Health Care

A couple of things are converging to make this post. One is that on the same day a new report told us that more than 40% of moderate-income American adults went uninsured for at least part of 2005 (on top of more than half of low-income and 1 in 5 middle-income Americans--Kevin Drum has graphs), the State Senate approved a tax break for "health savings accounts," sending to Governor Doyle a bill that, most likely, will not help any of those moderate-income folks. Two bi-partisan bills that actually would help people--the Gielow/ Richards bill and the new Decker/ Musser bill will, unlike HSAs, get nowhere in this same legislature.

Conservative Peter DiGaudio (along with a big chunk of the Badger Blog Alliance) is upset at the impending death of a woman under Texas's "Futile Care Law" that allows hospitals to stop treatments that will not, ultimately, save a life, under certain conditions. DiGaudio claims that this kind of rationing to health care is just a preview of greater government involvement. At the same time, conservative Rick Esenberg defends insurance company Wellpoint for, essentially, signaling to a cancer patient that they would rather she die, too. I guess they, like the Texas hospital, are thinking, Why wait for the government to take over?

Plus, I haven't written a long, substantive post in a while, and my fingers get out of shape when I miss my one 1,000-word post a week minimum.

More proximately, the cause may be that in the comments to this post on TABOR and TABOR-like symptoms, several of you voiced your opinions on health care. While I don't think that we here in the folkbum community (hey, I have enough regulars I think I can call it that) will solve America's health care crisis, it seems appropriate to open up a thread here to see what kind of common principles we could all work from, whatever our perspectives.

When I think about health care, I start from a few basic core positions:

1. Collectively, this country spends too much on health care. We spend double per capita than most other western countries, yet we don't get care that's twice as good or double the satisfaction (read the whole thing). Related to that, medical inflation outpaces the CPI by far too much. (eRiposte has some telling data.)
   
2. The cost to individuals to get comprehensive health care coverage is too great and, indeed, even negotiated group plans purchased by employers cost too much.
   
3. The quality of Americans' health care absolutely should not be an accident of where they happen to work. The peculiar and uniquely American system of health insurance as a benefit of employment has distorted both the health care and labor markets.
   
4. The U.S. should not settle for a health care model that puts the most important decisions--from who your doctor is to what level of care you should receive--in the hands of anyone but consumers and patients.
   
5. One of the most backwards things about health care in this country is the secrecy, the multiple price-points for the same service, and the loopholes in care. I support the idea (proposed by, among others Steve Kagen) of unitary and transparent pricing. No reform can go forward without it.
   
6. Health care is, and should always remain, a two-word phrase.

There are a variety of reforms that I would support that fit in with those beliefs.

It is clear, though, that the number one task ought to be cutting the cost of delivering health care.

Here's one thing we know: Patients are paying more, but doctors (and nurses and PAs and techs and anyone else who earns a living seeing patients) aren't making more. Another thing we know: Most of that extra money is going to the middle man, the entity that takes your money and then hands it to doctors. There's where we need to start the reform.

I figure there are two extreme ways to do that. One would be eliminating insurance companies entirely and paying for everyone's care at the state or federal level. The other would be cutting everyone loose and letting them all negotiate for themselves the best deal they can get and hope the market looks out for the best interest of the ill and poor as well as the rich and healthy.

Anyone can see that neither of those extremes will be satisfactory to anyone except the extremists. What to do, then?

Seems to me, just ball-parking a plan here, that the best answer would be a combination of the two, a middle ground, if you will. Here's what I think a plan could look like. Figure that this gets done on a county-wide--or perhaps regional--scale; in fact, if I ever ran for county board or anything like that, this might be a significant part of my platform (any other candidate is free to use it):

• Start by gathering every public sector employee into one buying pool. Rather than letting each unit of government fend (and do the paperwork) for itself, put everyone in one group administered by a small agency that does only this. The agency will be partially paid for by the units of government, who would almost certainly contribute less here than they do to their own benefits departments.
  
• Ask insurance providers to submit plans to get access to that pool. The cost of admission for any insurance company would be a percentage fee--say, 3%--based on the previous-year's business in the county (or region). If a provider did $3,000,000 of business last year, they'd pay $90,000 to get in on the deal. The fee will offset the cost to the units of governments to set up and run the agency, and insurers will see it as part of the cost of doing business--cheaper than cutting themselves off from such a large pool of potential customers.
  
• Send a "rough draft" of the collected plan proposals to each insurer to ask if they want to make changes. That way, each insurer sees what the others are offering, encouraging them to compete with lower prices.
  
• The final set of available plans is sent to the employees. The specific units of government can then say--as the state does now with its employees--which, if any, of the plans would be "free," and which would result in a deduction of the difference from salaries. Employees choose the plan that looks best for them, and, like that, we have cheaper health care across the public sector.
  
• Then cover everyone without employer-provided insurance on a sliding scale based on the previous-year's income. People pick a plan from the same set of choices offered the public-sector employees. Cover the cost of the sliding scale with a small fee against businesses that do not offer health insurance to their employees.
  
• Finally, open it up to the private sector, letting business use the same set of choices (further encouraging more insurers to offer plans) the way the private sector does. As we do with insurers themselves, and with the units of government, assess a fee--perhaps a small percentage of payroll--to help pay for the administration. Any business that opts out--providing insurance itself--pays no fees at all to anyone, though access to lower-cost plans will almost certainly move employers into my plan.
  
• Here's the kicker: Make the fees on business and contributions from the units of government to participate larger than the fee levied against those who don't provide insurance at all. This will encourage a slow migration of everyone--public and private sector--into a system that allows for maximum transparency and competition among insurers (and providers--see above), maximum choice for consumers, and the power of the state to bargain with insurers to keep their costs down. It takes employers out of the losing game of providing health insurance, but doesn't add up to single-payer.

That's my idea. Tear it apart in the comments below--but only if you provide some ideas of your own.