I wrote a philosophical piece last week on health care. Here are some details:
To understand the repeal of the ACA, you have to remember what healthcare delivery was like BEFORE it. Americans have a difficult time remembering yesterday …much less five years ago.
The first thing you have to put in perspective is that INSURANCE isn’t the same thing as health CARE. Insurance is there for catastrophic things. But we have been using insurance as the payer of all things medical in this country. To me, that’s our first mistake. We NEED to pay something for care. Otherwise, it starts losing it’s value.
I like mini clinics. I think they are a great innovation in medicine. They’re generally inexpensive, quick and easy for things like a cold or the flu or a strep test or some weird bump or bruise that isn’t going away. These guys aren’t going to diagnose a brain tumor. And they’re not there for that. But they are a pretty darn good first line of defense for basic stuff. And you can usually walk out of there for less than a hundred bucks …about the price of nice dinner out. To me, that’s worth it. And it keeps big, monolithic 3rd payers out of the process.
I was on a flight with a dental supply salesman, once. He was already drunk at 10 in the morning and dropping all kinds of secrets (to anyone who would listen) about the world of medical and dental. He asserted that dentists have figured it out by getting OUT of the insurance game and accepting cash only. He said they’re making WAY more money than their general practitioner doctor counter parts. And if doctors were smart they would stop taking ALL insurance completely.
Pretty soon after that, MY doctor stopped taking insurance altogether. He is now VERY expensive and we don’t always spring for his services. But that leads me back to those clinics. If there’s something only he can deal with, we pay the money. Otherwise, we make good use of walk in clinics. And so far …it has worked.
Then, you get into insurance …
Monthly payments to ANYONE are revenue streams …nothing more. And they are bought and sold on the open market. Gym memberships, car loans, online subscriptions …they are all revenue streams that are bought and sold. This is what has happened with health insurance. And the only mechanism to keep them honest is to make them compete fiercely for those streams. They must get creative with their products and get their companies lean and skinny. Because once they become public utilities, propped up by the government, they will have NO incentive to innovate or evolve.
The basic gist of health insurance used to be this: you could buy an individual insurance plan on the open market (IN YOUR STATE ONLY). But it probably had lots of loopholes in it. The best healthcare plans (meaning INSURANCE plans) came through group insurance plans provided through employers. Those plans were better because insurance companies could dilute their costs with high numbers of people paying in.
THAT’S why one of the main keys to getting insurance rates to drop is to open their potential business to bigger pools of people i.e. erasing state lines in the sale of health insurance.
I would like to see a few simple things happen:
1. Purchase health INSURANCE anywhere in the country.
Opening the pools of insurance plans up to the pools of potential buyers cannot be understated. It would start a conversation inside states about being attractive to those product providers, probably lowering state taxes and regulations. This one move alone could market correct several other industries. Without THIS, all the other moves are almost a moot point.
2. If there’s going to be a mandate, let it be on anyone who wants to get in the health insurance business.
NOT on individuals or other types of business. The mandate should say that you have to keep a certain percentage of your actuaries as high risk patients (say 5 to 7%). And FOR that you will receive a dollar-for-dollar tax break for all payouts in those pools.
I told this to Bob Corker once. He loved it but said he would never be able to get it passed (this was 2009). Because it would look like a tax break on the rich. Sure enough …as I scroll through social media, any tax cut on anyone looks suspect to a certain group of people.
3. ALL health care costs should be COMPLETELY tax deductible.
Not a percentage …but dollar-for-dollar. If I had been able to offset my IRS bill with my medical bills early in my daughter’s life, things would’ve been dramatically better for my family. Offsetting taxes with medical bills might mean less revenue into the government. But it’s basically taking the place of a government subsidy. The biggest difference is YOU’RE in control and no bureaucracy is required to process the taking in of taxes and turning them into subsidy money. That saves money.
4. Tax breaks for doctors who do pro-bono work.
Make it worth someone’s time to volunteer their services. If doctors could offset THEIR tax bills with pro-bono work (again, DOLLAR-FOR-DOLLAR) it might be worth it to my doctor to do a month of free well-visits a year. And again, the only thing the government has to do is …NOT COLLECT MONEY.
5. Keep S-CHIP programs and Medicaid solid. But funded mostly through the states.
My children are both considered “at risk” and are on S-CHIP programs provided by our state. That wasn’t always the case and it’s one of the good by-products of the ACA.
Someone like my daughter is always going to be a wild card when it comes to writing an insurance policy. My daughter cannot speak, bathe herself, feed herself or take care of herself in any way. She is a danger to herself and others. I do believe the state has a responsibility to people like her. It has a responsibility to Veterans. And it has a responsibility to the aged.
It DOES NOT have a responsibility to people like me. I do. And if my daughter can be cared for (at least in part) by the collective, my wife, son and I can take care of ourselves. I think that’s how it should work.
But once you introduce a (seemingly) free solution to someone, you can never take it back.
My belief is that eventually we will have single-payer healthcare in the United States of America. Because it will seem easy and sensible to everyone. And the government will have complicated it to the point of just throwing up their hands and saying, “Screw it. Let’s just throw the money in a pot and give everybody a card.”
But always remember that single PAYER also means single BUYER. That means some calm, bureaucratic, disaffected board will eventually make a well-informed budget decision on how many mammograms a woman needs in a 5-year span. And even if a certain woman has circumstances that transcend those guidelines, she will have no other choices in where she can go get that much needed mammogram.
In a free market system, she might go broke but she’ll be alive. In a state-run bureaucratic system, she won’t go broke for the care she needs. Because the amount of care she gets will be pre-determined …even if it kills her. These are the trade-offs you make when you turn all of your health care over to some monolithic machine.
My fear of a single payer system is that choices will go away, innovation will wane, the best and brightest will go into other more lucrative fields, scientific research (something my daughter desperately needs to stay robust) will taper off and decisions will be made that benefit the monolith, rather than the individual. Those things all happen NOW with insurance companies. But insurance companies don’t have the final say …not like the government will. This is why we need more competition …so we can say, “screw you, insurance company A. Insurance company B will do what we need for less money.”
THAT is the only way we retain ANY control over the price of anything …including healthcare. By being able to walk away from it to a different option.
Whatever healthcare system we build must include the individual having a voice and a say in their own care …through the coercion and power of their dollar. Otherwise, we might as well go ahead give it all over to the government now. And let them start telling us how long we’re allowed to live.