Wednesday, May 13, 2009

Health Care Reform - And they said Hillary's plan was too complicated?

Well, I watched another hearing on health care reform yesterday, and it will take a bill at least a hundred pages long, and an army of administrators, to implement everything that is being suggested.

The elements of reform:
1. Build on employer health insurance because many companies support it. (Could it be because health insurance benefits are tax-advantaged and are, thus, less expensive to provide than higher salaries?)

2. Competition (except from a public plan). People admit that the current system is flawed but, when push comes to shove, they do not seem to fully grasp that we have had a free market, competitive health insurance system for 60 years and that is the system that is not working. They insist that this flawed system must be preserved.

3. Require or not that self-insured companies provide employees with choice by somehow associating them with health care exchanges. And what about the companies that offer only a couple choices?

4. Health care exchanges (or not). Weren't these the centerpiece of Hillary-care?

5. Pay for bundled services rather than for individual services. (And just who will implement or enforce this?)

6. Cap (or not) the tax-free status of employer-provided health insurance. Lots of ideas here: regional caps, income caps, phased in caps over x number of years so, eventually, the differences are based solely on different COLs. Grassley thinks this would be unconstitutional. Some witnesses pointed out that COL differences exist even with a single state. Arkansas doesn't want to pay for New York's higher COL (where, of course, everybody's salary or wages are adjusted upwards anyways). Who would design these? Who would be responsible for enforcing these? What kinds of changes would have to be made to the income tax rules? How about the administrative effects for multi-state corporations?

7. Incentives for best practices. Again, great idea - but who sets the best practices and who enforces them.

8. Use health savings accounts.

9. Health IT. Obviously, paper records don't make a lot of sense. But health IT is a lot harder to implement than many seem to think, to say nothing of simply being used (every time I go to Kaiser, I'm asked the same question about drugs I'm allergic to. I've provided that information at least a hundred times.) Data format and data definition issues can be extremely difficult to solve. In addition, as one witness pointed out, hospitals may not want record interoperability because that would make it easier for doctors to move patients from one hospital to another.

10. Put a "tax" on bad behaviors such as smoking or overeating.

11. Tax credits or tax deductions.

12. Rein in costs before expanding coverage.

13. Expand coverage before reining in costs.

14. The Massachusetts experience gets nothing but high marks, but I've read criticisms from Mass. doctors who would much prefer single payer. Not a word about those criticisms.

15. A public plan option? There is some support, but the key seems to be in making it so unattractive that private insurance companies won't lose any customers. (It seems not to have occurred to anybody in power that if a public plan option would attract citizens away from private insurance companies that maybe the problem is with the latter rather than the former. And that it is the insurance companies which should be expected to change their policies.)

16. Preserve (?) the ability of citizens to keep the doctors they like. Again, selective awareness operates here. Employees who lose or change their jobs often lose access to the doctors they have because their health insurance options change.

17. In all of these hearings, I've not heard a single word about the dozens of forms doctors must complete, the army of clerks they have to hire, the hours they must spend on the phone trying to get a procedure paid for. I've not heard a single word about the portion of a health care premium that goes to the insurance company's administrative costs (mainly for denying coverage), executive salaries, or profits.

18. American exceptionalism. Baucus insists that we need a uniquely American solution. (I think he read a New Yorker article). No witness has ever been asked to explain why European nations pay less for health care but get better results. Are Americans a unique species? Is it impossible for us to learn anything at all from the experiences of different countries? Except for some negative comments about Canada and England re those awful wait times, nobody pays any attention to any system outside the U.S.

I've no doubt forgotten some of the other requirements. But the key to all of this sturm und drang seems to be that private insurance companies must be preserved at all costs.

As I said in an earlier post, real health care reform is DOA. We are doomed to lots of tinkering around the edges that will not provide universal coverage and that won't reduce costs (except, of course, by denying coverage).

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