Should we have a national health care policy? Isn’t there a better way to handle basic health care needs and reduce the cost or stem the rise in cost of health care?
The U. S. still does not have a national health care policy. Oh, yes, we have tried to start a conversation on this topic, way back in the 1990’s during the Clinton presidency, but nothing was achieved. With President Obama’s Affordable Healthcare Act, we have made a tiny step toward some kind of national health care policy, but about half of the states decided not to extend Medicaid for the poor, pretty much defeating the purpose of the Act in those states. Worse, health insurance premiums are rising there to cover the costs of the poor who are getting extended Medicaid in other states. I discuss then Candidate Mitt Romney’s comments on a health care policy, and one state’s attempts to solve the problem. I offer discussion about several ways to achieve affordable health care for all.
This is a Health Care Policy proposal with comments on “Mitt Romney Takes on Health Care in Mich. Speech” on Morning Edition on 13 May 2011 (see also “Vermont Steps Closer to Single-Payer Health Care” on All Things Considered on 22 May 2011), where I discuss how neither Congress nor the American people seem to understand the tremendous costs of health care, how we may have to rethink our expectations, and face the fact that no health care is free, and that much of the care we get is being subsidized by someone else who cannot get affordable health care. I analyze all the methods that have been proposed for a national health care policy and offer some of my own solutions that may be better at bringing down the costs of health care in the future.
Updated 3 Sept 2014
Ex-Gov. Mitt Romney gave a speech in Michigan on 12 May 2011, where he spoke on his reasons for signing into law the Massachusetts Universal Health Care Plan. NPR reporter Don Gonyea spoke with Steve Inskeep about his speech. Mr. Romney claims that his law was a state solution to a state problem and wouldn’t work on a national level. He feels that health care is a state problem that should not be dealt with by the federal government. Many “true conservatives” feel that there should never be a mandate.
What I Posted at NPR
For all the concern for “first principles” by the Tea Party and many other Republicans (as mentioned in the next report this morning), we cannot forget that health care costs are a problem that will not go away if we do nothing. We have done nothing for years as a response to the problem in the past. The only way to make a change in health care costs is to do something different. The Republicans have not come up with a solution, yet, and no one is completely happy with any proposed solution. When Obama proposed his plan, he never expected it to be the single solution that everyone becomes happy with in the end. He expected some tweaking, and even outright change, but the only change the Republicans have come up with is to suggest completely overturning the Health Care Overhaul Law.
A New Type of National Health Care Policy
I will compare two methods for paying for health care, health insurance and the traditional fee-for-service method, and propose a third. Although the term “fee-for-service” has come to be used for exacting extra cash from those on health insurance, it was the traditional way we bought health care in the past. When the doctor made a house call, he was paid for his services on the spot, either in trade or with money. No one flashed a health insurance card. Health insurance was a method for big business to make their companies attractive to large numbers of workers who were paid less salary (thus allowing the company avoid paying a higher amount of cost-of-living increases when workers won a percentage increase in salary at the bargaining table) in exchange for health care benefits paid directly by the employer. Health care was obviously a lot cheaper back then. With the rise in medical school training and greater professionalism among doctors and the greater use of technology in treatment, that cost started to rise faster than incomes, for both the company and the worker.
Other countries have tended to make all health care practitioners government workers, in an operation overseen directly by the government in the effort to control health care costs, with varying levels of success (as reported by NPR in the past). Canada has such a national health care plan where everyone must contribute part of their salary to a Social Insurance System. I remember back in 1984 when that tax rate, combined with the regular income taxes deducted from the paycheck, added up to slightly more than our Social Security/Medicare tax + income tax, about 29% compared with 24% in the US. It has risen in Canada since then, but not greatly.
The Canadian government can make a claim that all Canadians can get preventive and basic medical care, and most major surgeries/procedures are available, but usually there is a waiting list. However, many Canadians come down to the US to have these procedures done here to avoid that delay, even if they must pay, out-of-pocket for those services themselves. If you think that this is a solution that US citizens would never tolerate, then you have to consider another wrinkle.
Back in 1993, when the US was considering a national health care plan, the Canadian government admitted that it could not operate its own national health care plan effectively if the US changed to a similar plan itself. Why? Because research in medical care is underfunded in Canada when compared to research in the US. The US contributes a lot of new technology and procedures which Canada cannot afford to offer its citizens. It has a smaller population than the US has.
The big problem for GOP Candidates is that they do not like any plan where everyone is required to sign up for health insurance and pay for it. However, we all realize that we all benefit when everyone has access to health care and makes use of it because it ensures that we will not pick up dangerous communicable diseases from those who do not have access to health care, and helps prevent skyrocketing health care costs. These high health care costs have been attributed to, among other things, overuse of emergency room care by those unable to pay for health insurance and who wait until things become major problems before seeking care.
Let us look carefully at the Obama plan. By making sure that everyone is covered by health insurance, we spread the costs around. Because we add many very sick people to the group on health insurance, however, this most surely means that health insurance premiums will rise, not drop, unless we discover a huge number of very healthy uninsured people who will now be required to buy it (or are they?–there are many exemptions in place so we do not know their effect yet on the plan).
The problem for Democrats is that they are quite comfortable with a mandate for everyone to have access to health care, even if it means that some get subsidized for that access. An objection to this mandate rests in that a sizable number of people do not want to pay for someone else’s health care, even though they are paying now, through higher health care costs. Democrats realize that if we make health care something for which everyone must pay out-of-pocket in a true fee-for-service method (as some conservatives want), many will never be able to afford it, thus they back health insurance. Requiring purchase of health insurance by federal law also fits in with Democratic principles, since they realize that if something good for all is not required by every state, people will move from the “have not” states to the “have” states, and unfairly burden the latter. This happens in every economic downturn. Remember what happened during the Great Depression? “The Grapes of Wrath”. Other recessions have led to non-home-owners–in general, the poor–to migrate to larger cities and states where jobs and social welfare was more available.
However, health care is expensive and if the government pays for it, that means raising taxes and there will always be resistance to tax increases, especially now under tight economic times. That very reason explains why health insurance for all is not exactly wanted by everyone, since healthy people will be paying for non-healthy people. This situation is unique among economic choices on other fronts, since it involves a balance between freedom to buy what you want/need which has to be weighed against access to something that affects everyone else–health care (the same can be applied to broadband access because of its effect on internet congestion).
Republicans also want most people to buy health insurance as the only way to solve the problem, but they want it to be optional, as it is now. Democrats are not happy that the poor, and least healthy, get left out of this solution. Furthermore, by excluding the poor from buying health insurance and having mostly healthy people, who have been buyers in the past and who earn good salaries, buy insurance, it becomes less likely that their premiums will rise. This benefits insurance companies, whose huge profits from this practice, help to pay for conservatives’ election campaigns. This still leaves the most expensive group out of the solution.
Do the Math
A major problem with any solution, however, is the elephant in the room. Most people have forgotten what insurance is supposed to do. The purpose of insurance is to cover a once-in-a-lifetime, catastrophic event that would put anyone into bankruptcy if they had to cover all costs. This is true for life insurance, auto insurance (people who constantly have accidents usually lose insurance or face higher premiums), home insurance, flood insurance, etc. Unfortunately health insurance has been sliding into a different category ever since it was first made available.
So what is the elephant? Do the math. It is the same as the Social Security and Medicare/Medicaid problem. We never put into the coffers enough, over a lifetime of employment, to cover what we withdraw at the most expensive time in our lives, the last five years. This is precisely the time that we can finally go on Social Security/Medicare support (see NPR’s report on 30 April 2011 “Medicare’s Math Problem: Taxes – Benefits – Trouble“). The problem is that when you make something like health insurance the method for paying for the everyday health care you need, it ceases to be insurance any more. I’ll bet that most people with health insurance think of it as a way that they can avoid paying the full cost of the health care they get. However, the money they and their employers pay into their premiums over a lifetime, will never pay the full cost of lifetime health care , once they add up the costs (premium payments + copayments – benefits = trouble).
Another part of this math problem is Medicaid (see “15 States Try To Cut Back On Medicaid Programs“, a report on Morning Edition 7 June 2011. Reporter Julie Rovner, breaks down the recipients of Medicaid. It includes payments to children and disabled and the poor, but she says that 75% of a state’s money goes now to elderly long term care. Her conclusion: The only solution to the problem of skyrocketing Medicaid is to reduce health care costs overall. I agree. It is too hard to try to reduce Medicaid or Medicare without doing that first.
The Problem of Fraud and Misuse of Health Insurance
One problem with insurance is the fraud that gets perpetrated by doctors. I lived in a university town, and had health insurance. I was really sick for three weeks with pulmonary edema, and finally went to see a doctor who did absolutely nothing, telling me it would go away on its own, but I was really tired of the edema and very deep coughing. Every time I coughed I felt as if I was going to collapse of exhaustion. I got no prescription, no treatment. However, he said that since my insurance required me to pay for the first visit (back then it only cost $50 a visit), but would completely cover the second visit, I should return in 3 weeks if it did not go away. I did not bother to, knowing that he wouldn’t do anything as seemed to be the custom of doctors, even 30 years ago. It took another two months of severe coughing before it finally stopped. I realized the racket these doctors had. It was a rural town where the only people with health insurance worked at the university. Doctors there were vultures–their offices ringed the campus.
Someone else I knew lived in Los Angeles. She had really good insurance, and clearly more attentive doctors. Through routine tests, the doctor discovered she had a condition which might become more apparent with more tests. Since her insurance covered all tests, the doctor suggested she have a few more tests. She did not need to take the tests, since the symptoms were so minor and the condition was so easily treated. She was in no imminent danger to her health. The doctor never discussed what she should expect if she did not have the tests done immediately and what symptoms she should look for over the next few weeks to see if maybe the condition was getting worse, or was changing into something more severe.
Even 30 years ago her condition would have been easily treated once a true cause was known and after more severe symptoms appeared. So this woman went ahead and had the tests, which showed nothing. The doctor concluded that her condition was due to “stress”. The tests added another expense of $450 to her health insurance bill (worth about $2000 today), paid for in full by the insurance company. This practice contributes a lot to skyrocketing health care costs, poor decisions made by the patient and the doctor where a lot of money gets spent when it is not needed, and the informed patient would probably not have gone ahead with the tests until she had experienced more symptoms. An episode on 25 Sept 2013, repeated on 2 Sept 2014, called “Secrets Your Doctor May Not Be Telling You!” was a major discussion on just this problem, where Dr. Travis Stork spoke with three doctors, all of whom wrote books on various aspects of the problems with doctors, Drs. Leana Wen (“When Doctors Don’t Listen”), Martin Makary (“Unaccountable”), and Allen Frances (“Saving Normal”). Dr. Makary in particular spoke on the options that all doctors should be giving to patients: to not treat, to wait, to watch for specific symptoms first.
Not All Health Insurance Plans are Equal
We have heard about the “cadillac” health care plans where patients can get almost anything covered, or at least, far more than most plans allow. We have not heard much about the plans where the coverage is extremely limited. There is COBRA, to give unemployed a chance to get some kind of health insurance while they look for a job, but this won’t last long and most of the unemployed today are probably no longer eligible for it. Besides, how many unemployed can afford to pay $300 a month into an insurance plan? On what income? Where is the money going to come from to pay for it? Out of savings? Then where is the rent/mortgage coming from? The food? Transportation? Utilities?
COBRA is an extreme case, but there are other insurance plans that many people who have previously diagnosed conditions have to settle for (or at least before the Health Care Act was passed) that cover very little for a huge premium. Then, next up the ladder are the employer-provided health care plans which were the cheapest that employer could find. These have not been talked about at all. These plans limit the doctors you can see, not just for HMOs but also for the traditional insurance plans. They limit coverage for all sorts of things, often excluding pregnancy-related items, contraception, abortion, and other reproductive services (not just in vitro fertilization which might be covered in “cadillac” plans).
Furthermore, the doctors treating patients on these plans are also limited in what they can do. In all of these plans, the patient must be seen by a primary care physician who will refer that patient to specialists as needed. However, the insurance plan provider usually limits the physician in the number of such referrals that can be made, not only for that patient but for all patients put together. In fact, some plans are so limiting that the doctor is allowed to make only 3 referrals in total per month (private communication from doctors), for all of his/her patient load. Thus he/she will often have to encourage a patient to come back again in a month, hoping that the physician has not used up all referral rights for the month.
Most doctors caught in this bind, whether it is only three referrals a month, or 50 a month, will only guarantee referral to cardiac, pulmonary, or cancer patients, and only those patients with clear symptoms for the specialist to act on. All other cases get “lost”. Thus, those nagging symptoms that can become debilitating, like fibromyalgia, never get treated, let alone acknowledged. It is no wonder that black lung disease still exists among the coal fields, and is still going untreated in rural America where there are just too few doctors and too few affordable health insurance plans, besides the fact that coal companies refuse to acknowledge that it exists.
How Are Our Doctors Trained?
Another aspect of this dilemma, raising the risk of what we could call “fraudulent behavior” is seen in a hypothetical case presented by Charles Ogletree, a lawyer, who raised questions of ethics to a panel of experts (including Supreme Court Justice Scalia, and at that time, Surgeon General C. Edward Koop, news media representatives, oncologists, bio-ethicists, public health experts, and others) on a Fred Friendly seminar program on Ethics in America (Ethics in Medicine) on PBS TV in 1989. Ogletree tells Dr. Koop that his patient, Betty, has discovered a lump in her breast. He asks Koop a series of questions about what he would tell Betty. Koop says he would refer her to a specialist, an oncologist.
Ogletree then turns to an oncologist on the panel, telling him that Betty comes to him for advice. The oncologist lists all the possible types of cancer, and the suggested treatments. For most he pushes surgery. Ogletree says Betty wants a second opinion, and the surgeon says she is entitled to one. He points out that he will give her the names of two other oncologists to go to, but, “if you go to Midas, you’re going to get a muffler”.
The implication is clear. The doctor is trained to do one thing. No matter what your problem is, he will recommend that thing he can do for the patient. At that time, the oncologist was going to do surgery, either lumpectomy or breast removal. No other choices existed. Today, we can recommend other therapies:
chemotherapy, radiation therapy, or surgery, or a combination of two or more of these. Few will recommend acupuncture, spinal manipulation, herbal treatment, or mind-body medicine but there are centers where they have practitioners of all of these types of treatment, and most are very much geared toward treating cancer.
However, we cannot say the same for all other conditions which require a specialist. In fact, what struck me by this interchange between Ogletree and oncologist is another stark reality, even in today’s medical market: Who speaks for the patient? Who directs the patient to all the practitioners who might be relevant? If the oncologist back then could not do this, can the proctologist, neurologist, urologist, geriatrist, obstetrician, orthopedist, cardiologist, etc. do it today?
The serious problem here is that the physician is not the advocate for the patient. In fact, he/she will face denial of payment by the insurance company if he/she prescribes any treatment/procedure/medication that is not approved by the insurance company, even if the prescription is not experimental at all. The physician is reduced to looking at the patient as a list of symptoms, not a person.
The symptoms have to add up to what the doctor learned in medical school will fit particular protocols. The protocols are memorized so that the student can pass the medical boards. The doctor does not look at the patient as a biology problem in search of a solution, but as an object that can be forced into a package that is correctly sized, not for the patient, but for the protocol. If the patient can not be fit to any protocol, too bad. The doctor can do nothing for that patient. The patient can ask for a second opinion and go from doctor to doctor, etc, but still will get no answers because none of the doctors is trained to solve problems anymore. You cannot be graded on your ability to solve problems on multiple choice exams. Practical boards only test that you can remember the correct protocol and use them only on patients which properly fit the criteria. There are no medical boards that test future doctors on their ability to come up with real solutions for the individual patient who doesn’t fit the protocol’s criteria.
This is not to say that there aren’t any physicians out there who will understand the biology well enough to suggest to the patient some of the protocol that appears to fit some of their symptoms and suggest some other treatment for the rest of the symptoms. However, these physicians are few and far between. Furthermore, no physician seems to think that maybe he/she can think out “equivalent symptoms”. Really understanding the physiology is critical for defining “equivalent symptoms”. This means being able to see a symptom that appears to be unusual but which clearly involves the same tissues which would cause different symptoms in other people who fit the protocol, and thus could be considered a possible outcome from unmitigated symptoms for a particular syndrome.
The medical student learns very quickly that he/she must follow the protocol or risk losing his/her license to practice medicine. Now this constraint has produced consistent results in medicine today, but most of that consistency has ended up raising the costs of medicine, as more and more medicine relies on independent tests and less on the doctor’s observational skills, and leaving a sizable number of people out of the population that get regular health care. We have produced a large number of doctors who go into specialized medicine where the problems are complex and challenging, the protocols well worked out, and the monetary benefits are high. However, the baseline medicine needed by everyone is not well served by a an abundance of practitioners (GP’s), who will get poorly reimbursed for their jobs, who must spend the rest of their lives paying off medical school and start-up loans.
The Third Solution
The only other solution, making everyone buy their basic and preventive health care via fee-for-service, without insurance, is rejected by both sides. But should it be? Stated as I just said is, on the face of it, completely unacceptable by anyone. However, there is no reason we cannot tweak this method a bit. Maybe we still need a government subsidy to level the playing field, since the aim of insurance companies is to insure the healthy, not the sick. However, this does not mean getting rid of insurance companies. It means changing the way they work today.
How about expanding (and I say, legitimizing) medical savings accounts as a method for paying for health care? Right now they seem to have been created only as a poorly formulated afterthought by Congress since what a person puts into it must be completely spent by the end of the year or the account holder loses the unspent “savings”. They are also limited in their use to those expenses not covered by insurance–a very clear signal that Congress wanted those campaign donations from the insurance companies.
To make these savings accounts workable as a replacement for insurance, they need to be established in such a way that the holder cannot use the money for anything other than their health care. They should also keep them active and saving for the rest of the account holder’s life, in other words, very much like Social Security savings. However, being a savings account, the money in that account can be inherited by relatives upon the death of the account holder, or lent to their relatives when needed. Thus a grandmother might forgo that fifth coronary bypass to fund her grandchild’s need for a kidney transplant.
We would still need a mandate that everyone sign up for such an account, even the poor. The reason such a mandate is needed is that all money going into a savings account is pooled and acts as leverage for the loans that new medical savings banks, established to hold these accounts, get to buy and sell to those needing more money to cover major health expenses, or to invest in research and new technology. Thus these accounts can become interest-bearing accounts. The account holder can now buy medical services from whomever they choose, on the advice of their medical savings bank.
Insurance companies have most of the comparative information on practitioners and services, and they could easily become these new medical savings banks, now with a different kind of purpose. The money they hold does not belong to them, but to their account holders. Since insurance companies hold the information about costs and quality of health care to themselves, and will not reveal it, even to Congress, they would be more than likely to show it to their account holders if it helps the account holder to make wise health decisions that promote keeping most of their money in a savings account held in that “bank”. Having this kind of mandate would thus be far less objectionable to those against any mandate, because it keeps all money in the hands of the individual beneficiary.
Medical savings accounts were conservative solutions in the past. This new type of medical savings account is not a “liberal” solution to the health care problem. They are still conservative for the following reasons:
- Holding medical savings accounts in these new medical savings banks allows a client to continue saving for long-term care at the end of life, reducing the demand for Medicare.
- By making the consumer directly responsible for buying the goods (the medical care), they change from the fake market forces that have operated in the past (insurance companies) to real market forces that can control costs much better (the law of supply and demand). The buyer will not buy something that is too expensive, or, on the advice of their medical savings bank, not effective.
- This solution also puts a larger burden on the account holder to make wise decisions about lifestyle, to budget their savings, and to learn about their bodies to be able to make good decisions.
- As a further check on medical costs, the “banks” would notify the holders when their accounts are draining too fast, and what their clients need to do.
Not the Grand Solution
This is not the great solution that many would want because so many Americans think that their insurance will cover more than the individual can afford for health care (part of the elephant in the room as stated above). It still means that many will not be buying their first, let alone their fifth, coronary bypass at the end of life, simply because they could not save enough money in their savings accounts to cover it, and would not be able to get a loan unless their own children are willing to lend them the money.
A part of a government solution could include tax reform. A simple line on the annual tax return stating what the individual or couple has paid into a savings account gets automatically deducted from their net income, reducing their tax percentage-wise. Taxes paid by all would have to subsidize the poor, however, but the poor will most likely be paying only for what they can afford–basic medical care without the frills, based upon what the government is willing to put directly into their savings accounts.
This solution does not end health care insurance, it only changes it back to what it was meant for when it first became available. People can continue to make payments for premiums, knowing that they may never use all of the money they paid for their health care, but will be able to cover major catastrophic events for which they could never have saved enough money during their lifetimes. There will be many who will not be acceptable to insurance companies for this future health insurance because of their lifestyle or the dangerous work they do, for which there are other types of insurance readily available today.
The medical savings account solution as proposed in this paper promotes the following:
- basic health care for everyone (we would have to be willing to define what basic medical care means and would most likely include preventive medicine)
- saving money to cover an expense we all face
- development of a method of payment that is subject to normal market forces (the law of supply and demand), controlled by the user and not the insurance company. Thus prices will rise and fall as in other commodities.
- it helps take the burden off of Medicare, not immediately, but in the long-term
- it may provide a model for changing Social Security in the future.
There are still aspects of health care that deserve much more thorough discussion, even with this plan.
- What exactly is catastrophic health care and what should be considered basic enough to be covered by health care savings accounts? Is cancer catastrophic, even if the form of cancer is easily treated? Most cancer treatment is very expensive, even if some is covered now by health insurance, and because of this, contributes to skyrocketing health care costs as the cancer rate increases, treatable or not.
- The cost of subsidizing the poor for their contribution to these accounts would not be negligible during the start-up years, since there are more people lacking good or any health insurance now than those who have it. However, the costs would most surely drop as health care costs drop in response to true market forces where the buyer is the user, not the insurance agent.
- What information must the insurance company-turned-medical savings banker provide to the savings account holder? A major change in behavior must be achieved. Secrecy maintained their share of the market for health insurance in the past, and transparency makes them more visible to future savers and thus more marketable in the brave new world of medical savings accounts.
References & Resources
Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big Pharma, and the medicalization of ordinary life. New York, N. Y.: William Morrow. [Amazon].
Makary, M. (2013). Unaccountable: What hospitals won’t tell you and how transparancy can revolutionize health care. New York, N. Y.: Bloomsbury Press. [Amazon].
Wen, L. & Kosowsky, J. (2013). When doctors don’t listen: How to avoid misdiagnoses and unnecessary tests. New York, N. Y.: Thomas Dunne Books. [Amazon].
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