Declaring healthcare political theater over last weekend may have been premature. A recent column on new bipartisan efforts in Congress referred to Republican reform proposals as “a circus of half-truths and no-truths and obfuscation and skullduggery.” Ironic, considering the author of the Democratic reform said “Obamacare only passed due to the ‘stupidity’ of the American voter and a lack of ‘transparency.’”
Nobody wanted to increase health insurance premiums by double digits, push doctors into early retirement, or drive deductibles out of reach. Nobody wants to kill people by taking away their health insurance. These are the unintended consequences of good intentions to expand access to healthcare and reduce the metastasizing national debt.
There is room for political consensus. We prefer to be healthy. We fear the cost of catastrophic events or chronic conditions. We want high quality care. We want to decide who cares for us. We are exasperated at obfuscated pricing for medical treatment, including prescription drugs. We are sure somebody is overcharging us.
Question is, what system best addresses these goals and concerns? How do we retain quality and lower cost? How do we respect individual freedom to take risks and exercise conscience?
Insurance, whether non-profit or for-profit, public or private, is a tool, not a goal. It is well-suited to catastrophic events. Some of these may be exacerbated by lifestyle choices, but the size of the pool mitigates the risk for the insurer. This is the original get sick and fix it insurance system.
Insurance is less efficient as pre-paid healthcare. It doesn’t deal well with conditions involving a predictably higher level of healthcare needs for pre-existing or chronic conditions. But the insurance model can work when catastrophic costs are shared in one very large group or distributed among all groups.
Most people have no choice over what their insurance plan includes when their employer does the buying. It may not pay for the doctor who provides the best care for their particular health issues, or for the treatment that is most effective. Employers can’t ask. Employees can’t tell.
Quality of care is almost an accident. Highly capable doctors and nurses spend hours on the phone arguing with third-party payers over appropriate treatment. Recently a provider said it out loud to me. “Since you don’t have insurance or Medicare, we can do what’s best for you.” Quality is driven down when patients and doctors lose control of decision making.
The most wildly unpopular part of Obamacare is the mandate to buy insurance, especially since it hasn’t “cut the cost of a typical family’s premium by up to $2,500 a year” as promised. There’s additional resentment at having to pay for essential benefits that aren’t essential to us.
We have strong and differing opinions on what essential benefits means. We resent paying for benefits we believe are non-essential or immoral. A national consensus on essential benefits is unreachable.
But an either/or choice between single payer or the old insurance market is a false premise. We need to apply America’s vaunted leadership in medical innovation to replace a 20th century sick care system with a healthcare system for the 21st century.
We can start by replacing employment based insurance with voluntary associations, with their own consensus on essential benefits and personal responsibility. Any social, business, labor, religious or community organization could offer a plan as long as membership does not exclude anyone based on pre-existing health conditions.
The Swiss model of a robust private insurance marketplace without a government option is attractive, but we are not the risk-averse socially complaint Swiss. Medicare is now firmly planted, but American culture is rooted in rebellion and risk-taking. Incentives in lieu of a mandate to purchase insurance would address our obstinance. Swiss-style price controls are a non-starter, but pricing transparency through government data base or tools like the Healthcare Bluebook have potential.
Let’s try new approaches. Remove barriers to insurance company competition across state lines. Encourage innovation in primary care delivery beyond the office visit fee for service model. High-touch retainer based care and high-tech tele-medicine consults have great potential for wellness coaching. Market forces will always better meet individual needs than centralized planning, and few things are more personal than healthcare.