My healthcare brain dump
I'm certainly no health care policy specialist, but as people debate the various proposals and scary scenarios put forth in the effort to reform our healthcare system, I find myself increasingly feeling a need to clarify it all down into what I think should happen. So, without any recognition whatsoever of whether this is all achievable, here is what I would love to see come out of this effort:
1. Medicare remains as a separate entity, rather than being rolled into some sort of national healthcare plan. The disruption of changing how everything works for the millions on Medicare would be expensive and upsetting to people who rely on regular healthcare more than any other demographic group.
2. I would like to see people like me have an option. It can be an option between my employer-provided healthcare and a publicly available alternative, or it can be that every person has more than one option from which to receive their care. It really doesn't matter to me. But I don't want to be forced into one public option that everyone has to be a part of, and I don't want to be stuck with my shitty work-provided insurance program. I would like the ability to shop at least 2 different options and decide which is better for me.
3. Previous proposals have involved expansion of the government employee healthcare programs to uninsured Americans. I like this option, because the people I know with government-employee healthcare seem happy with the service they receive.
4. The biggest prohibitive factor for the uninsured is the high cost of obtaining health insurance on your own, without the benefit of the volume discounts that large employers can negotiate. My parents, who retired in 2005 but will not be eligible for Medicare until after 2010, pay $600 a month for their health insurance--and they have a TEN THOUSAND DOLLAR DEDUCTIBLE. Because they are retired and have no employer through whom they can obtain insurance, they have to go on the open market to buy their individual health insurance policies. So, they are getting the worst possible price. Aside from a handful of routine visits to the doctor in the last five years, neither of them has had any serious medical conditions or required any major treatment. Essentially, they are paying $7200 a year PLUS the full cost of their care due to the high deductible. People like this need a way to leverage the bargaining power of the other uninsureds out there who can't obtain insurance through an employer. If we are going to keep private insurance as an option, there has to be some way for insurance purchasing collectives to form that would lower the cost for people like my parents.
5. I would also like to see the public purchasing option available short-term to the unemployed so that they have alternatives beyond the exorbitant monthly COBRA payments that they must make to keep their employer-provided coverage. When I was unemployed in 2002, I received approximately $600 a week in unemployment compensation (which was the maximum at the time.) My COBRA payment every month was over $600. In order to keep my coverage, I would have had to pay one quarter of my monthly unemployment just to stay insured. Needless to say, I decided to take the risk of winging it. When I found a lump in my thigh a few months later, I had to agonize over whether to pay $2400 in "back" COBRA payments to make the coverage kick in, or go to the doctor on my own dime and pray that it was something minor. That is a choice that nobody should have to make.
6. There needs to be an option for repayment assistance for people who incur massive healthcare bills even while on insurance. We have all heard the stories of people who have had to declare bankruptcy because they ran up tens of thousands of dollars in medical bills for uncovered costs. 2 years ago after a fainting spell, I had an MRI to make sure I didn't have a brain tumor. That MRI cost me $700 after insurance. Thankfully I have an income that allowed me to pay that right away, but if I were a secretary or paralegal at my firm, I might have had to work for six months or a year to save enough money to pay that off. If instead of an MRI I'd had emergency gallbladder surgery, or been in a car accident that required me to be hospitalized for a week, I could have racked up $10000 or $20000 in bills, between the deductible, co-pays, and the 20% of "in-network" charges that my BCBS requires me to pay for. How are people with average salaries supposed to pay those bills off? Who do you know who could pay off a $25000 bill in under a year? I am not necessarily suggesting that the government should be responsible for paying them, but perhaps allowing people to take out a loan similar to a federal student loan, with deferment and payment adjustment options, that would allow them to work towards paying off the outstanding balance without having to declare bankruptcy to get out from under that debt burden.
7. There needs to be some way to maintain physician and facility choice. The thing that scares me and other opponents of universal healthcare the most is the idea that you are assigned to a doctor or a hospital, and have no choice in who provides your treatment. But, so much of good healthcare relies upon the trust of your doctors and the personal relationship that leads to good treatment. Much like a PPO, whatever options the government puts forth should allow for a range of physicians who are available to people on the government-subsidized or sponsored plan.
8. I do NOT believe that tort reform needs to be an essential element of any healthcare reform proposal. While I am hesitant to write about this here because my personal views on the subject conflict with those of my clients, let me just say that people vastly overestimate the impact that medical malpractice costs have on the healthcare system. In addition, Georgia enacted tort reform as to medical malpractice cases in 2005. But I challenge you to find a doctor in this state whose insurance premiums have dropped significantly in the last 4 years. (You may not even be able to find one whose premiums fell at all, if the doctors I talk to are to be believed.) Even if premiums had gone down, those savings are not being passed on to consumers, as healthcare costs continue to rise. There is absolutely zero evidence that tort reform leads to reduced healthcare costs. Quite the oppposite, healthcare costs have continued to rise even in the states that have enacted tort reform. Instead, a CBO report found that all that tort reform really did is increase insurance companies' profitability.
9. It may be that we need 2 different options: a "safety net" of government-provided catastrophic healthcare coverage for major illnesses and injuries, and a separately administered routine and preventive health care system that continues to be mostly privately-provided but with a public option or alternative. I tend to separate out catastrophic healthcare and "everyday" healthcare because I would like to believe that every citizen has a right to the former, but not necessarily to the latter. I have no right to have my annual checkups with my ob-gyn paid for by the government or anyone else, but I would hope that nobody involved in a bad car accident would be unable to receive hospital care because they were uninsured and could not pay privately. These catastrophic situations are also those more likely to result in the extreme scenarios we all hear about, when insurance companies are denying people potentially life-saving but expensive treatment, or when a patient has lost their job due to prolonged hospitalization, lost their insurance, and been forced to declare bankruptcy and go on Medicaid in order to receive even a bare minimum of care. I could certainly make a much stronger argument for a right to catastrophic healthcare coverage than I can for routine. (And yes, I know, preventive medicine reduces future healthcare costs and should be encouraged, etc. I agree, but I don't think that makes it rise to the level of a right. However, I might make an exception for vaccinations and early detection screenings that can catch serious diseases early and thereby save more lives and prevent lengthy catastrophic hospitalizations.)
10. Above all else, and as the rhetoric grows ever more heated, I try to remember that we all agreed not so long ago that the current system is broken. I don't think even most conservatives or those in the healthcare industry itself would disagree with that. The current system, while better than that available in many other countries, is not providing most Americans with what they need or want. While we certainly can have legitimate and serious disputes about what form reform of the current system should take and how far it should go (as well as how much it should cost), I would hope that nobody is seriously arguing that sticking with the current system is the best option. If you are, then I respectfully suggest that you simply haven't lived without healthcare recently and/or have not faced a significant health crisis recently. Much like the old saying that "a conservative is someone who has never been arrested," an opponent of healthcare reform is probably someone who has never been both broke and seriously ill.
Anyhow, these are just the thoughts percolating in my brain as I try to sort out all the options. I have other goals too, relating to the costs to small businesses and government debt burden, but they have already been covered ad nauseum by the standard conservative voices out there. I've also heard all the utopian dreams about that mythical single payer system where efficiencies and cost savings lead to great healthcare at a fraction of the current price, but I will believe that when I see it. I also think we are at least a decade away from even seriously considering a single payer option, so we need to be realtistic that a hybrid option is the most likely to actually pass this go round. So, I approached this with the goal of thinking about what I definitely wanted in that option, and what I perhaps didn't.
I hope others will share their fundamental goals and hopes for such a plan in the comments. However, anti-reform astroturfers can stay away because I have an itchy ban finger today.
