Thursday, September 17, 2009

My Prescription For Health Care Reform

I have followed the national conversation about our broken health care system, and how to fix it, long enough and with sufficient depth to be able to come up with a list of suggestions (which, in fairness, I have drawn from different sources, such as Dr. and Gov. Howard Dean, T.R Reid, etc.) Here we go.

1) Everybody in, nobody out.
All Americans and legal residents would be automatically covered for basic health services (defined further down). No more exclusions for any reason whatsoever, no rescissions. Basic dental and vision care should also be included.

2) Shared, progressive responsibility for health care costs.
With the exclusion of those who make less than a certain amount of money, who shall receive free or subsidized health care, everyone must pay according to his means, with increasing surcharges and/or out of pocket expenses as income increases, not to exceed a maximum cap. This would be a simple and fair way to recognize the fact that we have a shared responsibility in the well-being of our fellow Americans.

3) Basic and necessary care v. elective care
Public option or no public option, the government shall produce a list including all services considered necessary, basic health care. Everything else would be covered under voluntary supplemental policies. Necessary does not mean cheap, it means non-elective. For example, reconstructive plastic surgery would be covered under the basic plan. Elective plastic surgery (rhinoplasty, breast implants--except following mastectomies) would not be covered under basic care, but would be covered by the voluntary supplemental policies. Dental implants would not be covered by basic care, but crowns, full or partial dentures would be, and so on. Heart surgery would be considered necessary care if it is the only or best way to address a patient's heart condition, all other considerations being equal, including quality of life.

We should pay particular attention to simplifying the list of what constitutes basic care without burdening it with exceptions, and also of what is tax deductible. For example, an entertainer might argue that a botox injection is a necessity even though it is a necessity for a factory worker. Well, sorry: I would argue that it still and elective procedure and, as such, that it should not covered under basic care. And I would cap tax deductions (or not allow them at all) for procedures that a doctor does not consider necessary (which would entail the necessity of an independent audit of doctors' practices to determine if they have been gaming the system to their advantage, or their patients'.)

Also, I don't know what the rate of hypochondriacs is in this country compared to others, but apparently a problem with the current system is that some individuals are guilty of overuse. Well, to address this problem, which I am sure is exaggerated, the system could be set up to pay up to a certain number of exams, procedures, etc., deemed necessary by a doctor. Any test, procedure of care beyond that limit should fall under the voluntary supplemental coverage. If a patient disagrees with a denial, s/he should be able to appeal the doctor's decision and the appeal process should be handled by a competent panel, expeditiously for cases in which the life of a patient may be at risk.

Call this rationing, if you like. The rest of us, people of at least average intellect and disposition, will call it common sense.

4) Incentives to doctors and patients for improved health.
Doctors should be paid more as their patients' health improves. For those who say this is unrealistic or difficult to measure, the National Health Service in the United Kingdom already does it. Additionally, patients should be rewarded with discounts for improving their general health, as this can help to reduce costs. Subsidies should be provided for those who exercise regularly.

I strongly believe that incentives are preferable to disincentives because they eliminate (or at least minimize) the danger of discrimination. For example, you could offer disincentives against risky behaviours, like smoking, and make smokers pay a health care surcharge (which is what insurers already do). But there are other risks that we currently have no disincentives against, for example eating fast-food, drinking soft drinks with high a content of high-fructose corn syrup, snacking too much on unhealthy snacks, and so on. Snowboarding may be considered healthy on one hand, risky on the other hand. How would you determine when the benefits of a behavior outweigh its risks? Who would decide. It would be hard to reach agreement on which behaviors should be discouraged, and which ones should not. Besides, there would be strong opposition from targeted industries, which would make disincentives harder to achieve than positive incentives (in the form of discounts.) It would be much easier to measure the effect of positive incentives than to gauge that of negative behaviors.

5) Medical Tort Reform
In other countries, as T.R. Reid notes in his book, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, it is uncommon for a doctor to ever be sued, so much so that doctors usually don't remember the amounts they pay for their malpractice premiums. You would be hard pressed to find a doctor in the United States who is not painfully aware of that information.

Let's be honest. The United States is a litigious country compared to many others. Given this premise, I will accept the conclusion that many malpractice lawsuits are frivolous. However, many are not. I am no expert of tort law, but there must be a way to limit the ability to impose damages only in cases of gross or recidivist negligence by a medical practitioner or hospital, while throwing out all others.

There are no guarantees in life, much less the guarantee that a remedy or procedure that worked for one person will not cause another to die or to be impaired. But unless it can be proven that such consequences have resulted from discriminatory or seriously negligent care, people should just accept two basic facts of life: life is not always fair and shit happens to the best of us.

6) Single-payer care for basic care.
Finally, the government should run the reimbursement system for all basic care services. Insurance companies can continue to run their operations as usual for elective care. This is an important point, perhaps the most important point, of any health care reform.

As mentioned in my previous post, T.R. Reid explains that we pay so much more than other countries to provide health care to a segment of the American population because we are the only country where the middle-man, insurance companies, is allowed to make a profit, and a handsome one, on basic health care services. One way that insurance companies use to increase their profits, and dividends for their shareholders, is to deny as many claims and to rescind as many policies as possible. I have already noted elsewhere on this blog that insurance companies refer to every dollar paid out to reimburse a claim, whether by a patient or by a doctor or hospital, as a "medical loss." Good grief, what a country!

Also, for every dollar patients pay for their premiums, insurance companies are typically allowed to keep up to 20 cents for administrative costs (which include the cost of paying for claim reviewers whose job is to find a way to deny claims, executive compensation, marketing costs, etc.) There may be exceptions to this rule that I am not aware of (and I bet you that, if they exist, they are skewed to favor the insurance companies.) This is insane! In the middle of a growing health care crisis, allowing an insurance company to waste one fifth of the money it takes in instead of directing it to services that should never be denied approaches the definition of insanity (and falls squarely into the definition of immorality.) The United States is the only country that not only allows such waste, but sanctions it with the weight of law.

Under a single-payer system, the government would have the authority to set the maximum amount of money that an insurance company can claim for its profits (and of money a pharmaceutical company can charge for its products), and would have the authority to set the maximum rate that a company can charge its customers for a basic premium. There would be no limits on what insurers can charge for supplemental policies, leaving companies free to charge their customers what the market can bear (but the government should guarantee adequate competition in this regard.) This is what the governments of Germany, France and Japan, to give just a few examples, already do successfully. The one thing they have in common is that they provide no less care, and no worse care, than the United States, at much lower costs. Anyone who tells you differently is either shilling for the status quo or is simply ignorant or misinformed.

This list is only the beginning. It is open to criticism and improvement, and I would love to hear your opinions on it (or your encouragement, if you think it is a good start and could be expanded.)

There is a very good chance that health reform in Washington will either fail to pass or, if it passes, that it will be inadequate and that it will not contain some or all of the elements listed above. But there is a backdoor for reform, and that is at the state level. T.R. Reid has predicted that in January 25 states will introduce their health care reform proposals in state legislatures. That is how health care reform started in Canada. It started in Saskatchewan and spread like wildfire, until the whole nation embraced it. While I am not too optimistic about the reform that is taking shape in Washington, I know that justice will eventually be achieved. Whether it is a matter of months or years remains to be seen, but I will not give up until it happens. And I welcome your help.


John Stockwell said...

Dear Sir Fab,

Just to say something dissenty:

A modest proposal: Ban health insurance
for vision and dental and see what happens.

My prediction is that you would see the
costs of these services plummet, because
opthamologists and dentists would not have any of the
overhead that goes with collecting from insurance agencies.

Furthermore, I believe that the enire cost increases that we have seen in vision and dental are *because* an increasing number of people have vision and dental plans. Provide the cow and it will be milked.

With the success of reducing the costs of these services, move on to other aspects of health care, and ban insurance for select items there,
as well.

Now, while you are at it, find a way to provide a financial incentive for medical suppliers to reduce the costs of the goods and services that they supply to dentists and opthmologists and later to other areas of the medical profession. The Walmart model seems to be quite effective in this area.

Sirfab said...


Being that I deeply mistrust insurance companies, your suggested approach has a certain appeal. It is certainly better than the health care "reform" plan that Senate Finance Committee has come up with earlier this week.

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