What is it that you think we should have had?
OK, I'll play benevolent despot, or maybe chief analyst for the benevolent despot. <g> Here's what I would have started with, subject to vetting and costing. Back of the envelope, of course.
I'd approach cost first, both micro (affordability) and macro (budget). Then deal with universality. The reason is that if you get costs down, there will be fewer people who can't afford their own health care and who need some help. Cost reduction would take advantage of competition, skin in the game, and portability.
There are a couple of obvious steps right off the top including tort reform and anti-trust. Probably a couple of others that aren't coming to mind right now. [One investment would be to support digitization and sharing of medical records. Should produce savings long term but is an up-front public cost.]
Next there's reform to the insurance market to get costs down. First, I'd head towards a real insurance model, not the prepaid health plans we currently favor. Insurance policies would be major medical and catastrophic. There would also be policies just to guarantee renewal of the other policies. And a super-catastrophic policy to kick in when lifetime maximums of the other policies are exceeded. These policies would cover the big stuff. They would all cost dramatically less than typical policies today. That last one would cost practically nothing. For portability purposes, cross-state policies would be allowed.
If folks want to sign up for some kind of health plan for the every-day stuff they could sign up with an HMO as an umbrella alternative to the above. Alternately they could add a retainer type arrangement with a PCP or a clinic to supplement the big-ticket policies. Or they could pay out of pocket.
To support this competition among providers for popular services would be encouraged by the IRA, SBA, whomever. There would be low-cost mammograms, wound management, blood testing, vaccinations, whatever arenas business-oriented providers wanted to create. Doctor's orders wouldn't be required. (Some of that is going on now with blood testing.) And urgent-care or every-day other clinics. Charity services would be encouraged.
Employer-provided insurance would lose its tax advantage, at least for every-day coverage. All policies other than employer-provided insurance would be individual, no family coverage.
Then there's coverage. I'd require all babies to be covered before birth with either a major medical or catastrophic policy and a guaranteed renewal policy. Additional policies/care arrangements are optional. A pregnant woman either gets the kid insured, gives him up for adoption, of has an abortion. The required policies would be really cheap because kids don't have a whole lot of major medical problems. When the kid comes of age, he does what he wants re insurance but he'd be a damn fool not to continue the policy mom got for him.
Government programs, Medicare and Medicaid, would continue. They would all be HMO type. They would be subject to best practices and effectiveness measures (rationing) as determined by experts and appropriately vetted. The insurance companies would likely go to school off this when setting their benefits. Seniors could opt out and cash out of Medicare and use the insurance market. Hospitals would be required to handle any life-threatening condition as they are now regardless of getting paid. They would be compensated at cost. Non-life-threatening conditions would be redirected to the then prolific urgent-care clinics. Medicaid eligibility would be adjusted to meet needs based on the changed cost of health care. For those above the threshold, either a Medicaid variation could be available with income-based fees to the extent that there's still a gap in affordability or insurance could be subsidized.
That's the system as already in play. Transition would be required to it from the status quo ante re the prior cohort of uninsurables until such time as the universally covered babies age into their own insurance. They would be covered in a government subsidized high risk pool until they age into Medicare. The transition public costs would diminish over several decades after which the program would be gone from the budget. |
