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State: How does individual responsibility fit into the healthcare
equation?
DW: There must be shared responsibility on the part of government,
employers, and individuals. There are four main dimensions
to health care: access, cost, quality, and personal responsibility.
From the standpoint of access, we have the highest uninsured
rate as a percent of our population of any industrialized nation.
We spend 50 percent more of our economy on health care
than any industrialized nation. On quality, we have below average
health-care outcomes for an industrialized nation. Examples
of that would be above average infant mortality, below average
life expectancy, and a much higher medical error rate. So we
are zero for three in those dimensions. If there is one thing that
can bankrupt America, it is health care. It is that serious. We
are also number one on the leading indicator of health-care
challenges: obesity.
We need to recognize reality that the individual must assume
more personal responsibility. And we must think about dividing
who’s responsible for what. Today’s system does not provide
appropriate incentives or adequate transparency and does not
assure appropriate accountability in order for the system to be
successful and sustainable over time. We need to differentiate
between wants, needs, affordability, and sustainability.
The discussion also needs to focus on separating the issue of
access to procedures and technology and then who pays for it.
We’re spending a lot of money now on heroic measures that
don’t meaningfully improve life spans.
If we could identify evidence-based national practice standards,
we could avoid unnecessary procedures, better control costs,
and improve consistency and quality of outcomes.
State: How about reforming Social Security?
DW: Reform of Social Security is easy. You can reform Social
Security and exceed the expectations of every generation of
Americans. One way you can do it is as follows. You can say
for individuals of a certain age or over there is no change – that
means people who are retired or nearing retirement. For people
younger than that age you make gradually greater changes
– you phase in gradually higher retirement ages over time – to
encourage, but not require, that people will work longer.
Furthermore, you can change the replacement rates such that
you strengthen the benefit for the poor and somewhat reduce
the benefit for middle- and upper-income individuals. You also
look at the indexing formulas to make sure they are reasonable
and appropriate. You can do that without any additional taxes,
make Social Security solvent, sustainable, and secure and exceed
the expectations of every generation of Americans. How you
go about the reform is important, taking into consideration
the effect on various segments of society, but it could be done
without raising additional revenues. On the other hand, we can’t
solve health care without additional revenues.
Also, when you look at Social Security, you can’t look at it in
isolation. It was intended to be only one element of an overall
retirement income security strategy.
All factors considered, Social Security needs to remain a defined
benefit program to provide the foundation of retirement security.
Then, like a house, you need to build on that foundation.
That could include supplemental private accounts on top of a
reformed defined-benefit Social Security system.
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