Public option? Co-ops? Triggers? The arguments over them seem to get all the press these days. But while I believe a public option is a very important part of health care reform (assuming that we don't go single-payer, which I would love to see, but acknowledge is politically unlikely), I wanted to bring up some of the other details, like new regulations on the insurance industry, for example, which I believe are just as important as the public option.
I'll go ahead and say it now: the newest and coolest Kennedy/Dodd plan in the HELP committee seems to get me most of what I want to see, so I'm giving it a thumbs-up. There are a few hiccups, like restrictions on who can enroll in the public option, questions as to whether the $750 fee for not covering a worker with insurance is enough, and so on, but I think this bill does have promise and should generally be supported.
But as for what I want from health care reform? I'll start attacking the details below the fold...
First of all: Public option.
Yes, we absolutely need it. It's necessary to bring some fresh competition to the health care market, and to keep the private insurers honest. While I'm absolutely in favor of new regulation to keep the private insurers in line, I'm certain that without genuine competition they'll play the oligopoly game and keep finding new ways to game the system, which is why we're in our current situation today. The insurers no longer compete on price and quality of service, and the public option would force them to start competing on those fields again, rather than just dumping sick people or gouging them with outrageous premiums.
Let me toss in some ideal rules for the public option. First, yes it needs to compete on a level field with the private insurers. That means that they must be able to negotiate their own prices with pharmcos and providers, not just eat list price like Medicare D, or have pricing dictated with arbitrary rules. As far as subsidies go, they should get whatever the private insurers get, like I said, for a fair playing field. The whole point of this exercise is that the public option plan negotiates its prices down to sane levels, which forces the private insurers to do the same, so they can compete.
Throwing a bone to the private insurers, I would suggest that private insurers be able to do a couple things that the public option can't - that might make this bill more palatable to the conservadems, and maybe even Republicans. Don't get me wrong - I think that the public option should be able to provide all necessary medical care to patients. I'm talking about allowing private insurers to provide things like luxury care - if you're in the hospital and you have a luxury plan, that means you get a private room, you get tastier food instead of mystery meat, you get to watch HBO on the hospital TV, you get fast Internet, and so on. Private insurers should also be able to provide plans that provide for things like cosmetic surgery, alternative treatments, and so on that can't really be financially justified being paid for in the government plan. Of course, if you go for the public plan, you get all the mainstream basics - care should consist of pretty much everything that is considered good practice by mainstream licensed doctors and their professional associations. I do insist that the public plan give people very good medical care. Private insurers should be able to provide the optionals and luxuries.
At the same time, the public option should be under financial rules and oversight so as to maintain its competitiveness - its purpose is to provide a baseline for how much health care should cost, which becomes a competitive ceiling that the private insurers stay under, and an example of good service that the private insurers are compelled to follow. If the GOP takes control of the government, I don't want them to be able to sandbag the public plan by overcharging, or hobbling negotiations with providers, or screwing patients. The public plan needs a strong oversight mechanism that keeps things transparent and honest.
One thing I don't like about the Kennedy/Dodd plan is that people working and getting insurance through their employer won't have the option of joining the public plan (though the employer itself might switch.) One of the big problems with the status quo right now is choice. The GOP argues that health care reform would take choice away, but the problem with that argument is that we don't have much choice to begin with. Don't have insurance, have preexisting conditions, or just can't afford it? Your choice is to go to the ER when you're sick, then declare bankruptcy. Not much of a choice. Got health care through your employer, but think your insurer sucks? Too bad, you have to take what you're given. Unless you're filthy rich, you don't have choices.
A thing I'd like to see, which an unfettered public option would provide, is choice. Rewrite the rules so if you don't like your current insurer because they've been screwing you, you can switch to the public option, or switch to a different insurer, and give your old insurer the finger. That's competition. Right now, that doesn't exist. You don't have choices. You're restricted to open-enrollment periods, and usually are locked into your current plan (can someone explain to me why we have these open-enrollment period rules?) And the problem with the Dodd/Kennedy plan is that you can't just sign up for the public option unless you don't get insurance through your employer, or you're unemployed. If you have insurance with your employer, you're stuck with it. No choice.
Insurance regulation
It doesn't get much press, but people need to be talking about regulation of the private insurers. Like I mentioned, we need a level playing field for the competition between private insurers and the public plan. And one of the reasons for that is because the private insurers would love nothing better than to dump the sick patients on the public plan, while being able to shut them out of their own pools, so they can keep making profits, while the public plan gets bogged down with all the expensive cases. That's unacceptable. Private insurers need some strong new ground rules.
First, I'd suggest a mandatory minimum set of benefits. And like I mentioned for the benefits of the public plan, they should consist of every treatment that is considered good medicine by licensed doctors. I'd also suggest rules be put in place so that the list of benefits is in a publicly accessible database, so doctors can look up the list, and if the treatment they want to give a patient is on the list, they don't have to play the current game of begging for permission from the insurer. They can just do it, and send the insurer the bill, and the insurer has to pay, because the treatment is on the list. On top of eliminating a lot of the insurance headaches, the mandatory minimum also ensures that there's a minimum standard of care that all insurers have to provide, and makes it problematic for them to do things like claiming that chemotherapy is not a covered benefit. There should also be procedures in place so doctors can easily get permission for treatments that are medically necessary, but aren't on the list, maybe because they're new, or they're rare, or because some bureaucrat didn't put it on the list yet. As long as it's medically necessary (maybe verified by a second opinion from another doctor,) it should be covered.
Mandatory Community Rating is another thing that should be on the list. If you're buying an individual insurance policy, chances are you're subjected to experience rating, which means you fill out the questionnaire, document all your medical conditions and risk factors, and based on that information, the insurer crunches the actuarial numbers and calculates your premium. If you have preexisting conditions, your premiums are either insanely high, or you're denied a policy altogether. That should be illegal. What we want is community rating, where he insurers are made to calculate the risk on the entire pool of insured - everyone in the region aggregated together, and calculate a premium that's the same from person to person. In other words, the healthy 25-year-old male pays the same as the 55-year-old transplant patient. The Kennedy/Dodd plan gets us most of the way there, though you'd still pay more if you were older, though the rates are restricted to two times the rate of younger adults. Preexisting conditions do not enter the equation.
Also, insurers should be completely barred from excluding patients based on pre-existing conditions. And because of mandatory community rating, they can't jack up their premiums either. They should also be barred from rescission of patient's policies, except in cases of flagrant fraud. Rescinding the policy of a patient with cancer because she forgot to mention being treated for acne is unacceptable, and should be illegal. In short, no discrimination against the sick. Insurers should be required to take everyone who can pay the premiums, and cannot dump them, refuse to renew policies, or otherwise screw them.
Accounting and insurance pool gaming: One of the ways that insurers game the system is by breaking their customer base into a bunch of small insurance pools instead of one big pool. Then, as they dump sick people, the small pools shrink, enabling the actuaries to calculate larger risks for each pool, and jack up rates. If you don't like the elevated rates you're paying, you can apply for a new policy, assuming you don't have pre-existing conditions and can make the new, extra-strict guidelines for going into one of the new pools that is set to only accept young, healthy customers. WRONG! No more gaming the system. Every insurer should have one large risk pool, to spread the risk fairly, and ensure that no games are being played to make the risk calculations come out higher than reality.
Toss in some rules requiring that insurers pay out at least 95% of what is paid in, so premiums go to actual medicine, not to the CEO's new bizjet. In short, I want a series of rules that compel insurance companies to act like insurance companies, not Mafia rackets.
That's most of what I want. Like I said, Kennedy's and Dodd's new bill that passed the vote in the HELP committee gets most of what I want, and I can live with it, though I think it could be far better. In any case, the status quo cannot stand. Like everyone else, I'm sick of being gouged and then abandoned by insurance companies.