So the government has launched its consultation on health insurance — again. Isn’t that the fourth time in the past 20 years?
When I started paying attention to this critically important issue, I was a spritely 40-year-old. By the time any legislation comes into effect, I will be an elderly and in need of the insurance cover myself.
And yet even now, our pusillanimous government is backing away from this fundamental challenge at the heart of effective health insurance: that you only get the funding pool needed to pay for the needs of the sick if contribution is compulsory.
The arithmetic is so simple: if a scheme is voluntary – as the government proposes our future scheme should be – then the sick and old people will sign up, while the young and healthy will not. As a result, the pool will be too small, and the demands made on it by the old and infirm who sign on will be too heavy.
The government has consistently backed away from the compulsory option because all polls say Hong Kong people don’t want to be compelled. In particular, they don’t want to pay for health insurance as they are currently getting world-class hospital treatment for next to nothing.
For me, this simply constitutes a fundamental misuse of polls: polls should not be used as an alibi to duck out of tough but necessary decisions. They should be used to identify key areas of concern, to enable us to communicate more effectively when grave or difficult messages are not getting through.
In this case, our hospital system faces a funding crisis, and the only viable insurance-based solution must include the well and the young as well as the old and infirm. In other words, it must be compulsory.
But I have come to learn that I can hyperventilate on this issue forever, and will still not make progress. Our government and our legislators do not have the spine or conviction to fight this through.
So let me focus on some other points.
The new proposals clearly aim to make sure that adequate insurance cover is affordable. But that is not the government’s ultimate concern. First and foremost, it is concerned about the potential “blowout” of healthcare costs as public expectations steadily rise. So apart from trying to build adequately large insurance pools, the government should also be focusing on controlling and reducing medical expenses. And here, two thoughts arise:
1. In most rich economies (in the United States and Europe, in particular) most healthcare spending is used in the last five years of a person’s life. Even more shocking, in the US and the United Kingdom, around half of all medical spending is on gravely sick patients who die within the year – on expensive, complex and often surgical procedures aimed at squeezing a few extra weeks or months.
In the words of Atul Gawande, the US surgeon and author of a brilliant and distressing new book Being Mortal, we have created a hugely expensive system trapped between the mistake of prolonging suffering, and the mistake of shortening valued life.
“We have created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets – but have only the rudiments of a system to prepare patients for the near certainty that those tickets will not win,” he said.
His solution, strongly supported by the US health insurance industry, is to build assisted living services – essentially networks of home hospice care – which keep the elderly sick out of hospital beds and out of nursing homes.
This means equipping homes to make sure the physically infirm can cope, and building a professional “carer” system that can be deployed speedily when urgent needs arise. This would cost money – but hugely less than the cost involved in keeping the chronically sick in hospital intensive care.
2. Hong Kong’s future health system must build upon “wellness care” delivered by networks of community-based clinics, not on hospitals and accident and emergency departments. Again, this network will cost money, but it will save billions by keeping people away from expensively dispensed hospital-based healthcare. Health insurance policies should cover the challenge of staying well, rather than just the challenge of dispensing medicine when we are sick.
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