Monthly Archive for October, 2009

The health care debate has been one of extremism on both sides, with nobody really seeking to find a middle ground. This article will attempt to do exactly that.

Emergency Health Care
One thing many people opposed to universal health care fail to recognize is that we actually already have it. Any person can walk into any emergency room at any time and cannot be refused service for lack of ability to pay. This law has directly resulted in many emergency rooms going out of business since they have been forced to provide health care to patients with no ability to pay. We really do have to examine this area first to determine whether we view health care as a “right” or a “privilege”. Those who truly view it as a privilege ought to oppose this existing requirement, and can accurately point out that it is greatly increasing the cost of emergency services for everyone. Since I haven’t heard much complaint about it though even from those strongly opposed to current reforms, I would assume that most Americans are in favor of mandatory emergency care.

That  said, there is still the problem of who pays for it. Under current laws, hospitals are required to simply eat the cost of emergency health care. This appears to be a fundamentally unfair requirement. If the federal government is going to require hospitals to provide emergency care, the very least they can do is to ensure that compensation of expenses is provided. For this reason, I would be willing to support a “mandatory emergency insurance” program enforced on all citizens, legal residents, and legal visitors. People from all three groups will be granted access to our emergency services if needed, and should be able to guarantee payment. This insurance program doesn’t necessarily have to mean that the insurance company covers all expenses, but rather that the insurance company guarantees that the hospital gets paid. Individual contracts between patient and insurer would determine whether the insurer pays out of pocket, with a “health savings loan” to be repaid by the patient, or  from a “health savings account” owned by the patient. Obviously, the premium cost of the first would be the highest and that of the last would be lowest. Even in the last case though, the insurer would have an obligation to work out with the patient how any costs in excess of the account balance.

Health Care for Minors
The next area of  likely agreement is with regard to children. In the US, we consider those under 18 years old to be legally unable to make their own decisions, delegating these decisions to the parent with some supervision from the state. Most children have little to no choice whether they have medical insurance, and again most Americans would argue that children should not be refused medical treatment by hospitals. Statistics show that around 8 million children are uninsured. One assumes that most people would support programs to insure these children, and in fact “Nearly three quarters of uninsured children are eligible for health insurance coverage under Medicaid or SCHIP. The remaining uninsured children are not eligible primarily because their family incomes exceed program eligibility levels (Figure 3).” This leaves only 2 million kids in non-poor families uninsured.

This gives us another low hanging fruit that is being intentionally ignored in the current debate. Rather than arguing about universal  health care for adults, why don’t we first enroll the 6 million uninsured children who are eligible for government care? This can be done through a combination of health care drives where we pull together all the people needed to enroll these children and explain the benefits to their parents and by simplifying the enrollment process. No major legislation or national debate needed. For the remaining 2 million children, I would be willing to support either mandating that they be insured or extending government programs to cover them.

Insurance for the Rest
Getting clearly specified preventative care should be a pre-requisite for all insurance. A great deal of the expense in insuring people results from not catching problems early, and insurance companies have a (moral) right to try to reduce their expenses in this way. The easiest way is to just tack the cost of a yearly visit onto all policies, and provide the patient with a mandatory appointment if they fail to make their own by a pre-determined date. Insurance companies would be allowed to set their own rules about this though, since their interest is in reducing total cost. If a company decides yearly visits are unnecessary, they wouldn’t have to pay for them. In fact, a more piece-meal approach to insurance is desireable all around. Insurance as a concept is really only useful for unlikely disasters, since it is only in those cases that the average person can ever expect to get more out than they put in. That being the case, other than mandatory checkups as described above most insurance should probably be high deductible insurance.

Insurance that kicks in at 5 or 10 thousand dollars has always been cheaper, and allows people to have help when they really need it without paying inflated premiums when they don’t. Current estimates of the uninsured are around 48 million. Subtract the 8 million kids we already discussed above, the 6 million people who aren’t here legally to begin with (but will still get ER care), 9 million making more than $75k, and another 6 million non-minors who also qualify for existing benefits to get 21 million (note that these groups may have a little overlap). What would it cost for this group to get a high deductible plan? Maybe those worried about their status would be better off creating a medical relief charity to buy them coverage than trying to use tax dollard to do so?

All such insurance should be owned by the individual, though it can be purchased through collaborative negotiating groups if desired. Tax benefits that favor employer based coverage should be ended or shifted to cover all insurance plans whether through an employer or not. By having the plan owned by the individual, one wouldn’t experience changes in insurance due to job changes. (That said, an employer might still offer negotiated rates from insurers, though those rates would not change due to a future employment change.)

Health Savings and Health Loan Accounts
The  final piece needed is coverage for the expenses between the mandatory office visits and the point where the high deductible insurance kicks in. The best place for this is in health savings accounts, which could remain tax exempt to encourage contribution. Companies wanting to attract talent could also provide automatic or matching funding, much like they do with 401k plans. (My own company currently provides $1500 a year in a health savings account to anyone choosing a high deductible plan.) Throw in a loan program for those who encounter expenses before accumulating enough savings, and you have a nearly complete program.

Conclusion
The above provides health care for almost everyone with very few changes to the existing system. Most people can probably agree about the children, and the ER coverage ought to have been part of whatever bill mandated that ERs take all comers (so you should either support the coverage or oppose the mandate). Encouraging a greater focus on savings and responsible lending should also be acceptable to everyone. I understand the last part is likely contentious, but it really is the best solution for everyone else. The only people whose needs WOULDN’T be met by the above are those with extreme long term illnesses that have an early onset. For these people, the high deductible every year would be a problem, but my hope would be that these people can be addressed through friends, family, charitable organizations, or even government welfare.