There's lots of talk about our broken health care system, lots of agreement that something must be done and lots of "solutions" being proposed. Most of the solutions, however, forget about what the overwhelming majority of Americans want--a lifetime guarantee of affordable health care coverage that allows them to choose their doctors and hospitals and protects them from being pushed into poverty if they or their loved ones have a complex condition and need costly services; and, a health care plan that requires personal responsibility and has everyone paying in on a sliding scale for it.
As I see it, the solution that makes good sense gives people the choice of keeping the private insurance coverage they have if they like it or paying their fair share of the costs of coverage through a public option offered without a private insurer middleman at lower cost. Here's why:
With health care reform, we have many goals, all important, most of which an exclusively privatized health care system cannot achieve.
1. Covering everyone: The idea here is that people who work hard, pay their taxes and play by the rules should not be penalized because they or someone close to them needs costly health care. The only way to ensure they have coverage is to make it automatic if they do not elect a plan themselves. If you force people to sign up for coverage as we do with auto insurance for example, lots of folks fall through the cracks.
2. Eliminating waste: One central way to eliminate waste is to cut out the private insurer for-profit middleman. Another way is to negotiate on behalf of a large group as does the federal government for the Vets and Medicare population. A third way is through well-managed care (something that a public insurance plan could do well with good administration (e.g.,Veterans Administration) and that the for-profit plans are not particularly good at, as we all can see from the endless news stories, especially regarding people with the costliest conditions.)
3. Spreading risk through a single national pool (or perhaps a few very large pools:) Since 10% of the population consumes 70% of health care costs, the broader you can spread the risk, the easier it is to make health care affordable to everyone. (Opening Medicare to allow people under 65 to buy in (Kennedy, Stark, Yale Professor Jacob Hacker) would expand the Medicare pool even further.)
4. Health security/Protection from bankruptcy if you need a lot of care. The managed care plans are good so long as you are relatively healthy. When you need costly health services or need to move out of area, you too often have huge bills. Even out-of-pocket limits may not protect people who have to pay either in full for uncovered but necessary services or a large part of the cost of covered services.
5. A system designed to promote good care over the long term for people with complex and costly conditions. Private insurers tend to focus on short- term costs. They have no clue whether you will stay with them from one year to the next and they need to report good annual results. They also want to avoid insuring people with the most serious conditions, the 10% of people who cost the most to treat. So, private insurers do not design their plans to do well by people with costly conditions. Rather, they tend not to market their services to people with costly conditions and withhold information about their treatment protocols and cost-sharing claiming it is a business trade secret.
6. Care coordination: Most managed care plans simply manage access. They compete on premium costs, provider networks, and a few bells and whistles. There is little evidence of good care coordination for people who most need it.
For all these reasons, public health insurance should be an option for all Americans who want it or have no insurance; and, everyone who likes their private health insurance should have the option of keeping it. The plan I most like is Jacob Hacker's plan, Health Care for America. To read it, visit www.ourfuture.org.
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