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Daschle: Good, Wrong, and Terrible

President-elect Obama has named Tom Daschle to head the Department of Health and Human Services. By some measures the largest department in the government, Daschle is sure to take center stage in Obama's inevitable effort to reform the U.S. Healthcare system. So what of the choice? Well, Daschle has some good ideas, one wrong idea, and one really bad one. A quick rundown: Good Ideas: Daschle believes that individuals, mostly, should have to pay for their own health care and opposes the current mixed-economy health-care system that costs a ton but doesn't provide good care for most Americans. The current U.S. health care system--which isn't a free market in any sense of the term or "freer" than most other developed countries' health care systems--seems largely devoted to cost-shifting rather than actually providing health care. Every party involved--consumers, insurers, the government, hospitals, doctors--tries to get somebody else to pay its bills. The pendulum swings back and forth a bit but nothing really changes in a fundamental way. Like Daschle, I'd prefer a mostly private system where hospitals remain private, most people pick their own health insurance, and pay for it themselves in a free or mostly free market. Netherlands, Switzerland, and, to some extent, France, have systems like this. (Germany has an employer-based system that's basically the same as ours with a few more subsidies, mandates, and price controls.) All these systems are far from perfect but have less government involvement than ours (France is about the same) and give individuals more choices than ours. None are a free market but they all move closer to that ideal than what now exists in the United States. Obama has also advocated this type of system. Like everyone who thinks about health-care, Daschle also favors some nice-but-difficult goals like electronic medical records and evidence-based medicine. These can make a difference but none are likely to change things absent other changes. Daschle seems smart enough to know this. The Wrong Idea: Daschle loves to repeat the frequent piece of folk wisdom that the United States is alone in the industrial world in not providing health care to everyone. Not true. Only one G-7 country, the United Kingdom, truly covers everyone. Basically, the British system operates almost all hospitals and contracts with nearly all doctors via a single enormous national health care superstructure. There's no billing system for many types of procedures so, by default, everyone is "covered." The system is cheap relative to that in other countries but isn't very good by many measures and saves money mostly by pushing down wages for everyone in the medical field. Just about every other country has some gaps somewhere. And, of course, in some countries (Canada, Germany, the UK) there are long waiting lists for certain types of care. What good is insurance if you can't get care? (Waiting lists, contrary to many conservative claims, are not a necessary consequence of what Obama and Daschle want. Countries like Switzerland, France, and Netherlands manage with no more waits than exist in the United States.) Generally, the gaps in the U.S. are a bigger than those in other developed countries--although not significantly so in every case. Daschle knows enough about international health care markets to know all of this but insists on repeating it. The Terrible Idea: Daschle's big idea--which he's written a whole book about--is that the United States should create a national health board accountable to nobody but itself. The board, taking the Federal Reserve as a model, would basically control all health care decision making in the country. This is a crazy idea. Why? Because any board, no matter how well chosen, will make mistakes. And, if only one board has control over the whole health care system, then any mistake it makes will impact everyone. Although some of the things he imagines the board doing do make sense, there's simply no reason to concentrate so much power in the hands of a few mandarins. And the Board, frankly, scares me.