Universal health vouchers.

Great article. ("Solved" by Ezekiel Emanuel and Victor R. Fuchs, June) Great suggestions. This really moves things past the sky is falling stage to that of creative thinking. However, I do worry about the dependence of Emanuel and Fuch's plan has on risk adjusting to offset the costs of adverse selection. I am unfamiliar with any method of adjusting that produces a reliable estimation of even 30 percent of the variance due to this, leaving at least 70 percent unexplained. How can such an imprecise hammer be used to nail down this problem? Especially given the fact that tomorrow's high utilizers are likely to be very different individuals than are today's?

Pierre-Andre La Chance

Chief Information Officer

Kaiser Permanente Center for Health Research

Northwest/Hawaii

Nice theory, unrealistic conclusions. Some points:

As soon as a VAT is imposed, it will never decrease. It will only increase over time. Then tinkering with the VAT will make it a political football. Once the VAT exists in some form, other "feel good" programs will be linked to it to enable their funding. The VAT thus is another way for increased taxation and spending with no accountability. by the government.

For universal voucher insurance coverage, a 10 percent increase in costs is projected by the authors, for nearly all products excluding food and other products which "disproportionately impact the poor." This cost will have huge consequences for the economy. The net increase in costs will surely exceed the present costs of corporation provided health care.

The authors did not mention the hidden cost sharing due to government mandates. Will government mandated coverage for say prenatal care be required for all insurance plans? If so, what about the single male who can't physically have children? Why should he pay for a woman's government-mandated benefit?

What about the large number of people who use the hospital emergency rooms as their personal and free medical care? What about the illegals who cross the border and then birth their children at taxpayer expense in hospitals? Will these people be turned away (currently against federal law) because they could not prove they were covered? I think not. Those costs will still be forced upon those who pay through higher costs for services.

Last, how will our personal information be protected? Will Social Security, numbers be linked to it? Will credit history be linked to it? Will we be required to carry our "universal voucher proof of membership" card with us at all times in case we are in an accident?

The present system works for me. I feel no need suffer an increase in my taxation because some people in society want to pay more money for some program to benefit some people somewhere.

Johnny Smith 

Via email

Regarding the health care voucher concept espoused by the authors, I question their use of a value-added tax (VAT) as the payment solution for the system. A significant portion of today's population is covered through corporation health plans. While part of these plans are paid by employees, an even larger part usually is paid by employers. By using a VAT for coverage, employers healthcare costs will turn into company profits since most of the VAT will be passed on to consumers. I doubt that Emanuel and Fuchs had this company profit windfall in mind and I suggest they re-think their payment solution.

Tony Kawas

Matawan, N.J.

The case for a system of Universal Healthcare Vouchers rests entirely on its supposed greater political viability. There is nothing that a UHV system could accomplish in the way of improved care, cost control, or universal coverage that a single-payer system could not do equally well, a number of issues better handled by a single-payer plan. Moreover, a single-payer system has the enormous advantage of being a proven quantity: We know that such a system works, while we know no such thing about totally untried UHVs.

That being the case, it's disappointing that Emanuel and Fuchs do nothing to demonstrate their numerous unsubstantiated assertions that various corporate interests "should support" their plan. If they want supporters of single-payer like me to jump on the UHV bandwagon, they need to do more than toss around scornful rhetoric about "liberal sugarplums." They need to show hard evidence that there in fact is a sizable dement of corporate America which, while rejecting single-payer, is ready to make a genuine commitment to UHVs.

What would I consider a genuine commitment? How about a binding pledge to totally shut off the flood of corporate campaign contributions to any Republican who does not support UHVs.

Mark Wylie

Via email

The Universal Healthcare Voucher system less renders the healthcare problem in America solved, as it offers only a partial, unlikely solution. One of their theory's key principles, is the Reliance on Private Delivery System. The destructive, combative maze of health plans and providers remains in their system. Power, the ability to choose, continues to be taken away from the individual, whether that be the patient or doctor, and held in the grasp of insurance companies. That, for all the never-ending attacks on universal healthcare, is communistic evil and it is the system we currently have.

One need only look to school voucher programs for the empirical evidence as to the likely failure of their proposal. Until health and not money, whether that be government subsidies or the cash of capitalism, becomes the key principle of our healthcare system, we Fail.

Alexander C. Ives

Palm Beach, Fla.