Well, six hours anyway. I wouldn’t miss tomorrow’s health care political extravaganza. I’m planning to crack open a brewski and a bag of Cheet-Os, and splay out in front of the boob tube for the full six excruciating hours. C-Span on steroids.
What’s wrong with me? Don’t I know health reform is dead? Don’t I know the Obama administration was dumped into the dustbin of history following election to the Senate of Massachusetts Republican Scott Brown, which overturned what all viewed as a permanent Democrat/Kennedy lock on the ultimate safe seat?
Oops, there I go, getting wonkish. Well, that’s what it is with me. I used to cover health policy – wrote, edited and published a newsletter called “Health Policy Week,” for God’s sake – and I can’t get it out of my blood. The issues I covered during 1982-86 are, basically, the same issues as today. They weren’t resolved then – indeed, the solutions of the ‘80s and ‘90s (managed care, prospective payment) may have made things worse – and there’s a fair chance they won’t be resolved this time.
But that doesn’t have anything to do with my plans for tomorrow. Sure, I believe passionately that health reform must pass or this great nation will go bankrupt. And yes, in my opinion the current compromise pretty much stinks, may not work, needs the public option or something like it, yada yada yada. Health policy does indeed matter to me. But the reason I’ll be glued to the TV tomorrow has more to do with spectator sports. What NFL football and NBA basketball are to others, health reform is to me. Even if I had a full schedule, I’d cancel all engagements.
Now, as it happens, I don’t have any engagements tomorrow. The decks are clear for stultifying TV. I’ve been home from the hospital since last Friday, recovering from total knee replacement.
An improved patient delivery system is a necessary pre-condition for affordable and quality health care.
What do I mean by a “patient delivery system”?
Understanding patient delivery system means recognizing that people without health insurance do not receive treatment until they are in an immediate life-threatening situation.
I cannot back this up with a scientific study, only my daily experience. But that experience contradicts an oft cited myth that no one who needs health care is turned away. One of the most common reason that people call our office is because something happened to their health insurance that lead to a denial of treatment.
It may be as simple as the doctor calling the wrong number or it may be that the member has failed to pay their share of their health insurance premium. But the reasons don’t make the stories any the less heart breaking.
Why is there not more support for an expanded employer role in providing health insurance to all Americans? I sense a certain exhaustion among decision makers and employee benefit professionals as they grapple with costs that just defy control. I notice at professional conferences an increasing openness to the single payer model.
We have seen one cost control fad after another. More and more employers are dropping health benefits in order to stay afloat. In this game of Old Maid, those employers who do provide benefits struggle to maintain their social compact with their employees without footing the bill for the rest of the world.
The rest of the world? How does that occur? In a number of ways.
With the election of Barack Obama, there is a lot of hope and optimism about the potential for health care reform.
There is also some nervousness.
The nervousness originates from those who think that the current economic crises will inhibit reform efforts. That somehow the price tag of reform will scare people away from health care reform. I am encouraged by an insightful article by Ezra Klein on Obama’s choice of Director of the Office of Management and Budget.
According to Klein, Peter Orszag believes that health care reform is the key to the fiscal future. Since it his office that will pin the price tag on any health care proposal, his biases matter.
Others are worried that Obama might be soft on insurance companies.
I am not a great friend of the insurance companies. I deal with them every day. But neither am I a knee-jerk opponent of insurance companies.
Insurance companies reflect the markets they operate in. And health insurance companies function in a market that brings out their worst qualites.
Unlike home insurance, or auto insurance, there is no legal or market mandate to have health insurance. This allows health insurance companies to avoid insuring the very people that need it the most – high risk (read sick) individuals.
Outside of the Medicare supplemental insurance market, there are very few limitations on what should be covered or not covered in a health insurance plan. This gives insurance companies the license to put restrictions and exclusions in their policies as they, or their customers, see fit.
Health Care Reform in Germany
This past spring, Health Affairs, the premier health policy journal, had an interview with the German Minister of Health, Ulla Schmidt. The interview focused on reforms to Germany’s health system instituted principally in 2007. Minister Schmitt was asked what were the goals of the reforms. Her answer – she wanted to preserve the principles of social solidarity and affordability that had always been a part the German health system.
In comparison to health care in the United States, the Germans system could hardly be called a system in crises. The per capita costs were about half of what they were in this country $3,200 per person in Germany compared to $6,400 here. But they did have too many uninsured – about 0.2% of the population. The United States, by comparison has 15% uninsured.
So the question is, What do Germans understand by social solidarity? Minister Schmitt explained that everyone in Germany has guaranteed access to health care and everyone contributes to the financing based on their ability to pay. Well, if that is social solidarity, where does affordability fit in? For Minister Schmitt, if the entire system is not affordable, the social solidarity begins to break down.
Too much of the health care debate in this country is muddled by ideology on both sides. For many in this country, European health care sytems smack of “socialism.” Yet, two of the defining characteristics of the German system are not real popular among progressives in this country. The Germans have an individual mandate and they rely on insurance companies, although in Germany they give them a more accurate name, Krankenkassen, or Sickness Funds.
Since November 4th, interest in health reform proposals has understandably intensified. I like to flatter myself that this blog might make a small contribution. But I do have a day job and so the horn I blow here only has one note; if we simplify the system we can find the money we need to cover the people without health insurance and increase product satisfaction among all stakeholders.
I am not a policy wonk who views the health care system wonderfully distilled through the glorious abstraction of statistics; nor am I encumbered by practical politics. I view the system from the bottom looking up. I have a stake in the present system, but that stake is poorly represented in these musings. I am a gatekeeper to the health care maze. In my ideal world there would be far less need for the work I am doing.
I know from daily encounters just how daunting that maze is for people needing care. I tend to demonize piece rate physicians who are too quick to deny care rather than trust the maze.
So when I read others who write about health care reform I look for my theme. On Sunday, November 23, 2008, the Washington Post published an opinion piece by Shannon Brownlee and Ezekiel Emanuel, 5 Myths About Our Ailing Health-Care System. The authors are right on target with four of the five myths that they debunk. They drive home the point that we are paying a lot of money for our health care, that we are paying a lot of money for not particularly good health care, that we really are paying the price through premiums, taxes, and lost wages, and that Americans are ready for a change.
Every health care reform proposal attempts to offer some relief for small businesses. According to the National Federation of Independent Businesses (NFIB), small businesses create 2/3 of American jobs, yet half of the uninsured are in small businesses.
Look at President-elect Obama’s health care proposal on his campaign’s web site. The first two items:
- Require health insurance companies to cover pre-existing conditions so all Americans regardless of the health status or history can get comprehensive benefits at fair and stable premiums.
- Create a new Small Business Health Tax Credit to help small businesses provide affordable health insurance to their employees.
What’s remarkable about these proposals is that we are still discussing them.
Let’s look at the second item – a tax credit for small businesses. In my opinion, it is a mistake to separate the small business market from the individual market. Almost every small business starts out as a solo enterprise. How many creative ideas never come to market because the would be entrepreneur is afraid to go without health insurance?
Yet we don’t make it easy. Anyone who has ever itemized deductions has experienced the limits on the deductibility of health insurance costs. There is also something called a section 105 deduction that you can learn about elsewhere. Yet business owners can deduct the full cost of their medical insurance. I would welcome an explanation that justifies this disparity, or at least explains the politics to me.
The real nut is the first item. That we allow insurance companies to only insure healthy people is the greatest tragedy of American health care. This is called medical underwriting. Jonathan Cohn in his book, Sick, has a wonderful chapter on this stain on American health care.
Instead of focusing on Joe the Plumber and his tax phobia’s, perhaps the presidential candidates should talk to Jesse the Artist and ask him or her about health insurance. On Sunday, October 19th, I visited the Bethesda Row Arts Festival in Bethesda, Maryland. I did just that. In a very unscientific survey, I talked to a number of the artists about their health insurance.
Why should anyone else be interested in artists? Because they are small business people. They are also very creative. It is this creative entrepreneurship of small businesses that candidates like to support because it is the economic engine that drives the American economy.
Artists as Small Businesses
I was curious whether health insurance was a barrier to entry for these artists. Two of the artist referred to a study (but could not name the source) that 83% of artists had health insurance. That was consistent with my own unscientific study. I talked to close to 20 people. Only three had no health insurance. But, on the other hand, only three paid for their own health insurance.
Perhaps they asked the wrong question.
Amazing seems a most appropriate word to describe the financing and delivery of health care services in the United States of America.
According to Merriam-Webster’s Collegiate Dictionary, 9th Edition (OK, I have an old dictionary) amazing is derived from a French word meaning “to confuse”. Obsolete meanings include consternation, bewilderment and perplexing.
Yes, health care in the US is truly amazing. Rube Goldberg could not have invented a more illogical maze of non-systems. Lewis Carroll’s might have added an additional chapter on Alice’s efforts to get those pills that made her big and small. Kafka might imagine a special Penal Colony for those responsible for this maze.
I should be careful on this last point, since I am part of that system. I administer the benefit plan for approximately 25,000 participants. I like to think that we do our best to help our members navigate what is all to often a daunting and perplexing maze.