We’ve recently been having discussions with a variety of people and reading and listening to a number of public statements on health care. I have read the four-page table of contents and parts of the 1018 page Dingle House bill as it existed about a week ago. It is heavy going but interesting. It has three divisions, Affordable Health Care Choices, Medicare and Medicaid Improvements, Public Health and Workforce Development. It does not reflect the ideas presented below.
I have reached some conclusions that make sense to me. I am a registered Republican but for some time I have felt disconnected from what the party has become. What follows below is apolitical.
The Need
The fundamental point is that everyone needs to be covered by some form of medical insurance. It is a moral issue. When it comes to illegal aliens there is some wiggle room, but since they already get medical care in emergency rooms, we might as well include them too, at lower cost.
Some say that we don’t need medical reform because anyone can get emergency room care. However, emergency rooms are not a substitute for appropriate medical care. In the first place they are too expensive for many of services they provide. Doctors’ offices and urgent care clinics are the most appropriate and economical place for much of what goes on in emergency rooms. Secondly, preventive medical care is what people need, and nobody goes to the ER to deal with obesity or high blood pressure until it is too late. The nation’s medical costs will be reduced if we develop more universal preventive care practices. And we will feel better.
I have heard that the death rate for children under one year in Europe is 4 per thousand while in the US it is 6.3 per thousand. Although there are differences in the standards of measurement, it says something about the quality of our health care. We can do better, and part of the solution is better preventive medicine.
The Public Option
I believe we can and should expand Medicare as the “public option”. For the most part, people on Medicare are satisfied with the service they receive. The fact that Medicare is “running out of money” is due to a number of causes including the aging of the population, fraud, and the high cost of medical care in general. We absolutely need to fix the fraud problem. The aging of the population is an actuarial problem that we just have to accept. The high of medical care is discussed below. It looks like the “pay as you go” approach will not work for Medicare and so we will have to accept substantial support from the government (your taxes) as is done in other countries. Our schools don’t pay for themselves, and neither do our libraries.
Consider the United States Post Office. It provides excellent service. The fact that you can use a competing service at lower cost in some cases may be that they can at least theoretically tailor their service to minimize their costs, while only the Post Office is legally required to provide economical service to everyone no matter where they may live.
In effect, the US Post Office is the “public option” for mail delivery, with UPS, Fedex, etc., playing the role of independent providers. The analogy soon breaks down, but it does provide a starting point for discussion. The point is that they are an example of public and private service providers that successfully co-exist and compete with each other.
We would need to charge a reasonable price for the “Public Option”, which will allow private insurers to compete. They may not make money at the same level as they do now, and that’s why they are lobbying so intensively, and apparently, successfully so far.
We would need to subsidize those who cannot afford it. Of course this is a tricky issue, and one which will need fine tuning along the way.
Another tricky issue is how to handle people in marginal categories such as illegal aliens, people who have not yet gotten green cards, those who have, and so forth. I think that is a matter, while extremely controversial, can be worked out and must be worked out. It cannot be allowed to divert us from the overall goal.
Insurance providers should be required to accept clients with preexisting conditions, and should be prevented from dropping patients with poor medical histories. Portability would be a feature of all future insurance coverage.
There are many details to be worked out, and that is, in part, why the proposed bills have so many pages. We have to rely on our legislators and their staffs to get it right, or at least close to the mark.
The Cost of Medical Care
The high cost of medicine, is to a certain extent, a separate issue. Two reasons for the high cost seem to be 1) Our current fee-for-services approach to medicine, and 2) The lack of tort reform.
The fee-for-services approach, which pays a doctor for each test or procedure performed, provides an incentive to provide services that might be only marginally necessary, especially when justified on the basis of defensive medicine as a result of lack of tort reform, in which some settlements are allowed to be unreasonably large.
The Mayo and Cleveland Clinics operate at low cost and provide excellent medical care and service. They operate as multi-specialty clinics and the doctors are on salary. That doesn’t mean they are not well-paid. They are rewarded for the quality of the care and service they provide, and not the number of procedures they perform. Can we extend that model? I think we have to. Not every multi-specialty clinic would have to be a center of excellence as the Mayo and Cleveland are, but the others could provide excellent care with the doctors appropriately rewarded.
Tort reform would require bucking the lawyers’ lobby, and our legislators are primarily lawyers. I don’t have a high expectation of solving that problem anytime soon, but it is needed.
The high cost of medicine cannot be allowed to divert us from the goal of acceptable health care for all. High medical costs are a problem that requires a solution, but we can’t do everything at once.
I am not qualified to comment on the effect of medical care reform on our national budget and deficit. We can probably agree that we have spent much more than the cost of medical reform on activities that have returned significantly less value. Regardless of the cost, it is something that must be done.
The Need for Leadership
Achieving the goal will take the kind of Presidential leadership we have not seen in many years. At a minimum, Barack Obama will have to bring his own party into line, and hopefully convince many others that it is time to “do the right thing”. As journalist and commentator Bill Moyers said on Bill Maher’s “Real Time”, it’s a moral issue. “We need to care about each other.” If Obama is beholden to insurance companies and/or pharmaceutical companies, he will have to cut himself loose and take the political consequences. It could cost him a second term, but it might instead make his place in history.
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