragmentation by covering most services that doctors and hospitals order. But moving toward “capitation” — fixed annual payments per patient, adjusted for medical risk — would trigger opposition. Doctors would feel their independence threatened by dictates from the network. Patients would correctly fear that their “choice” was being restricted. Payment limits would raise the specter of important care being denied.

Much of our system is already capitated.  That’s what your HMO is all about.  Medicare’s DRG system for hospitalization is a capitated approach.

But the kind of system Samuelson suggests can work. My mother has a Medicare Advantage plan with Kaiser.  (Let’s not get into horror stories about K, I know they exist.)  I have been very impressed with its efficiency and the quality of care she has received.  It resembles an assembly line, but it works for her.  In fact, the day of her recent physical, we received the lab report summary by e-mail the same day.  The next time she has to have an eye problem looked into, it will be with a certified nurse practitioner, who is perfectly competent to take the measurements to ensure the condition is under control.  We only will need to see the doctor if there is a problem.  That saves costs.

What promotes ethical health care in capitated system is that regulators (and trial lawyers) are on the patient’s side for receiving efficacious care, not on the provider’s side for restricting access based on economics or any “quality of life” judgmentalism.  If we pass Obamacare, that balance of power would shift.

There are many other ways to make health care more affordable, for example, community based clinics.  But no matter what system we adopt, we will need to triage government.  If we believe health care is a priority, we must cut spending in areas of less concern to the bone.  If we don’t, the entire structure–as Samuelson notes–could collapse.