Posts
the public option is only a means to that end...
In his speech before a joint session of Congress, President Obama dismissively described the so-called "public option" of the proposed health care reforms as a "means to an end". I get that. It's hard to argue with such broad goals as "... provid[ing] more security and stability to those who have health insurance. ... provid[ing] insurance for those who don't. And ... slow[ing] the growth of health care costs for our families, our businesses and our government. ..." In a way, it's like saying "we're in Chicago right now, we want to get to Washington, DC, and there are more than one way to get there from here."
But as anyone who looks at a map can tell, some paths will get you there more quickly than others. A single payer plan such as HR 676 would be the fastest way; it clearly would provide stability and security to the insured, provide coverage to those who don't currently have it, and would control the growth of health care costs and decouple them from employment, reducing their burden on employers. A "public option" could work as well, if all health care providers are require to accept its payments (preserving your ability to choose a doctor) and if the plan has open enrollment (allowing everyone to access its benefits). The tepid "reform" proposals included in the President's speech, with no public low-cost competition for private carriers, are like walking from Chicago to California, then hoping you can hitchhike from there to DC. The byzantine regime of proposed regulations may be effective in controlling costs and keeping people healthy if they are coupled with aggressive enforcement and penalties for breach. Of course, this will inevitably add to the amount our country spends on "health care", without actually using that amount for providing care.
Let's also not lose focus on the main item insurance companies want to get from the current proposals: a mandate that everyone be required to purchase coverage in a "health plan". The insurance companies will benefit greatly by having 47 million new premiums paid (many or most subsidized by our tax dollars), and they will fight hard to make sure they can capture that revenue without onerous regulation or meaningful competition from each other or a public entity. If all we end up with is a "mandate" without a public plan to compete with private insurers, we will end up with a situation worse, not better, than what we have now.
7 comments:
I don't think the issue of costs has even been explored, except to say that health care costs a lot. Sure, we want lower costs, but that's like wanting a less expensive car. There are reasons things cost what they do. What are we giving up? Wishful thinking says we're just giving up waste and profits to the greedy boogymen.
Simply mandating lower costs is a violation of the laws of economics, and there will be unintended consequences. It doesn't have to be in the form of rationing or death panels, but those are some of the obvious ways to get there.
Hmm.
I've been too busy to read the whole 1,000 page bill, so I can't speak authoritatively, but I have the impression that there's no attempt to mandate lower costs. Instead, it seems to me that people are proposing different reforms and asserting they will potentially have lower costs because of various factors. Creating a care provision system which competes with private insurance companies and which does not involve multiple reimbursement regimes (saving money at the provider/doctor side), marketing, advertising, and profit (saving money on the payer side), and an incentive to avoid paying for preventative care (saving money over the life of the patient) apparently would either lower costs overall or make more money available to provide care to individuals.
To address the idea of rationing: clearly, the current system of private insurance companies rations care; profit equals income minus expenses, and as a corporation you try to raise income and lower costs (outlays on care). The policy you currently have excludes various items from coverage, imposes different reimbursements for various treatment regimes, and limits your choice of doctors and hospitals. There will be rationing in any system; it's a bit dishonest to point to rationing in any proposed reforms as if it were something new and different.
The phrase death panels, as far as I can tell, refers to a proposal that individuals be counseled by their doctors about possible decisions relating to medical power of attorney and early declarations about possible interventions to be attempted should the patient be unable to decide for themselves. These are already all standard practice, and I'd be surprised if you or your parents and family don't have similar health care directives already in place, memorializing your choices concerning your care. Compare that to another regime which could also be called death panels: the employees at health insurance companies who deny coverage for pre-existing conditions, who revoke coverage through recission from the already insured, and who deny and delay claims for things like kidney transplants for their insured. They are making their choices about your care.
It's hard to build a good analogy between the example of the less expensive car and less expensive health care. But clearly if there appears to be a systemic change that would rationally build better cars less expensively, I think we should discuss, encourage and support such a change.
Michelle Malkin gives a nice wrap-up of the concerns about death panels. It is not about end-of-life counseling, but about making decisions about which lives are not worth saving. It is a particular form of rationing.
In what sense is the government plan supposed to "compete" with private plans? If there's really no marketing and no advertising, how is anyone to know whether it's worth switching (apart from those who can get it — but not any of its "competitors" — for free)? And what is its incentive to be either cost-efficient or service-oriented (which are to some degree competing objectives)? The Post Office (which does advertise) at least has the requirement of being self-supporting. Although it's always having trouble.
We currently have four ways of paying for health care: private insurance, Medicare, Medicaid, and (God help you) a la carte retail. It is not my impression that Medicare and Medicaid are giving us tremendous amounts of bang for our buck relative to private insurance, though it depends on how you measure it.
In any case, three of those means are functioning more or less as they're supposed to. There's always room for improvement, but that doesn't mean replacement (or a government-run alternative) is necessary or will improve things. In an ideal world, single-payer is a great idea, but in an ideal world, so is just about any other scheme.
I tend to favor solutions that directly address the problem to be addressed in as targeted a way as possible. One conceptually simple way to bring in the uninsured is to expand Medicaid.
There are targeted solutions to problems in the private insurance situation, as well. In particular, I'd like to see the negotiated rate of a medical plan separate from its insurance. That is, anybody can join a medical plan and pay the negotiated rate for services. Pre-existing conditions and high-risk lifestyles are laregely irrelevant, because the company isn't paying claims, just negotiating rates for you. Nobody's stuck in the a la carte pool, subsidizing people in medical plans. The price is purely administrative, and, I would expect, pretty affordable.
There would still be issues with insurance to deal with, but decoupling the problems makes it easier to address.
Here's one of my senator's take on it
In response to Roy above:
I would agree that a much easier "reform" would be to expand eligibility for Medicaid or Medicare so it immediately can cover all the uninsured, and eventually can cover everyone. You would also have to require all licensed providers to accept payments from this plan, so participants would have their choice of doctors and hospitals. In this way we can have a system which already works with much lower costs compete with private insurers. The private insurers can always choose to compete and/or offer supplemental plans to those who can afford them.
I don't agree with the "negotiated rates" approach. If I understand you correctly, you're proposing that alternative in addition to some catastrophic coverage (true insurance)? Without insurance, the negotiated rates are not sufficient. And worse, I think we've already seen that approach fail with the prescription drug plans - with so many rates/payments to analyze, it's almost impossible to determine which plan is best for you. There's a dramatic information asymmetry - you as a consumer can hardly match the companies' ability to procure and analyze all the treatment options and rates and compare them to your expected outcomes. People already have trouble picking out cable and cell phone plans, never mind homeowner and auto insurance. I don't see how making the purchasing environment more complex can improve the provision of health care. My instinct is to have a more efficient system we need less complexity, not more.
You would also have to require all licensed providers to accept payments from this plan, so participants would have their choice of doctors and hospitals.
Absolutely not. If you do that, there's no reason for the government to pay anything at all. "Ha! You have to accept whatever payment we decide you get! And that happens to be zero!" Medicare already under-pays for care, which losses have to be made up from private insurers (and the unfortunate non-covered).
Would you also require that medical providers accept every private insurer's payments?
If I understand you correctly, you're proposing that alternative in addition to some catastrophic coverage (true insurance)?
As I said, I'm decoupling them. Your point about complexity is taken, but I don't know that it's adding that much complexity. The pricing for a medical plan will be based on administrative costs (things like how much a doctor visit costs). You don't have to have a "co-pay", you just pay for stuff at an advantageous (relative to retail) rate. That's more efficient anyway - money goes from you to your doctor, not via an insurance company. The insurance comes in for major medical (insurance is for unexpected, major expenses, after all), and its pricing is entirely actuarial.
D'oh! Administrative costs are not how much a doctor visit costs. It's just how much overhead the insurance company has for performing its service of negotiating rates for you.
Post a Comment