‘ ‘ ‘ Both candidates want to expand health insurance coverage. But what is health insurance? … ‘ ‘ ‘ Both candidates want to expand health insurance coverage. But what is health insurance? ‘ ‘ ‘ We talk about health insurance like a commodity, like corn, that you have or don’t have. Health insurance is actually an idea, though ‘mdash; a guarantee that an insurance provider will pay for certain medical treatments. ‘ ‘ ‘ Of course, every time health insurance starts covering a new treatment ‘mdash; a new therapy for throat cancer, for example ‘mdash; we don’t give it a new name like ‘health insurance strikes back,’ or ‘health insurance: European gigolo.’ ‘ ‘ ‘ So, it looks like the same product is more expensive, even though we’re actually talking about a different, better product. ‘ ‘ ‘ A close analogy is English. We say someone speaks English when she knows a number of words more than five, but she doesn’t have to know every word in Webster’s. ‘ ‘ ‘ Likewise, to comfortably say everyone is insured, we want them covered for more than appendicitis, but not everything that can be done for one’s health. We want coverage only to an extent that’s ‘reasonable,’ with reasonable being dependent on how we feel, not some absolute standard. ‘ ‘ ‘ Consider: In ‘Bowling for Columbine,’ Michael Moore asks some Canadians about their free health insurance. ‘ ‘ ‘ They’re satisfied. But the movie was made in 2002, so they aren’t covered for any of the treatments invented after 2002. If the government of Canada announced today that it would only insure the treatments covered in 2002, there’d be an uprising. Even though Canadians don’t recall 2002 as a year of deprivation, losing what they’ve come to expect would seem awful. ‘ ‘ ‘ If our government is going to help insure more people, the ambiguity of health insurance presents three problems: ‘ ‘ ‘ First, we have to be stricter about which treatments are covered and subsidized. Through our government-run insurers Medicaid and Medicare, as well as the private insurers that our government subsidizes via the tax code, we’ve maintained an anything-goes attitude that fuels waste and inflation. At present, the United States won’t even fund existing commitments to Medicare, even with higher taxes. ‘ ‘ ‘ Currently, demand for medical treatments is divorced from the gains and costs entailed: Covered services are free or the co-pay is just a fraction of the cost, and there’s no government rationing. The long-term problem with this system is the direction innovation takes. ‘ ‘ ‘ If insurance pays for every new treatment granting any benefit, regardless of cost, entrepreneurs only profit from inventing better and costlier innovations. There’s little incentive to find a cheaper alternative to an existing treatment, and no gain at all for an alternative that’s slightly inferior but significantly cheaper. ‘ ‘ ‘ Second, the government should be more open-minded about how treatments are provided. ‘ ‘ ‘ Even for what looks like a simple task ‘mdash; a check-up, for example ‘mdash; there are hundreds of circumstances to be decided. ‘ ‘ ‘ What tests does the doctor do? How much time does she spend on the patient? How much time did she spend in med school, and what did she have to do to get in? ‘ ‘ ‘ In ‘Sicko,’ Michael Moore visits Cuba and asserts that Cuba’s health care is good. I hope, then, that he’d support our government health insurance outsourcing expensive treatments there, or other poorer countries. ‘ ‘ ‘ Qualified doctors in Mexico, Brazil, Thailand and India can do a surgery at 30 percent of the cost, with recovery in a luxury hotel included. No one should be forced to go abroad, but if someone on government insurance has reservations about foreigners, our tax dollars don’t have to accommodate: Beggars can’t be choosers. ‘ ‘ ‘ There are still other biases about health care to conquer. What if family practice doctors started schooling at 18 and ended by 25, like in many countries? What if nurse practitioners and physician assistants could give more treatments? ‘ ‘ ‘ What if we let more foreign doctors practice in the United States? What if doctors could advertise prices? These are ways the government can make health care affordable by doing less. ‘ ‘ ‘ Third, we should distinguish equality from tyranny. A Feb. 21 New York Times article, ‘Paying patients test British health care system,’ explains the plight of breast cancer victim Debbie Hirst before Britain’s National Health Service: ‘ ‘ ‘ The Service doesn’t cover Avastin, a cancer drug commonly prescribed in the United States, so Hirst decided to pay the $120,000 cost of the drug herself. ‘ ‘ ‘ The NHS then ruled that, if Hirst paid for Avastin herself, she’d have to pay for the entire rest of her treatment, under the justification, ‘allowing Mrs. Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones.’ ‘ ‘ ‘ I’m libertarian-ish, but I wouldn’t hate a plan that defined coverage explicitly, got the best deal and did no harm. ‘ ‘ ‘ I might even call it healthy. ‘ ‘ ‘ E-mail Lewis at [email protected].