When the political process is not working, one option is to examine the shared values of most Americans. Values are learned, clarified and even negotiated. They are the algebraic axioms from which the formulas of public policy are derived.
Society should care for the sick, written into the EMTALA law that prohibits turning patients away from emergency rooms.
Free enterprise is the engine of material prosperity.
The government must correct the dangers and inefficiencies of free enterprise through regulation and provision of services such as national defense, roads, airports, etc.
Diagnostic and therapeutic technology will continue to develop improving outcomes and increasing cost.
A significant fraction of the population will never be able to afford healthcare.
The individual is fundamentally responsible for his own health.
The government is not efficient enough to provide healthcare economically.
The health insurance model is failing because almost everyone needs health care sooner or later, unlike homeowners’ insurance where most homes are not destroyed, so premiums remain affordable.
Catastrophic insurance is not a viable option for many needing ongoing care for asthma, diabetes, hypertension and health maintenance.
The fee-for-service model is inherently inflationary providing many services of little or no value.
From these axioms and observation of the various political and economic experiences in the U.S. and other systems, it is not hard to rationalize the following outline for a system design.
A politically independent, Federal Reserve Insurance (FRI), single-payer with a standing similar to the Federal Reserve Bank will collect premiums from individuals and families qualifying tax deductions or credits based on need. Moderate co-pays and deductibles will apply but can be paid from individual or family ($2000/$4000) HSAs. A reasonable range of primary care services and sick care will be provided. Comfort care will be provided to those over 85 years of age or with dementia or fatal illness. Comfort care has been shown to result in greater well-being and longer life. Expenditures will be limited to rise no more than 3 percent per year. Other gains must come from improvements in efficiency. Expanded or expedited services or amenities may be obtained through individually purchased supplemental insurance or direct payment in a separate market.
Health care providers will be investor-owned for-profit public utilities granted partial regional monopolies in exchange for rate setting and quality and service oversight by the FRI. Competition across state lines will be permitted. These utilities will be created by the merger and acquisition of health insurance companies with hospital, nursing home, medical practice, home care, lab, imaging systems; a process that is already accelerating in many parts of the country. Although some health insurance shareholder equity would be lost in the conversion from growth to value stock, it would be compensated by the acquisition (at a price paid to communities) of currently not-for-profit assets. The utilities are paid risk and geographic adjusted capitation. Pharmaceutical prices will be moderated by the purchasing power of utilities. Providers can participate in the supplemental private free market noted above according to free market forces.
The relatively simple knowledge and habits of health with personal safety, exercise, prudent diet, drug avoidance and safe sexuality must become a part of nationally accepted values promulgated by the FRI, evidence-based and independent of politics. This is currently ongoing from the surgeon general, CDC and others establishing fair knowledge but poorer levels of habits. There is a growing literature on incentives that might act from various points of leverage. Private groups can always advance competing views.
This system aligns the incentives for individuals, providers and the government. Similar systems work well in Germany and Switzerland with barely more than half the cost per-capita. It is a broad outline but benefits from relative simplicity and comprehensiveness while acknowledging national values, controlling costs.
It will be very difficult to overcome the power of entrenched interests that currently benefit from our failing systems. A greater crisis is required. We need only wait. President Trump’s suggestion to reach across to the Democrats shows insight. Segregated solutions have not worked. Removing the 40 to 50 percent of waste, mismanagement and self-dealing at all levels will go a long way toward keeping quality care available to all. While various groups flail at this problem, it is valuable to keep this centrist values-based solution available. It is the Eisenhower National Expressway System for our era.
Thomas Birch is an infectious disease physician.
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