I keep trying to measure all the health care reforms against what seems right to me, and I find most of it falling short. Neither the single-payer, everything-is-free approach nor the no-hell-no approach seems to solve everything. I've vacillated between single-payer and public option and co-ops, and wondered if private even has a place.
My conclusion is that we need three different systems, that can all happily co-exist: public catastrophic insurance, routine medical insurance with co-pays, and private insurance to fill in the gaps. I have 3 simple principles in mind:
- No American should be financially destroyed by an emergency, a catastrophic or a cronic illness. The costs of care for these diseases, above a stop-loss point, should be paid for by insurance that pools everyone into a common risk group.
- All Americans should have access to routine medical services in a routine setting at an affordable price.
- Not every condition or expense needs to be covered 100%. Americans should take some responsibility for their own health care and should be able to buy private insurance or use their own funds to pay for items not covered by the public system.
For catastrophic coverage, a public insurance program with an individually-determined stop-loss seems like just the ticket. These are the things that insurance companies fight paying for, that can totally devastate families, and that usually are simply bad luck. It is perfectly reasonable to put all Americans into a common insurance pool for those things. Moving coverage out of private insurance would significantly reduce their risks and costs and the incentive for them to deny coverage. If you're a die-hard private enterprise guy, maybe it's re-insurance for the private carriers. Whatever, it covers everyone against the worst. Because the stop-loss is individually determined, Lucy the Laborer is covered fully, and Rush Limbaugh isn't covered at all. That should make them both happy.
For routine medical care and diagnostics, I have to pay a co-pay with the private insurance I have today. The concept of standard payments with sliding patient co-pays seems just right. The co-pays should be based on individual situations, so it ranges from nothing up to the full price of the service. Doctors could even charge above the standard rate if the patient wanted to pay the difference. (Caveat: the government rate should be negotiated so it is accepted as full payment by a majority of the doctors and labs in a local area, not just arbitrarily set.) That provides complete freedom of choice in choosing doctors, albeit at a price. This coverage could be single payer or could be private insurance with government reimbursements.
Finally, I really don't think the public plans have to pay all of the tab for every medical service. There are deductibles and co-pays in the plans above. I also think there is a legitimate argument against public resources paying for things which are not life-threatening, don't affect public health, and are within the control of the patient. At the risk of losing my liberal bona fides, viagra, facelifts and abortions come to mind. People should be able to buy private insurance to mitigate co-pays and deductibles, "excessive" provider rates, and cover non-covered conditions. Private insurance becomes a way for those who would be subject to very high fees under the public plans to manage their risk. Seems just right.
There is one more element I think is essential to achieving quality care at a fair price: Health Monitoring Boards. I think we need Health Monitoring Boards comprised of providers, insurers, public health professionals and citizens, and they should be set up at every level, from national down to local communities. The Boards would monitor costs like that study in Texas did, allocate the use of public funds including hiring doctors and running clinics if necessary, and act as an appeal court for patients with adverse decisions. In fact, borrowing an idea from Charles Krauthammer of all people, they might even serve as a jury of peers in malpractice cases. Their basic goal would be to balance health care and costs from a public standpoint, not just from an insurer standpoint as we have today.
With respect to paying for it all, I think we need a new trust fund, like the Social Security trust fund, to collect and disperse health care funds. I really think it needs to be seen as something different from the taxes that go to support the rest of government. Although there would be many sources of revenue, everyone should pay something into it, even if it's only $10 a year. It should be a line item on paycheck withholding and a line item on income tax returns. Probably makes sense to include Medicare, Medicaid, and maybe SSI Disability in the same pool, as it is all about keeping people healthy.