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Ezekiel J. Emanuel, M.D., Ph.D. Headshot

Sustainable Health Care Reform

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When it comes to health care reform, the question is no longer whether, but what: What kind of reform is needed?

The current health care system is dysfunctional. The financing part -- how we pay for health care -- is inequitable, inefficient, and fiscally unsustainable. For instance, the McKinsey Global Institute concluded that selling insurance separately to each of the millions of employers wastes at least $64 billion in underwriting, sales commissions, marketing and billing costs alone. The delivery part -- how we actually provide services to sick people -- is costly and provides haphazard and poor quality of care. Many studies show that only about half of Americans get proven care, and thousands if not millions are unnecessarily injured.

A good test of reform proposals is whether they address both sets of problems. If a reform addresses either financing or delivery system problems but not both, it is not credible or sustainable. Incremental changes will not fix these problems and are not sustainable.

The Guaranteed Healthcare Access Plan proposes to repair the health care system by giving all Americans a voucher to select a standard benefits package offered by insurance company. In most areas, American will be able to choose between 5 and 8 insurance companies. And the insurance companies will be required to enroll anyone who wants and cannot exclude coverage for pre-existing conditions. The standard benefit package is based on what Congressman and Senators receive, and is more generous than what most Americans currently have through their employers or government program. Americans will also decide if they wanted to buy additional services, say wider selection of doctors and hospitals, more mental health benefits, or coverage for alternative medicines.

The Guaranteed Healthcare Access Plan will be administered by a National Health Board and regional boards modeled on the Federal Reserve System with fiscal, administrative, and political independence to make tough decisions based on the merits, not special interest lobbying. There will also be an Institute for Technology and Outcomes Assessment to assess the effectiveness of new drugs, devices, procedures, and other interventions. It will also assess and make publicly available data on the clinical outcomes of patients in different insurance companies. This will permit comparative shopping based on real quality results.

No one receiving Medicare, Medicaid, or any other government program will not be forced out, but there will be no new enrollees. People who turn 65 will simply stay in the Guaranteed Healthcare Access Plan. The special tax benefits related to employer based coverage will be eliminated and most employers will stop offering health insurance.

Maybe the Guaranteed Healthcare Access Plan sounds too good to be true. How much more will it cost? It will not cost any more than we are paying today. By using a standard benefits package open to all Americans, there will be huge savings from reduced administrative costs to insurance companies. The end of Medicaid, SCHIP, and coverage of state employees, will produce huge savings -- decreasing state budgets by about a third. Similarly, phasing out of Medicare reduces federal taxes. When employers stop providing health insurance, workers' wages will increase commensurately. Instead Americans would pay a dedicated Value Added Tax. "Dedicated" means it only goes to fund the Guaranteed Healthcare Access Plan and is not diverted to defense or Social Security or highway construction. "Dedicated" also means that not other revenue will be used to pay for the Plan, requiring fiscal discipline and providing value for money -- giving patients interventions that work rather than just more and more tests and treatments.

Under the Guaranteed Healthcare Access Plan, Americans will have total freedom of choice, 100% portability, and complete security that if they lose their job, get sick, or some other calamity befalls them or their family, they will never be without health insurance. Furthermore, the Plan provides the incentives for higher quality care. Forcing insurance companies to provide a standard benefit package for a fixed price and report outcomes will drive them to integrate care, emphasize quality and prevention.

Experts -- including supporters of other reform proposals -- agree that the Guaranteed Healthcare Access Plan is the best health reform proposal. They question whether it is politically feasible. It seems a strange, self-defeating strategy to begin a reform effort -- even before negotiations occur -- by conceding the best option or even that comprehensive reform can occur. We will never know if we do not try. And if we try, we are likely to get more than we expect.

Ezekiel Emanuel is an oncologist and chair of the Department of Bioethics at the National Institutes of Health. He recently published Healthcare, Guaranteed: A Simple Secure Solution for America from which this article is adapted.