Healthcare Reform - Democrats versus Republicans - Where Do We Find Compromise? - The Future of Medicine

January 28, 2008

The United States is the only country in the industrialized world that does not assure insurance to cover the catastrophic medical care costs of all its citizens.

Despite major expansion over the past decade of government funded coverage, especially for children, the number of uninsured is has risen with some 47 million Americans uninsured; many others are underinsured. Whether one believes in a government-sponsored and managed insurance system or not, it is unconscionable that we do not assure everyone of catastrophic medical care and the poor to basic and preventive care. The question should not be whether everyone has a right to care but rather how to provide it to everyone.

Medical costs consume about 16 percent of our GDP and rise at about 10 percent per year, well above general inflation. Insuring everyone means that it will cost someone - you and me as taxpayers - more money. So costs of medical care need to be addressed as well to maintain a balance.

But it costs each of us today to have our fellow citizens uninsured. An uninsured sick person with no insurance shows up at an emergency room seeking care -and care is more costly because the disease has progressed further. The ER is not designed for continuity of care; primary care physicians are much better at addressing high blood pressure at its inception; diabetes at an early stage before vision, heart, or kidneys are damaged; high cholesterol before it becomes a heart attack.

In Maryland anyone can go to any hospital and obtain care, whether they can pay for it, and whether they have insurance. Hospital rates are set by a state-mandated commission and include a provision for uncompensated care.

But nationally, care for the uninsured is problematic. Even in Maryland, the uninsured do not have basic primary care. And although hospital costs are covered, the physician's are not.

A national survey by the Kaiser Family Foundation published in August 2007 indicates that citizens are clearly divided on dealing with the uninsured. Registered Democrats tend to favor a system where everyone is covered in a fairly comprehensive insurance plan, even if it's a government plan that would increase everyone's costs/taxes. Republicans tend to prefer either a health plan that would keep things as they are or would add some citizens and encourage personal responsibility while working to reduce costs. Not surprisingly, the presidential candidates' positions, along with those of our federal legislators, mirror that of their constituents with little evidence of a middle ground.

Can compromise be reached after the elections? Let me offer one

Begin with the concept that everyone should have adequate medical care but that each of us also needs to accept responsibility for our own health - diet, exercise, nutrition, seat belts, dental hygiene, stress reduction, no tobacco. Medical insurance years ago was for catastrophic needs such as hospitalization for a serious illness or surgery but it has morphed into prepaid medical care for everything from routine visits, immunizations and well baby care and a host of well-meant but expensive mandates such as drugs and vaccines, mammograms and colonoscopies. All of these are important to good health but should they be part of basic insurance?

The concept of insurance is to spread the risk among many - pay a relatively low amount to provide for the catastrophic event that seldom occurs. Fire insurance is cheap because every homeowner buys it but few have a home burn down. Medical insurance as we know it today is in actuality prepaid medical care, i.e., it covers essentially everything. That, plus not allowing for risk stratification as with life insurance, means medical insurance is therefore very expensive.

Let's move to a system where everyone can obtain insurance but let's have it cover catastrophic needs, not routine needs. This means that there will be a high deductible, say $1000 or even more. Just like with car collision insurance, the higher the deductible the lower the cost. Price it based upon age and life style risk factors such as weight and tobacco, just like life insurance. But let everyone, no matter their health status, have access - no denial for "pre-existing conditions." And everyone needs to be part of the pool so as to spread risk- no one should be allowed to "opt out" because they are young and their health is good. Such an approach will mean a lower insurance bill but it will also mean that each of us will pay for routine care. Having health saving accounts (HSAs) to pay for routine care with pre-tax dollars makes this approach more palatable and asks each of us to accept more responsibility for our care.

Every company would be required to provide this type of insurance to employees or pay into a state pool. For those who cannot afford insurance, subsidize it either through tax credits or automatic enrollment in a government plan akin to Medicare. Individuals must participate or loose tax benefits. Those who buy their insurance individually would have the same tax benefits as corporations do today. And for those who can truly not afford basic care, insurance would cover an annual exam and basic prevention strategies such as the recommended vaccines, and critical screening tests such as cholesterol and blood sugar levels along with a drug benefit generally focused on generics.

The results? Everyone is insured, the risks will be spread over the entire population, those who chose to engage in high-risk behavior such as smoking will pay a higher rate, no one will be denied coverage and those truly unable to pay will be covered by government, either through tax credits or a direct subsidy. Both the Democrat's desire to assure universal coverage and the Republican's desire to assure greater personal responsibility will be met.

What about here in Maryland? Since action by the federal government is not likely soon, our governor and legislators should enact the program outlined above, at least to the extent that is possible without federal involvement. Annapolis should insist that everyone enroll in a basic insurance program, thus spreading the risk, and should revise the insurance laws to allow for fewer mandates to reduce insurance costs. It should prevent insurers from cherry picking only healthy applicants and create a system of tax credits and subsidized care for those who cannot otherwise afford this basic level of insurance. It would be a good start at reform.

Stephen C Schimpff, MD
January 2008
OP-Ed Baltimore Examiner

 

Last Modified: June 11, 2010

Copyright (c) Stephen C. Schimpff, MD