Nearly 20 years ago, health economist Henry Aaron characterized the US health care system as “an administrative monstrosity, a truly bizarre mélange of thousands of payers with payment systems that differ for no socially beneficial reason, as well as staggeringly complex public systems with mind-boggling administered prices and other rules expressing distinctions that can only be regarded as weird.”1(p801) However, Aaron insisted, our weird system exists for a well-understood set of political reasons, “including a pervasive popular distrust of centralized authority, a federalist governmental structure, insistence on individual choice (even when, as it appears to me, choice sometimes yields no demonstrable benefit), the continuing and unabated power of large economic interests, and the virtual impossibility of radically restructuring the nation’s largest industry.”1(p802) We do not get radical restructurings in the United States. Instead, we get incremental changes. Sometimes these incremental changes have the effect that their proponents intended. At other times, they have unintended and surprising consequences. Sometimes they have both. Often, it is hard to figure out the specific effects of specific policy changes.
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Lantos JD. Medicaid Expansion and Childhood Cancer Care: What Effects Has It Had? JAMA Pediatr. Published online March 23, 2020. doi:10.1001/jamapediatrics.2020.0071
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