This diary is an expansion of some comments I've made on the Ryan plan to kill Medicare and Medicaid, and why I think it's really important that we not fall into the trap of merely defending the status quo on Medicare and Medicaid.
First things first: we need to be clear that we DO have a problem with the long-term affordability of Medicare. We really cannot afford to allow continued spending growth on these programs, if we don't want them to eat the entire budget and more. The kind of growth in Medicare costs that we've seen is unsustainable, and needs to be pulled back. The Republicans want to do this by simply throwing the elderly and poor to the wolves by having the government wash its hands of the problem instead of working to fix it. Their plan is heartless, cruel, and amounts to a massive theft from all the people who have been paying into Medicare for decades and will continue to do so. And it's obvious that they don't really care about the budget and are just using it as a bludgeon against a program they don't like. But we need to offer the voters a comprehensive, credible alternative.
That alternative is getting our overall healthcare costs under control.
The Ryan plan does NOTHING to solve the problem of exploding healthcare costs: it merely shifts the problem of paying for them off of the government and onto individuals. If that's their idea of a responsible solution, than Alan Grayson was right about their healthcare plan: don't get sick, and if you do get sick, die quickly. In order to fix that problem, as well as the fiscal problem, we need to control healthcare costs both in and out of Medicare. This, in turn, would help us to counter the nonsense charge from the GOP that our side has done nothing to control healthcare costs (a false charge even against the PPACA, but true in the sense that we haven't done enough to actually solve the problem).
So what are some possible components of a credible and humane healthcare cost control plan?
- We could move to single payer, probably by expanding Medicare to cover everyone. This plan has numerous advantages, which we've been over many times on this site. It would spread the costs over a larger pool, and thus make them more affordable for each individual (just like group insurance plans do). It could give the government stronger negotiating power in the purchase of healthcare for Americans. It could cut administrative expenses vs. the private insurance industry dramatically, simply through centralization of functions and elimination of unnecessary jobs focused on denial of care and submission of insurance claims to numerous different insurers and plans. Maybe even more importantly, it could also help give us a mechanism by which we could enact other systematic cost control reforms, and cut administrative expenses vs. the private insurance industry. Medicare currently has a strong influence on practices in the private healthcare market, simply due to the size of its patient pool, and a single payer plan covering everyone would have even more influence to force necessary reforms on care providers. Finally, it has the advantage of being politically popular with voters, if sold to them correctly. It has the disadvantage of being extremely threatening to many entrenched interests and corporations, mainly because it would actually be effective in controlling costs.
- We could seriously reform Medicare's provider payment model, to move at least partially away from fee-for-service towards fee-for-quality. This would reduce the incentive for needless healthcare use designed purely to drive profits for providers. Part of the problem with costs we have right now is that there is no incentive for doctors to actually care about saving Medicare money, even if they aren't actually actively defrauding the government and patients. I do not believe the Republican dogma that HSAs or other "consumer responsibility" in healthcare is the way to go, because patients are not trained to perform cost-benefit analyses on healthcare needs and do not have access to the proper information to make informed choice even if they could. Doctors who have directly seen the patient should be making the decisions about what healthcare is needed, but there still needs to be some reward for doing a good job of balancing costs vs. care needs. I'd like to see some portion of doctors' pay be based on patient outcomes (accounting for their initial condition, of course). Single payer would make this much easier to do than in our current system.
- We could allow Medicare to aggressively negotiate the cost of everything it pays for, just like the VA does. The Republican Medicare prescription drug plan, in particular, is a giant giveaway to corporations in that it doesn't allow the government to negotiate drug prices effectively on behalf of Medicare patients. Essentially, this gives corporations a blank check made out to themselves from the taxpayers.
- We could spend more on combating fraud in the Medicare and Medicaid systems. This is a huge and complex problem that takes many different forms, and a huge topic in and of itself. The amount spent on fraud enforcement has to be carefully balanced against the amount of money saved, but I would guess that we could still do better in this area.
- We could try to modernize our healthcare payment and delivery system by adopting best practices from overseas on how to administer these things efficiently through electronic systems, etc. For example, I think it's ridiculous that most healthcare providers still send me a paper bill months later, and have to process personal checks, etc. I'd like to see some system where we have a national electronic healthcare ID card, linked to our medical records, that also allows patients to manage their payments to providers electronically. You could go to a government website and authorize electronic bank account withdrawals to view and pay your bills to providers, and providers would submit all their bills to a common system. This would also allow for more effective enforcement of anti-fraud, anti-waste, etc laws, as well as reduce duplication of tests and so on by making medical records available. To deal with unequal access to computers and computer knowledge in the population, we could deploy kiosks in various places like doctors' offices, libraries, government buildings, etc that would let people manage their accounts and get help with understanding it.
- We could invest much more into comparative effectiveness research in order to maximize our bang for the buck on healthcare dollars. This one is a no-brainer, and it's not a "death panel".
- Most importantly, we need to take serious steps to systematically improve the health of our population, including addressing obesity/diabetes/metabolic syndrome/heart disease and other "Western diseases". It would be good for us to take a system-wide look at all the contributors to bad health in our country, including sedentary lifestyles, agriculture policy, the overwhelming car society, marketing of unhealthy food, social inequality, etc. A healthier population reduces the need for healthcare spending, and we're ignoring many of the things that are making us unhealthy. We don't have to take away people's right to eat junk food to do this: we just need to regulate the industries that are contributing to our bad health so that being unhealthy is no longer the path of least resistance for Americans or the "default" for people without the resources to spend on getting and staying healthy. We also need to address our infrastructure choices in a systematic way: we shouldn't be funding any new road projects that don't also make accommodation for bicyclists and pedestrians, for example, since feasible active transportation is such a major contributor to good health.
I'll conclude by mentioning that Republicans have made two "proposals" recently that they claim will reduce healthcare costs, both of which are of dubious merit. Their two proposals are "tort reform", and "selling insurance across state lines". Many studies have estimated that tort reform would have little overall impact on the cost of healthcare, and I'm also worried about its possible negative impact on people who are harmed by doctors and corporations and their ability to seek redress. Selling insurance across state lines is transparently just an attempt to destroy state level regulation of insurance corporations and create a race to the bottom like we saw with the credit card industry. I highly doubt that it would have any positive impact of healthcare costs, either, because regulation of the insurance industry is not a primary driver of costs (while consolidation and greed, which this proposal would increase, is).
This is all only a starting point, but I think we need to get serious about this. We can no longer keep tiptoeing around the special interests who profit from keeping the status quo. Our choices as a nation are to either fight the entrenched interests and build a better future for us all, or to give up and decide we don't want to be a real developed nation anymore. The Republicans have their vision of the future; we need to provide a strong, clear, alternative that doesn't require us to give up what makes our nation great.
(Apologies for the poor writing: diaries are not my strong point. I just wanted to use a longer format than the comments typically allow.)