The hard reality is that you can't have all three to the degree that people want.
So the best we can do is try to maximize each element without breaking the bank and so that is the premise I use to look at the issue before the nation right now.
We should be honest about the size of the problem.
If indeed 46 million are uninsured, we do have a problem. But looked at another way, that means 254 million do have insurance!
Do we tear up the whole system to address the problem?
Cost
(1) As much as the MDs might not like it but the bottom line is that more of health care needs to be delivered by well trained non-MD medical professionals.
image source: http://innovatorsprescription.com/profiles/blogs/the-importance-of
As research pushes more medical conditions into the upper right side of this chart, more medical care can be delivered by non-MD medical professionals.
Thus, health care reform must include re-writing laws to make this more likely.
(2) Another area of cost control is the success of entities like Kaiser. If the Federal government issues too many mandates and regulations (think there might be some of that in 2000+ pages of legislation?), the creativity and innovation of organizations like Kaiser will get stifled.
(3) Lastly, we need to look at tort reform. The trial lawyers who make bundles of money in medical malpractice lawsuits have a strong lobby on Capitol Hill. From what I have heard, there is no word of any tort reform in the current bill.
Access
(1) For primary care, there needs to be more creative delivery "Doc in a box" mechanisms like Minute Clinic and Take Care Clinic.
(2) From a government standpoint, there must be more funding for Community Health Clinics.
(3) For more expensive care, insurance access needs to be improved.
Part of the problem right now is that there is "cost shifting" because private insurance is distorted by two factors: the tax-advantage of employer-based insurance and the underpayment of care delivered via Medicare. These two factors drive up health insurance costs for those who obtain it outside of employment and Medicare.
Therefore,
(A) Phase in more cost sharing by subscribers of Medicare. Perhaps some kind of graduated scale where higher income seniors pay more than lower income seniors.
(B) Eliminate the tax advantage of employer-based insurance. We buy auto insurance with after-tax salary dollars. We should buy health insurance with after-tax salary dollars. I don't have the CBO at my disposal to calculate the numbers but some kind of graduated tax credit should be offered.
For example:
Income > X, no tax credit for health insurance
Income < X but > Y, tax credit of $ABCD
Income < Y, tax credit of 2 x $ABCD.
More tiers may be needed but a tax credit approach is more fair than taxes on "Cadillac" insurance policies.
To my understanding, under the current bill, high-priced insurance policies would be taxed at a punitive rate regardless of whether it is a high or middle income earner buying it. Under a tiered tax credit system, the high income earner can buy the "Cadillac" policy without a tax credit and the middle income earner if they want to buy it will do so with some tax credit help. The bottom line is give the option to the buyer.
How do we fund all this?
Will anyone have the courage to say, if all benefit from this, we should all chip in some extra taxes?
Instead, what we have is 2000+ pages of wheeling and dealing where politically well connected groups get a break and others get punished.
Quality
As much as politicians don't like it but the profit motive is necessary. The computer and internet revolution was driven by profits at high tech companies. And so the same is true for health care. The medicines and other technologies that make US health care top notch (though unevenly delivered) require risk taking for profit companies.
Thus, as hard as it is for politicians, they must resist demonizing the profit motive of drug, medical instrumentation and insurance companies. They must resist writing into law mandates and regulations that stifle innovation and risk taking.
Instinctively, the American people know this and as such that is why the public is so overwhelmingly against a "public option" or anything that looks like a government take over of health care.
3 comments:
Thank you for sharing, I like it worth reading.
Thanks for the nod to tort reform. For physicians, this is a gaping flaw, among others, in the pending health care legislation. For some personal views from an MD deep in the trenches, see www.MDWhistleblower.blogspot.com under Legal Quality.
I think you gave too much credit to the American people. They favor or oppose the public option depending on what they were fed (by the media, union, church political party ,etc). Government is not what stifles innovation, monopoly is. A public option can be established so that it is not a monopoly and introduces competition. A good example is the US Postal Service. Its existence did not kill Fedex or UPS. It gives them more reason to innovate.
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