What to do about Pre-existing Conditions.

So what about "pre-existing conditions"? A complicated problem!

To begin with it's pretty clear that the overwhelming majority of our citizens, regardless of political persuasion, accepts that everyone in our country who has serious illness, even when it's caused by bad health habits or personal neglect, should have access to at least reasonable medical care appropriate to that illness without causing major financial hardship. Let's put aside the "medical care is a right" argument and submit instead that in a country with such abundance it is not humane or socially prudent to ignore people who are ill or injured who could be readily treated.

In fact in my 50+ years of medical practice that's always been the prevailing attitude. When I was a kid doctors commonly saw poor people for free and there was no charge at the Scranton State Hospital. In the days before federal government intrusion when I was a student and intern in Phillie we had the ward services at Temple and Penn and of course there was Philadelphia General, all free to all comers. I did my residency at San Francisco General where there was no charge and all California counties had something similar. To be sure this was second tier care by doctors in training but in those days of low tech there wasn't really a heck of a lot of difference between how we treated patients on the ward and private services.

Nowadays this system has been replaced by Medicaid and obligatory Emergency Room and hospital care. We treat people who are seriously ill or injured first and worry about payment later and oftentimes such patients are then enrolled in Medicaid, at least temporarily. Medicaid is a terrible system, at the same time both excessively wasteful and underfunded, but it limps along in a crazy way, often providing its beneficiaries high cost items that the taxpayers who fund it can't afford.

The problem, of course, is the small percent not poor enough to be on Medicaid but for one reason or another left out of the insurance game. Particularly this is problematic for those with some form of stable chronic illness who have no one who will sell them insurance even if they could afford it. These people are stuck facing the grossly inflated prices for medical services caused by the fact that everyone else has some third party paying their way.

The knee jerk response has been to mandate that insurance companies sell policies to such individuals, and to do so for premiums that are too low to cover their costs which of course increase dramatically as soon as insurance takes care of the bill. If this is our answer then there is little point in complaining about the high cost of medical insurance for everyone else. It's all well and good to provide such persons with what they need and want, but it's the most wasteful and inefficient way to do it. When you take that approach you've got a new group of people with the highest medical demands really ramping up medical prices which are already inflated by third party payment and lack of market forces. This mandatory insurability device was one of the major causes for the Obamacare financial woes, namely dramatically rising premiums and insurance company losses and withdrawals.

So what IS to be done about the problem. The new Republican offering is complicated and disjointed, cobbling together a bunch of somewhat contradictory approaches to accommodate all sides. Nevertheless it contains several good ideas. I like especially the major escalation of health savings accounts, and the potential devolution to the states of control over Medicaid and provision of help for high cost individuals. It seems like a good idea to get multiple different centers working on solutions to these difficult problems.

Fundamentally though the solution to our medical economic problems rests in dramatically lowering the prices of medical goods and services by finally exposing them to market forces. We need the 350 million of us out there looking for the best value and all the hundreds of thousands of providers competing with each other for their business. How much better for all of us, but most especially the poor, if our medical goods and services were many times cheaper and more efficiently rendered.