David Kendall of the Progressive Policy Institute has issued a new study, “Fixing America’s Health Care System: A Progressive Plan to Cover Everyone and Restrain Costs.”
It’s an interesting mix of policy prescriptions, some of which are very useful while others are pie-in-the- sky. But the whole paper is tainted by a core belief that if the federal government isn’t doing it, it doesn’t exist. It will be interesting to see how well this tenet holds up in a post-Katrina world.
Kendall offers six prescriptions, the first of which is, “Universalize the health care choices members of Congress enjoy.” In other words, extend the Federal Employees Health Benefits Program (FEHBP) to all Americans and mandate that everyone participate.
Kendall notes the current system of employer-sponsored health insurance “gives health plans the wrong impression that employers, not employees, are their customers.” He emphasizes individual choice of plan and says each state should be required to create a statewide FEHBP-style menu of health plans. Like George W. Bush, he would create a tax credit that would cover at least half the cost of coverage “for moderate and middle-income workers.”
Kendall adds, “states should also allow eligible families to use the money from Medicaid and SCHIP [Supplemental Children’s Health Insurance Plan] to purchase or supplement coverage at work.”
Nothing Much New Here
Bravo! to most of that. It is a little difficult to see, however, how this state-run menu of health plans is different from the individual market today, in which the state insurance commissioner supervises the insurance offerings available in any particular state. And if all that is needed is a centralized database of such offerings, private entities such as eHealthinsurance.com are already providing that.
In addition, mandating coverage creates a whole host of new problems in enforcement. And once the programs (subsidies, access provisions, etc.) are in place to make such a mandate possible, there is no need for a mandate, since very few people will absolutely refuse to carry an insurance card.
Consumer Control, HSAs Dismissed
More importantly, while Kendall acknowledges some of the massive dysfunctions of the current system–poor use of management technology, unsafe and inappropriate care, lack of performance incentives, lack of trust in the use of health information–he misses, or actually dismisses, the role of third-party payment in causing these conditions.
Rather than giving individual patients more control over how their health care dollars are spent, Kendall would invest even more power in the hands of third-party payers to determine appropriate care, create “pay-for-performance” standards, define covered benefits, control costs, and so on. He dismisses Health Savings Accounts as “no panacea” and would instead rely on the same government and private third-party payers that have created the current mess, expecting them somehow to transform into a panacea.
There are other ideas in Kendall’s study that deserve a look and careful consideration. His suggestion for replacing our current malpractice system with a new era of “health courts” is very interesting, and his call on the National Institutes of Health to focus less on basic research and more on interdisciplinary problem-solving warrants serious discussion.
Alaska Senate Surveys Reform Efforts
On October 6, 2005, I participated (by conference call) in a hearing in Alaska held by state Sen. Fred Dyson’s (R-Eagle River) Health, Education, and Social Services Committee. The other witnesses on my panel were Jim Frogue, project director of the Center for Health Transformation, and Laura Clay Trueman, executive director of the Coalition for Affordable Health Coverage (CAHC).
Prior panels had included presenters from the Alaska State Hospital and Nursing Home Association on “user friendly” billing, the Alaska Division of Public Health on building a statewide patient information system, and Commonwealth North, which presented a report from a health care task force it organized.
Our panel mostly discussed Health Savings Accounts (HSAs), especially the early experience of companies using them, state-level efforts to use HSA principles with state employees and the Medicaid population, and related tools such as patient information and price transparency needed to make consumer-driven health care successful.
In my own testimony, I emphasized the problems created by exclusive reliance on third-party payment for financing health care, and how previous efforts such as price controls, centralized planning, and rationing of services have failed because they did nothing to change the demand-side incentives. I said we are trying to find the right balance between direct pay and insurance coverage, and added that we need to remove the obstacles to competition and innovation throughout the health care system. I concluded with a few comments on the Commonwealth North report.
Passion for Central Control
That report recommends the creation of a “health care roundtable” that would “foster action among parties that have a long-term vested interest in health care reform.” The roundtable would recommend health care reform legislation that would “get quick approval and become part of a long-term fiscal plan for Alaska.”
This idea in itself should set off alarm bells for anyone who believes in empowering consumers. Essentially the report is saying we should get the health care establishment (the same people who created the current mess) together to browbeat the legislature into approving, without scrutiny, laws that will lock into place the existing advantages of the fat cats.
The bulk of the report is a litany of current problems, generally posed as issues that only a centralized bureaucracy can fix. It regurgitates the various myths perpetually cited by the single-payer folks: that hospital prices are high because of cost-shifting, private insurance drives people into bankruptcy, technology is the culprit behind health care inflation, health outcomes in the United States are terrible, etc.
More Power for Bureaucrats
The Commonwealth North report twists the concept of “individual responsibility” by saying individuals are actually responsible for complying with a “collective” vision of worthy behaviors. Hence it wants to institute a broad, anti-smoking-style campaign to promote its own ideas of proper diet, exercise, dental care, and mental health.
Despite the “command and control” tone of the report, some of the ideas presented have merit. It suggests, for instance, that purchasing insurance pools for small employers would be a good idea, and that government programs should provide “adequate reimbursement” to providers. It also recommends prices should be transparent, and professional liability solutions such as California’s Medical Injury Compensation Reform Act (MICRA) should be considered.
But it also says “allocation and rationing might be considered,” “accepting Medicare patients [could be] a condition of licensure,” and “intervention programs [should be developed] for promoting the traditional rural diet.”
Legislators Interested in Options
In a distinct contrast to Commonwealth North’s desired approach, Republican and Democratic members of Alaska’s state legislature expressed strong interest in health savings accounts (HSAs) and high-deductible health plans, said CAHC’s Trueman, who took part in the hearing via phone. Rather than expressing a common concern, heard often in Washington, DC, that a high deductible might deter patients from seeking necessary care, Trueman said, the legislators wondered whether the deductible on HSAs and high-deductible plans was high enough to cause consumers to become more cost conscious.
One legislator asked whether those who met their deductible would then be tempted to schedule lots of medical care, specifically elective or cosmetic procedures. “Copayments still exist,” said Trueman, “usually at 20 percent, and policies are not likely to cover elective and cosmetic care.”
Instead of imposing new regulations by a committee of “vested interests” dictating from the confines of its round table, let’s hope the state legislature allows the people of Alaska to make their own decisions.
Greg Scandlen ([email protected]) is founder of Consumers for Health Care Choices.