Wednesday, July 22, 2009

A Fair Discussion

Recently, I have been exchanging e-mails with a colleague on an organizational mailing list (and probably annoying members of said list--sorry!). This is a reply to a graphic that was e-mailed to me. I think it is really interesting in the use of language: check out the two halves of the graphic and tell me if you can guess which side is favored. Here's my reply:


The graphic you sent is interesting--but I think it shows the difficulty in figuring out the best choices and the strengths and weakness of the various options.

The image on the left, the "Consumer-Centered System" highlights as a strength what I think is the greatest risk in the system: Consumers decide what health plan suits them best. I readily admit that many consumers could make this decision--but many, many would struggle to choose a reliable and beneficial plan without significant assistance. We've seen w/ the current subprime mortgage market that people can get themselves in terrible trouble by making bad decisions--many misled, some dishonest. However, when these decisions add up and the system collapses, you risk having a situation where you have exactly what we have now: many uninsured, many who pay for plans they can't get out of, many whose plans do not live up to benefits promised or perceived.

Interestingly, this graphic doesn't even account for any sort of government subsidy or tax break to help individuals fund their purchase. You would assume that patients would try to find the most affordable plan, but would they reliably recognize the limits on coverage that would almost certainly be present. The graphic also takes out any sort of employer-provided health care (it notes that families and individuals would choose their plans); so all the cost falls directly on families? Are employers supposed to pass the savings along to employees to allow them to buy insurance? It seems that this set-up would be riskier than the flawed system in place.

The graphic also doesn't address the issues of cost-shifting where the highest-need and highest-use patients would still likely be covered on government plans which still would not be able to recover costs by insuring healthier, lower-utilization patients.

I guess I just don't see how that model would address the issues of the unerserved or the issue of costs. In the long run, wouldn't we just end up pretty much where we are?

At the same time, the "Government-Driven System" graphic shows all the fears incumbent in any public insurance option: "politicians, bureaucrats in control at top", private plans can't compete, etc. My current understanding of legislation including HR 3200 doesn't fit with that.

This second graphic also seems to indicate that government-mandated "essential benefits" are a bad thing. If we're going to have a marketplace (which is the model in HR 3200 and other proposals) that include a public plan, patients will have hundreds or thousands of plans to choose among. We've seen the challenges of choosing Part D options: how can patients reliably and easily choose between the hundreds of benefits that would be part of each and every plan. Is it bad to require all plans to have some essential features? Maybe things like periodic health maintenance visits (Paps, Mammos, lipids, colon CA screens etc)? Maybe some sort of catastrophic coverage (or an easy way to add this to a basic-level plan). Maybe coverage for some essential level of generic meds at least--how long can we depend on Wal-Mart, Target, etc? If/when their generic plans stop making $ by bringing shoppers in to the store, those plans are at great risk. To me this is
a little bit like requiring seatbelts, brakes, etc on cars: aren't there some things that are SO essential that they MUST be included?

Medicaid and Medicare are terrible payers--we all know this. But is this in part b/c they can't meet their budgets b/c of the cost-shifting referred to above (covering so many patients w/ high utilization and so few that are healthy low-users)? Could/would the payments be better if the budgets were healthier? Wouldn't enrolling more healthy people in a public plan move toward that direction? Couldn't US businesses be more productive if they COULD find a plan with low premiums? So far, private plans have failed terribly at this. Would a public option be better?

To me, the fundamental questions involve fairness. To me this means universal coverage that is portable and affordable and that provides meaningful benefits. I haven't seen it from the private plans and I haven't seen it from Medicare/Medicaid. But this is a chance to make a difference, to provide care for all and to reduce the costs associated w/ healthcare in the US. Maybe even get better outcomes for the $ (which we do very poorly compared to other industrialized democracies).

Other countries are successful with this--public plan w/ private plans co-existing in a market, with varying levels of government control and requirements. Can't we find a system that will work to cover everyone, while still providing physicians w/ a good environment to practice? I think we need both, and I think we need to make sure we're looking at physician issues: malpractice reform, payment re-structuring, supporting EHR implementation, etc. If we don't have docs, we won't have healthcare. But I really feel that the efforts at the federal level can work and I'm troubled that so much energy is being devoted to breaking them down without any great sense of a sustainable, viable alternative.


Thanks for reading.

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