String Theory of Healthcare - The Solution to Everything.
Tell me why this isn't a good idea
a. There should be National Health Insurance to cover basic insurance for everyone; employed, unemployed, uninsured and people like me. Employers would contribute to it based on a percent of payroll. There would be no problems with adverse selection or horrible bookkeeping problems about who's in and who's out, since this National Plan would cover everyone for these "basic" needs. It is a policy choice as to how far basic coverage should go. But suppose we use current Medicare as a base.
b. Employers may also provide "wrap around" policies in addition to the Basic policy. Like Medicare supplements (or private retirement plans supplementing social security), they can be as stingy or as generous as the employer desires. These wrap around policies could be self-insured or be provided by insurance companies. The policy would pay supplemental coverages (supplemental charges above what the National Plan determines to be "average" (see below), long term/catastrophic care, additional days of hospital stays, dental, dog and cat medical, whatever). In this way, the private industry can continue to provide benefits on a less than universal basis, and can play their exclusion and denial games, yet the right to fundamental basic medical care will not be diminished.
c. This is the part I like the best. Under this Plan, when you go to the doctor that doctor has to tell you (a) what services are covered under the National Plan and which are not (e.g., experimental, beyond the basics, etc.); and (b) how much more, as a percentage, that doctor will charge over that allowed by the National Plan. So, for example, the doctor may say "I will be charging you 10% more than what the National Plan pays me" and that will be a binding commitment. It has the following charms: (1) Doctors, not patients, have the expertise to know this information; (2) Doctors, not patients, have the expertise (and resources) to challenge the National Plan on determinations they believe are incorrect.
If a doctor finds that the National Plan will only pay $100 for a procedure but the doctor feels $150 is appropriate, all he has to do is tell patients, "I will charge you 50% more than the National Plan." If other of the doctor's charges are identical to that paid by the National Plan the doctor will simply average it out and tell people "I charge 5% more than the National Plan." The doctor cannot say that a particular procedure, test, exam, etc. will cost x% more -- the percentage must apply to all services supplied by that doctor to that patient. In this way the patient can doctor shop and compare apples with apples; the doctor can determine her own fees (within a narrow range) by using a multiplier of the National Plan; and disputes as to what the National Plan should pay can be resolved between those with the expertise and knowledge.
Presently the payor says $100 is reasonable, the doctor says the payor is full of it and that $150 is reasonable, and the patient winds up losing $50 and having no idea of who's right -- or any simple means of finding out. No wonder people are mad as hell and just won't take it anymore. I think this has the elements everyone needs. People are happy because they'll at least have guaranteed access to basic medical care; employers/employees are happy because they can have greater coverage than the basic plan; patients are happy because they will have a pretty good idea going into the doctor as to how much it's going to cost them. More important, there aren't going to be any surprises like "pre existing condition" and "we don't cover that" and "we only pay 50 cents for that procedure."
So whaddya think?
Notably, as reported in USA Today, that venerable source, the Kaiser Foundation has published a study concluding that it's time we talked about rationing health care. It also notes, as Jeff & Norman have noted, that the political climate, unlike the Earth's climate, will not be warming anytime soon towards changing the health care system as we know it.
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=40473
Posted by: Ron Dean | October 19, 2006 at 03:18 PM
I agree with Norman that pushing the "submit" button is always better than pushing the "delete" button. Those who say it's better to be silent than sorry aren't living life to its fullest.
Posted by: Ron Dean | October 18, 2006 at 11:16 AM
I agree with Jeff that it is difficult, perhaps impossible, to ration care, especially if the wealthy can opt into private markets. What we can do, though, is redirect medical research priorities today, focusing on (i) improving quality of life rather than extending life for older adults; (2) finding less expensive therapies for expensive treatments now available; (3) curing diseases that afflict the young; (4) developing therapies that keep people out of expensive nursing facilities. If we don't create expensive new technologies, we don't have to worry about rationing them or, more likely, paying for them for everyone who would benefit from them. All this will not, of course, help a lot, but it might help ease future costs a little. I know there is a lot wrong with what I just wrote (how much research is actually devoted to extending life of older folks--and what is older, anyway?)and I probably shouldn't post in public ideas that just pop into my head, but I've already spent a few minutes on this and it is probably more satisying to push the submit button on the computer than erasing this. At least from the standpoint of immediate gratification.
Also, I agree with Frank entirely. I actually favor as a first step national catastrophic insurance, which I think eases a number of problems with our current system, although it solves completely few of them. And of course you get to the rationing question pretty quickly when you are dealing with national catastrophic insurance.
Posted by: Norman Stein | October 17, 2006 at 09:18 PM
Well, let's respond to Jeff first. Rationing of care is, of course, a political hot potato (no "e" at the end). While my idea does not take a position of whether or how health care should be rationed, it is set up to accommodate whatever decision is made. If the Base doesn't provide for a procedure, or for limited procedures or costs, so be it. Should you be able to buy private insurance on top of that in the event the Base doesn't cover it? Why not? So, the wrap around is modified, and only those who purchase that insurance will have that coverage.
As to Frank's comment, while I appreciate that Frank doesn't think it's a good idea because it isn't universal healthcare, I don't understand why it isn't a fair compromise between those in favor of, and those opposed to, universal health care.
Posted by: Ron Dean | October 17, 2006 at 06:17 PM
Ron, you ask "so whaddya think?" and my answer is "ya gotta be kidding."
There are so many things wrong with this not-quite-national-health plan. Ya wanna get national health? Get it - all of it, including single payer. Then at least yer emplyers will have a level playing field with foreign competition, since all the other manufacturing countries have national health already.
The one good thing I can say about this idea is that, if you view it as a first step toward national health, then fine - it's just the sort of first step that will collapse quickly and lead to the second. Get on with it, if that's what you have in mind!
Frank
Posted by: Frank Cummings | October 17, 2006 at 04:44 PM
The proposal does not deal with a major underlying issue. That is we currently have more care available than we can afford. In countries where medical care is financed by the government, there is rationing of care, either some care is not available or you must wait months or years for the procedure. Who is going to say for example, we won't pay for coronary by-pass surgery if you are older than X or you don't meet certain minimum criteria (which is what happens in some government systems)? Or who will say this is all that we do for premature babies and beyond that the care is not available?
Who is willing to shorten the patent period for drugs or make it easier for companies to make generics?
In our egalitarian culture, we have sense of entitlement to every possible proceedure or drug and that's that. Who will make the hard decisions that ultimately must be made if we are not to go broke paying for everyone's care? I can imagine that Congress will do a great job of saying no, just like they always do.
I'm sure the President would love to promulgate regulations which limit access to care.
Posted by: Jeff Clayton | October 17, 2006 at 03:43 PM