Sustainable Health Care Reform

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.

Comments

[alliecamus]

There is no doubt that we see a massive amount of waste going on in the health care system. Much of it is preventable. For example, you mention the 64 billion wasted simply because employers are given different plans.

But I have a strange opinion, perhaps. Maybe an opinion that will get me in trouble on a liberal site such as the HuffPost: Have we ever considered how wasteful the government can be? Heck, I just got my drivers' license. Do you know how long it took? About four hours. I can guarantee that if the DMV was privatized, I would only wait for about 1, tops, if even that.

Back to the issue of health care. http://www.assurant1.com states that Assurant has over 115 years of experience. That's just one company! If you include other health insurers (Humana, Aetna, etc.) you'll probably find their experience comparable.

Can we benefit from this experience. Most decidedly, yes. Is there room for improvement? Of course there is! Your mention of the marketing and administra­tion/paper­work costs. Those can definitely be improved. Massachusetts recently MANDATED, yes, I say, mandated electronic health records. This will save BILLIONS.

We can still have our privatized health care without all the added costs, or waste. That's a fact.

[Danny]

A single-payer system is what we need. Cut out ALL insurance. That's the way other democracies are able to provide for ALL their citizens for much LESS than we pay. The big flaw in our system is the huge amount of paperwork caused by the insurance companies. Single-payer means just that. Doctors and providers get paid directly by the single payor.

[Agent420]

Any universal health plan cannot include the insurance companies. Look at the news today about how meds bought through the privatized Part D of the Medicare cost 30% more than other programs.

[usna73]

Your plan will never happen. It makes too much sense!!!!!

[GoCards1978]

No program that discriminates against behavioral medicine is equitable. Allowing insurance companies to continue to treat mental illness as optional coverage that costs extra is wrong. The same standard must apply to dental care as well.

[UnbiasView]

The problem is that everyone thinks they have and behavioral problem that needs medicine and when people committ crimes they always blame it on some BS problem.

[Marlyn]

"able to choose between 5 and 8 insurance companies" ???

NO THANKS. If everyone is covered then there is no need for insurance. This plan would lock insurance into the health care system when we all know that getting insurance OUT is the way to go.

[UnbiasView]

Wouldn't want that freedom of choice now would we?

[ErnestineBass]

Mandatory enrollment with a private insurance company paid for by my tax dollars?

No thanks. The time has come for me and my family to leave Amerika.

This country is finished.

[MrsGreebers]

Don't let the door hit your ass on the way out.

[AlonzoQuijana]

But where will you go? Ghana? Guatemala?? Every industrialized, high income, high standard of living country except the U.S. has mandatory health insurance and significant government involvement..

[ceindependence]

Gee, you guys talk like the government can solve all the problems. Have anyone of you been in a social security office lately? Every social security office has armed guards not to protect from terror abroad but from our own citizens angry because of the government system. Have anyone of you heard of a company called UPS? They would not exist if the current system, US Postal, was such a great system.

But you guys say it will be cheap, cover everything and be available to everyone. Two out of three aint bad! Right!

[UnbiasView]

I agree with you, government run programs always start out with good intent but always end up as a giant mess because the government has no motivation to be efficient since they have unlimited funds.

[littleeli]

Yes, government is inefficient, but when it comes to healthcare, medicare operates on a much, much lower admin cost than the pvt sector. And the VA, despite the problems, is on the cutting edge of computerization of patient records etc. Finally, if waste is a concern, the defense budget is the ultimate dump. Ever seen any critism of that or critical analysis of what if any benefit results from one more $1bln nuclear submarine? That same $1bln would pay for 1,000 top-notch "James Bond" operatives paid $1million each, looking out for the country's security and "taking care" of threats BEFORE they become serious. IMO, much better bang for the buck! But will not happen, thanks to a corrupy system of vested interests+campaign finance $ that cares more about the gravy train than national security.

[tdbach]

This is nonsense, a typical Republican wet dream based on dittohead-type "information" instead of real facts and data. Reality has no place where ideology reins supreme.

SSA is remarkably efficient, even by private industry standards. In an organization that large dealing with the volume of services it renders (nothing in the private sector can compare) there are bound to be a few horror stories, And of course, you government­-is-the-pr­oblem types are only too happy to seize in any of them as "evidnce" of total, systemic failure, as though a single computer malfunction shows that IBM is doomed.

And UPS isn't born out of US Postal Service incompetence, any more than Blackberrys stemmed from an failure of PCs and Macs. UPS saw a niche market - large packages, national and international shipping - and went after it. USPS is in the business of dealing with staggering volumes as inexpensively and efficiently as possible, and for all its issues, it does that incredibly well.

Private enterprise exists to make money. By definition, it's about experimentation, innovation. Failure is as intrinsic to the private market as moeny and ideas. We need Govenrment to render services when failure is not an option. SS - and healthcare - seem like just such services to me.

[gorideabike]

Consider for a moment the clients at SS offices, who suffer from many problems besides financial stress. The guard's presence is what maintains the safety of the clients. A buzz lock controls office access. One could question the need to restrict public access to tax payer supported services. It is a judgement call based on a very few cases of mentally ill individuals acting out.
My experience at the local SS office went well. I was called inside at the time of the appointment, met with an informed efficient person who answered my questions and followed up by mail as promised. A good job considering the work load they carry.
I agree with you. I have some serious doubts about having the private insurance companies involved in this at all after their for profit destruction of the US health care system. How is the health care of our Congress paid for? Insurance companies or government check?
Peace.

[AlonzoQuijana]

The private clinic I go to has an armed guard. Why? To protect the doctors from citizens angry about a privately run system? Ceindependence, your logic is flawed.

Oh, and UPS -- as wonderful a company as it is -- charges considerably higher rates that the US Postal System and also is not legally obligated to serve money-loosing markets or clients. (Think of the post office in a 400-person hamlet in rural Kansas). Apples and oranges.

[jaglon]

The health insurance companies are in it for profit. That is the only thing for them they do not give a damn about the people they insure. The 'for profit' has to be taken out the system. Otherwise this sounds okay. I just do not trust the insurance companies and I am sure they will figure out ways to game the system.

[UnbiasView]

Why are Democrats so against the word profit?

[Marlyn]

exploitation, to benefit unfairly from the work of someone, typically by overworking or underpaying them.

[Gorgeousgertie]

(1)You are correct. The ONLY way to obtain health coverage for all is to make healthcare not-for-profit. No other plan is viable as long as insurance companies are taking profits that should go to healthcare providers. Seniors & low-income can still have Medicare and/or Medicaid & others could pay into these programs. Both are well-managed & already set up so no costly changes are needed. (2) No alcohol or substance programs should be based in a hospital since they all reuse to take medical patients. This is an enormous waste & should be in outpatient settings. (3) 24-hour urgent care centers should be available to eliminate the vast majority of expensive non-emergent visits to emergency rooms.

[NABNYC]

HuffPost's Pick

This sounds like just another give-away to the insurance companies. Just think: the government will deliver to them a guaranteed 100% enrollment. Lots of customers, little competition. Boy wouldn't I like to own stock in an insurance company if this goes through.

The problem with insurance is that it is the bedrock of fraud, the basis for denial of real healthcare, and a system which seeks to increase the amount of premiums and deny coverage in order to enrich the company owners. That's not what we need for our nation's healthcare. Why reward the insurance companies when they are the ones who are destroyed healthcare in this country?

What we really need is to have government-paid healthcare and non-cosmetic dental for all Americans. The government should set the rates for medical providers. Anyone who doesn't want to accept that rate can opt out. Of course the provider groups could submit the fee rate claims to mandatory arbitration for resolution and for increases. But no more gouging the public then watching them die.

People would be charged a portion of the cost based on income -- an ability to pay. But reasonable amounts. We need to get the insurance companies out of the way. They are just like the mafia muscle that shows up at the business asking for "protection" money, and if they don't get it, they'll burn the place down. They don't contribute anything -- they just suck money out of the system and act as parasites.

[UnbiasView]

"People would be charged a portion of the cost based on income -- an ability to pay"

What is fair about that? Should I be able to but the same house as Bill Gates but at a much lower price because I can't afford it?

[klmebane]

so you think that people who can't afford the outrageous cost of medical care should just be left to die? how compassionate of you.

[long333]

So the Insurance companies detroyed the Health care system? Ask yourself who is asking for double-dgit increases i from year to year? The insurance comanies? WRONG. They are in direct competition with each other. It is the providers who are dictating the cost of health care. Do you think the doctors and hospitals are not demanding those increases? Are the doctors greedy? No the doctors have to make up the losses they have on government programs like Medicare and Medicaid thus the rate they charge patients for private insurance goes through the roof and God help you if you don't get their discounted inflated rate. Private insuraers pay 125% to 150% Medicare/Medicaid. SO let's return to you scenario with government price controls. Guess what happens next in every Universal Care Program. The government pretends to pay and the providers pretend to work. Labor retracts and shortages occur. Say hello to waiting lists.

[Marlyn]

red herring

[Agent420]

If you have ever lived in Canada you would change your mind about so called socialized medicine. I lived there for 13 years and never had a complaint. I have lived in the USA for 4 times as long and wish I could say the same. I am now covered by VA health insurance and it is pretty close to complaint free. I wish they would cover dental and vision, but heaven forbid that the government step on anyone's toes, so we will not be getting that until we get rid of the people that hold vets with so little regard. It's coming, like it or not.

[AlonzoQuijana]

You make a good argument for getting the insurance companies out of the way, but I'm afraid they are such an economic and political power that they'll have a big role in whatever we end up with. We seem to be moving toward a socialist/­corporatis­t hybrid economy anyway (witness banking, Wall Street, housing finance), so a government program run by the private sector fits with the trend.

[TRYKER]

IF, as has been reported, that 50% of our medical costs are INSURANCE companies middleman operations, then why oh why are you advocating that Ins. Cos remain in the mix???
IF we want to cut the costs of medical care, we can not afford to pay middlemen to stand between the Dr and the patient, where they fail to cover even those who HAVE the Insurance, much to the dismay and sometimes death of the insured.
The Drs don't like it, the patients don't like it....hell­o!
Why does the Insurance Industry become the vessel of choice when they are the demon? More Ins. lobbyists writing our laws is criminal, thank you very much. Forget your voucher campaign already.
Single payer govt COVERAGE, not "INSURANCE" leaves no question that every single citizen is covered equally. You're born, you get a number, you're covered until you die.
Yes, let us follow the lead of the most successful programs from wherever they originate.
All of these monkey wrenches and stumbling blocks are only designed to assure we get NO progress.

[darcy]

Well said, Tryker!

[PATina]

I'm still leery of a plan that includes insurance companies. Are they going to forego profit? Or will they be limited to a set percentage pointfor their profit margins? If not... this isn't going to work as great as your article suggests. While it may start out okay... eventually someone will figure out a way to 'squeeze' more profit from it... at the expense of the patient.

Other than that... it does sound like a good plan.

[NMdonkey]

PATina,
I am too. We need to get the HMOs and insurance companies out of the equation. They'll still have the ability to turn people down for "pre-existing conditions" and deny treatment for some conditions, right?

[bdl0715]

I want to hear the right wingers try to rip this plan apart.

[bobwalters]

Dr. Emanuel's proposal sounds good, workable, affordable, modestly revolutionary until one gets to the part where provision of this largesse remains in the hands of those who will insure its defeat: the for-profit insurance, hospital and pharmaceutical corporations that now control the healthcare system in the US.  Unless and until the healthcare FINANCING segment is removed from the profiteers -- which includes the nominally not-for-profit Blue Cross/Blue Shield corporations -- and placed under either the current Medicare administrative arm or an agency such as that suggested in the article, both quality of care and access will continue to be subverted in the name of "managed care", which is nothing more than managed cost through rationing.
So to get there from here, Dr. Emanuel, we have to first remove these cancerous profiteers from the system -- a fact you, as an oncologist, should clearly understand.

[SeriousBlack]

Good point. The only aspect of the overall plan I too have qualms with. In my ideal world I would simply outlaw health insurance companies, excise them completely from the health care system in this country. I just fear that that is impossible to accomplish. What is in this article seems like the best alternative, comprehensive strategy I have seen that stops short of doing that...

What I would hope is that maybe a plan such as this could be successfully executed, then somewhere down the line, private, for-profit health insurance companies could actually be totally removed from the system.

[yappnmutt]

and yet the people elected to represent the people continue to represent the people who paid their way. if this weren't true then the people and the nation would have what it needs.