WHAT I WANT FROM HEALTHCARE & WHAT I REALISTICALLY WANT

What I want, of course, is what anyone in their right mind would want - a free lunch. I don't want to have to pay for anything, ever. Even if I decide I want cosmetic surgery for no more good reason than vanity, I want that for free.

I also want a new camera for free. And every book I now pay for. And gasoline. And super premium single malt whisky. And won't someone pay off my mortgage, please?

Okay, so I'm not going to get any of that. So what do I want that I might reasonably expect to get?

I was extremely happy with my healthcare when I lived in Hong Kong. It wasn't cheap, about US$3,600 per year that came out of my own pocket since my employer didn't pick up the tab. (I wasn't hired on "expat terms." My ex-wife's company paid for her insurance, but not mine.)

What I got for that $300 per month was, in essence, a credit card that never came due. The bills went to someone else who very kindly paid them on my behalf. Every licensed doctor in Hong Kong accepted the card. When I traveled, if I needed medical attention - for instance when I came down with malaria in Jakarta and went to a clinic there - I presented the card, they called a phone number on the back of it, and obtained authorization to take care of me. Doctor's offices, clinics, hospitals could make that call from anywhere, collect. (Not dentists though. At the time Hong Kong was a British colony and, well, you know what Brits teeth are like.)

The card was provided by a private insurance company, although it, like the very high-quality free, government-provided healthcare in Hong Kong, was heavily subsidized by horse racing. At the time there were a mere seven million or so of us living in Hong Kong, and the two racetracks made more money than most of the other racetracks in the world, combined. It was only reasonable that the Royal Hong Kong Jockey Club should fork over enough cash to pay a big chunk of my healthcare.

Actually, other than that bout of malaria, I was pretty healthy for the 12 years I had that insurance. The company no doubt made a quite reasonable profit on the $43,200 I paid in premiums. (The clinic in Jakarta would have been relatively cheap, even if I had to pay for it myself.)

I wish I still had that magical card. I just paid the annual premium for the utterly inadequate medical insurance I've got now - $4,780.60, plus another $239.40 to something called the Alliance for Affordable (sic) Services that I have to be a member of to get my insurance at all.

Last year, a year in which I did everything I possibly could to avoid going to the doctor or the dentist, and during which I was basically healthy - a few minor sniffles, Lipitor, blood pressure medicine, nothing out of the ordinary for a man my age - I had $7,928 in un-reimbursed, out-of-pocket medical expenses. (That was a whole lot better than 2005 when, in spite of being insured, my un-reimbursed, out-of-pocket medical expenses came to something over $20,000 thanks to a minor surgery for which my insurance did kick in about $9,000.)

I WANT MY HONG KONG MEDICAL INSURANCE BACK! Or something like it. I'd even pay more for it if I had to, say, $7,928 (oh hell, let's be generous and round it up to $8,000) per year.

Okay, so that's not going to happen. And even if it did, I'm lucky, I could (not easily, but I could) afford to pay more money for better health insurance. A lot of people couldn't.

On the other hand, what if there was something like this:

---Mandatory catastrophic medical insurance for everybody, that they could buy either through private insurance companies, or also through an expansion of the Medicare system. (Medicare's administrative costs are surprisingly efficient compared with most private insurers.) The private companies would set their own premiums and the buy-in to Medicare would be available to everyone on a sliding scale based on income. (Rich people would pay more, poor people less, really poor people would get it for free.) That might also help prop up Medicare, which is headed for demographic disaster if something isn't done. Private insurers would have to lower their premiums or increase their coverage to compete.

---The mandatory catastrophic coverage should have a preventative care and screening component. Something along the lines of a free comprehensive physical exam for everybody once every five years to a certain age, three years during another age range, and two years after that. That should include such things as colonoscopys (a matter of some concern to me, who is about to have to pay for one out of my own pocket), mammograms and other such procedures that actually serve to lower medical costs by finding problems at earlier stages than they might have been found otherwise.

---Private insurance companies would be freed from the current restrictions by which they have to offer a different plan for every state they do business in, so that they could offer competing, nationwide plans for the catastrophic, as well as other levels of insurance. That would create a greater economy of scale, and competition, which would almost certainly lead to either lower premiums or better coverage. I'm a member of the Author's Guild. It offers health insurance to its members, but not to its members in California because it's just too expensive here. If Cigna, who I think is their insurance carrier, could offer the same plan to cover all Author Guild members no matter what state they lived in, it would be a win-win for everybody concerned.

---In exchange for opening up the national market to private insurers, the insurance companies would have to offer coverage to anybody, regardless of pre-existing conditions or the numerous other factors they currently use to deny coverage to anyone who they think might actually have a use for it. And they could better afford to do that, since the pool of insured people would grow and the risk would be spread thinner than it currently is.

---There should also be mandated transparency in medical care costs. It is currently almost impossible to be an informed consumer of healthcare. My pending colonoscopy is a case in point. Since I'm going to have to pay for it myself - it isn't covered by my insurance (I guess they'd rather pay for treating colon cancer after it makes itself obvious, than at an early stage when it's cheaper and easier to treat) - I've been calling around trying to find out what it's going to cost. If I want to buy a new computer, I have no trouble finding out what that's going to cost. A colonoscopy? Not so much. So far I have found no one price from anybody. All anybody can tell me is what they might charge for their little part of it - doctor, anesthesiologist, the facility, the pathology, some other bits and pieces. (Actually, I did find one stop shopping at a clinic in Tijuana, Mexico. But it isn't so much cheaper than what I think I'll end up paying here, that I'm going to go there.) That's stupid. No matter what sort of healthcare coverage we end up with, there are bound to be some procedures that we're going to have to pay for ourselves. And we ought to be able to shop for them the same way we'd shop for anything else.

We are never going to see a British, or even Canadian or Dutch style medical care system in this country. It ain't gonna happen. It's too expensive at this point in our development and with our demographics, and there is too much (a lot of it justified) suspicion of government running almost anything in this country. (Although the ravings about denial of care are ludicrous. In every country where there is "socialized medicine" a private option is also available that is very similar to what people can get here. And on average, people who can't afford the private option still get better treatment than they would here in the U.S. where they have only emergency rooms or the occasional free clinic to rely on.)

But there needs to be a realization that healthcare is, to a certain point, a national security and economic issue. A healthy population is a more productive population. Illness is expensive, not just to the sick person, but to society as a whole. It is as essential for government to have a role in seeing after the health of its citizens, as it is to build roads, schools and maintain a military defense.