OK so maybe It is still complicated, but much less so than the stuff being batted around in the press. Here is my blueprint for a comprehensive redo of our healthcare system. Don’t complain to me if whatever politically motivated plan they come up with doesn’t work:
What did Obamacare try to do?
The plan was designed to bring in more money to pay healthcare costs by getting currently uninsured healthy people to become insured, thereby bringing in additional money in the form of their premiums.
Why didn’t that work?
Instead of healthy people that could pay in but were not using services, it turned out that many of the uninsured were actually consuming significant healthcare resources, and often in very inefficient ways such as using the ER for primary care. This meant that the idea of bringing new money into the system did not work.
OK, so now what?
Luckily, MACRA is more important. If you don’t know what that is and why, well, that should demonstrate how political the discussion about Obamacare is, and how that discussion is only marginally relevant to real, tangible revision. But in the meantime:
- Shift the focus from insurance reform – how to pay the bills – to reform that reduces the actual costs of medical care: encourage a change from fee-for-service to pay-for-performance. (That means paying attention to the roll-out and evolution of MACRA).
- Pattern health insurance after other successful insurance models like automobile insurance. Allow people to shop for the costs and benefits that they feel are important to them. Yes, we all want everything for everyone, but we have to recognize that this does not come without a very high price tag. Allowing people to purchase less comprehensive insurance at a low cost is better than having those people not insured at all because they have no viable option. Forcing people to spend a lot of money to have ANY insurance because you don’t want policy differential clearly doesn’t work.
- Remove attachment of insurance and employment, which reduces impact of pre-existing conditions. This is easy: remove it as a business deduction. Provide businesses tax incentives to assure the savings are passed on to employees. Make health insurance costs a tax deduction, meaning no change in individual tax liability despite increased pay, while providing an incentive to maintain insurance. As people stay with a single insurance company, the business model becomes viable.
- Continue to encourage full health insurance coverage by all using tax deductions and credits. DO NOT continue the practice of keeping young people on parent’s insurance. Instead, encourage them to enter the insurance pool as young, healthy individuals by allowing low cost policies designed for them. Consider tax advantages to parents that assist with health insurance for their kids vs. actually including them on their policies. This is an attempt to realize the hopes of Obamacare: getting truly healthy people in the system. But those people are actually young people, not currently uninsured people.
- Create a government sponsored health insurance option that functions essentially as a non-profit, as opposed to an investor-driven company. This can become a low cost option to facilitate providing some insurance to all. Some high-cost, low benefit treatment options will not be covered. This is competition at its best: put insurance companies to task to provide the best value for customers instead of value to investors. This would not just negate the need for single payer system, it would trump it: you have both a government sponsored payer AND competitive private insurance.
- Recognize the necessity of shifting some responsibility to the patient for their care: allow stratification of premiums based on modifiable behavior risk, require treatment participation with proven benefit (vaccinations, compliance with management of chronic diseases like diabetes).
Logical, realistic, doable. But too much of a rational compromise for politicians to get behind. Eventually perhaps we will get sick of their lack of performance.