Wednesday, September 12, 2012

My Ideas for Fixing our Healthcare System, 2

     The semiannual preventive visits for every American should be covered fully by the government, and would include, in addition to the objectives outlined in Part 1, the following:
          1.  Adult and childhood immunizations.  Education for the few who decline.  A national registry for immunizations so that every medical provider could gain access to information about when to give booster shots on schedule.
          2.  Contraception and condoms easy and available for everyone.
          3.  Obstetric care for pregnant women.
          4.  Parenting classes, required for those contemplating children, or who have children.
          5.  Drug and alcohol rehabilitation, available for everyone.
          6.  Psychological counseling for anyone who requests it.
          7.  Pap, pelvic, breast, testicular, colon and mammogram screening--and other health and cancer screenings as they become part of the medical community's guidelines for early detection of disease.
          8.  Mandatory gun use and safety training, yearly, for those who own firearms.
          9.  STD testing.
         10. Select labs and other tests based on an individual's genetic, environmental and past health history risks.
         11. Healthy, whole foods available and free for pregnant women and children.
         12. Dental care twice a year for everyone.
         13. Exercise programs for everyone, specific to age and goals for fitness.
         14. Vocational training based not just on what individuals want to do, as on where their proclivities lie.  Free career testing.
         15. Tax deductions for home food production in gardens, canning and preserving, saving seeds, keeping livestock and poultry, and feeding oneself and family in ways that reduce disease.
         16. Tax credits for maintaining excellent health, participating in regular exercise programs, or achieving goals established by a doctor and based on data demonstrating that they correlate with a reduction in healthcare spending.  For example, diabetic patients with a HgbA1c of 7.0 cost the system much less than those who maintain a HgbA1c of 9.0.  The effort required to lower risk in this way could correlate to tax credits.
         17. A national registry for medications, and a list of medical problems, allergies, addictions, and past surgeries on all individuals.  This should be available to physicians when they need such information to treat patients, so they won't guess, repeat tests, rewrite the medical history, or prescribe unnecessary, unsafe or redundant medications.

     How would our country pay for these free services?
     In due course, the savings that would ricochet back to the nation's coffers, as money not spent on catastrophic and debilitating disease, would help to fund the preventive services.
     In addition, taxes should be imposed on any product or activity known to increase health problems for society.  The tax rate could be proportional to the yearly health costs of the product or activity.
     For example, smoking exacts a toll on the Medicare program estimated at $27.4 billion per year.  If all the costs of tobacco related illness were tallied, then divided by the amount of tobacco sold in the prior year, a disease-added tax on tobacco would cover the healthcare costs to society of tobacco use.  Those who use any health-eroding substances would be required to pay, in the form of a tax, for the lifetime health costs of those substances.  Substances like pesticides, synthetic fertilizers, artificial colors, alcohol, charcoal, lighter fluid, matches, guns, and kerosene could be taxed as well, using figures that correlate with environmental allergies, cancer, house fires, gunshot wounds, and accidents or illness related to alcohol use.
     Similarly, people who drive automobiles would be required to pay an accident-added tax, and those who use non-foods like Cool Whip, candy, soda, artificial sweeteners, fast-food, coffee, and processed foods would pay a symptom-added tax for products shown by science to have costly, detrimental, long-term effects on health.
     Savings could accrue from relaxation of laws on drug use, freeing people who have been incarcerated for possession of drugs for recreational use.  Instead of spending tax money on court cases, probation, and prison, we could be spending it on drug and alcohol education and rehabilitation.  A clean-needle and free drug program, like the methadone programs now in existence, could be available for anyone, and would limit crimes related to drugs.  Canada and some of our European friends are way ahead of us on this score, and we could imitate some of their policies with success.


  1. I like many of the free market ideas you propose, however from a pure "fairness" perspective it seems kind of crazy to penalize people for legal activities (like eating) and reward people for illegal behaviors (like drug use). I agree that "vice" activities need to bear their full societal cost by those who choose to participate in them.

  2. The "penalty" for eating would only apply to nonfoods, or foods that pose a greater risk to health than nutritional benefit. Using drugs would no longer be an illegal activity in my program--there would be acknowledgment that people use drugs, and a penalty for doing so. Again, the penalty would be calculated as a function of the risk the drug use posed. If you consider the algorithm used by insurance companies, perhaps it won't come across as punitive. As I grow older, my life insurance premiums go up--is that a "penalty" for growing older, or simply an understanding on the part of both my insurance company and me that my risk has gone up, and the cost for it should be shared? People who drink sodas have an increased risk of dental caries, osteoporosis, and diabetes. The cost of soda, therefore, would include a risk-added tax. The revenues accrued from the tax would pay for the added cost of healthcare, provided by the nation, for individuals who choose to buy sodas. All of us participate willingly in a version of this system when we buy automobile insurance (which is required by the government), or health insurance (to a more limited extent than I have outlined), or when we have to pay out of pocket for dental care, paying more if we haven't cared for our teeth properly.

  3. So who determines what is a greater risk to health than nutritional benefit? For example, let's take fruit juices. Parents give their kids fruit juices because they think they are healthy (and to some extent they are) but ignore the calorie issues involved with their 2 year-old sucking down apple and grape juice boxes like Lindsay Lohan sucks down drinks. How about beef? Would you be given a ration - 4 oz a week ok, but 16 oz you pay a penalty? How would you enforce it, and how would you implement it. What would keep people from going from store to store using up their beef ration the way people go from doctor to doctor getting multiple prescriptions for the same drug?

    Secondly, the drug idea - let's take crack cocaine. I'm not a medical profession but it strikes me as a very bad drug, so as I understand what you are proposing we would simultaneously decriminalize the use possession, distribution and manufacturing of it and impose a tax on it. I assume the tax on crack would be higher than the tax on mushrooms or MJ because they are less risky. Is that right?

    So what would keep drug smugglers from dealing in untaxed cocaine the way illegal cigarettes are imported to avoid the taxes. If you've decriminalized the activity but impose a tax which has to be enforced, aren't you just shifting the enforcement from police to the IRS? I imagine customs would still have to be involved to ensure untaxed crack doesn't make it to our shores.

  4. The monetary cost of health problems related to cigarette smoking has been calculated. In the same way, the economics of other food and non-food items could be calculated. Most physicians agree that the caloric and sugar load of fruit juice outweighs the nutritional benefits, except for people who are malnourished or who have malabsorption. A health tax would be placed on foods if a cost to health could be calculated for those foods. Perhaps it would be more accurate to tax people whose weight exceeds a healthy limit, and who therefore will have obesity-related health problems, just as airlines are contemplating charging more for obese passengers. There are no fodds that are healthy for everyone. People with wheat or peanut allergies shouldn't eat these foods, but taxing wheat or peanuts for everyone wouldn't make sense. There should be a tax on crack cocaine, and mushrooms, and marijuana based on the health cost to society of these substances--this would be a function of statistical analysis,not ethics. There is a place for a national ethic about healthcare, but not when it comes to the cost of habits and substances that cost healthcare dollars. That's just mathematics. The problem of lawbreakers, smuggling, freeloaders wouldn't go away with this system. There should continue to be a national dialogue about what's good or bad for the country, what's healthy, what's not, and how a limited budget for healthcare can best be apportioned.

  5. Dr. Colasante, I accept everything you've said (and agree with most of it). But you haven't resolved the most basic question of how to practically decriminalize an activity while at the same time imposing a tax on it unless you have the tax enforced by the state's police powers (and therefore subject non-compliant participants with a criminal penalty)?

    Who would pay taxes if there was nothing the government could do to you for not paying? If you enforce it, then there will be bootleggers seeking to exploit the arbitrage between tax paid and untaxed goods.

    Just look at Amazon and the fights it has with states over the collection of sales taxes. In Florida, if you (the consumer) buy a good that is not subject to sales tax collection by the out-of-state seller, you are required to file a "use tax" return and pay the corresponding tax with the state of Florida. Do you know of anyone who has bought something on Amazon and has filed a FL Use Tax Return? I don't. Given the use tax collection data, almost nobody does, precisely because the state of Florida has no effective means of enforcing the tax against the consumer.

    So if you decriminalize crack and tax it, what will keep the same criminals from simply selling non-taxed crack? Don't you end up just replacing a drug crime with a tax crime?

    I agree that there should be a national dialogue about these things, but shouldn't that dialogue have a basis in reality. Idealized solutions offered by politicians sound nice and appeal to their respective constituencies, but as we know, rarely solve the problem.

  6. First, we have to agree on what matters to us, as a country. Second, we have to set goals. Third, we have to find practical ways to meet those goals. Fourth, we must work out the details of meeting those goals--which involves rules and laws and consequences--as we figure out how to make what we believe in a reality. Fifth, we revisit the things that matter to us, to see if they matter as much as they cost in terms of money, compromises, and the effect on our lives and our children's lives. You are asking me to jump to Stages 3 and 4, which require terrific group effort based on trial and error, and statistical analysis, and a lot of creative input from experts. I can propose how some of the details might be worked out, but then you will say, "But what about this?" and "What about that?"--citing one example after another about how people might abuse the system, or find loopholes. Putting ideas into concrete form is very difficult, and it's what separates nebulous dreamers from reality-based pragmatists.

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