More on the Mass healthcare issue

Commenting on Adam's post below, there definitely seems to be something wrong with a situation where somebody who is capable of working gets a large amount of quasi-discretionary healthcare for free. It's a serious problem when a "liberal program" like government healthcare provision makes even liberals want to tear their hair out, because it's evidence that it's both bad policy and likely to be broadly disliked and thus doomed to failure.

I'm trying to think about how to make a system like Massachussetts's work properly. The initial question is, what makes Adam's scenario so troubling? Is it that the woman was a "starving artist" and could have worked a "real job" that paid enough for her to pay for her own healthcare? Was it that the care was essentially free? Was it that the care seems discretionary?

Courts handling child-support routinely make decisions about what a person's "earning capacity" is- for instance, a doctor making $150,000 who quits his job to become a painter making $15,000 is going to be on the hook for child support based on his $150k earning potential. That could be applied to the healthcare system as well. One problem would be figuring out what to do with the investment banker who gets laid off and has to work at the Gap- no health care for him? Also, what about the lawyer who quits his unsatisfying corporate job to become a public defender making $25k?

A problem with completley free care is that, as your parents probably told you, you care less about something you're given for free. My fiance interns at a community mental health center in New York, where low-income people can get free counseling and mental health services. She has an enormous problem with patients not showing up for their appointments- usually about half of her scheduled appointments are no-shows. I have to imagine that if her patients were charged even a nominal fee like $5 per appointment, and had to pay even if they missed without calling to cancel, that folks would make their appointments or at least call if they were going to miss. The downside is that for the very poor, that $5 might be a reason to not go, or for the irresponsible it might be better spent on two ringtones or a couple beers.

In the Massachussetts case, it's hard to figure out where to draw the line. Adam suggests having patients pay for 25% of their care, but for $10 or 15k of care, you're looking at thousands of dollars, which would be an enormous burden on someone making.

As for the issue of the care being quasi-discretionary- without having all the details, a hysterectomy and vision care kind of split the difference between the purely optional (propecia, cialis, botox) and emergency surgery. An eye exam and glasses can prevent constant headaches, and can be critical components of safe driving, and a hysterectomy potentially necessary for sexual autonomy (again- neither of these immediately life-threatening issues). Here again we look at critical questions of where to draw lines on what the government should cover.

I think ultimately some kind of sliding co-pay, linked to a person's earning potential rather than actual salary, is probably the way to go here... but as always the devil's in the details.