The current system we have now is imperfect and it needs fixing but overall it is an effective system. I think most people out there will agree with this last statement. According to many polls, Americans are overall happy with their health care plans. As I see it there are a few issues that need to be remediated.
1) End the discount system- Our current system is a discount for services system. Every year I get a CD from Medicare with all the codes on it that tell me what it will pay for every service I will offer. Private insurance is usually somewhat higher on what it will pay us for the same codes. What we have to do is set our fees higher than that so that we will get the best possible reimbursement. For example, if Medicare will pay me $70 for the procedure, I will have to set my fee at $100 so that I can get $70. If I charge $70 for that procedure, they will pay me $50 for that same procedure. So as you might see, Medicare artificially elevates medical fees charged to patients by being a discount system.
2) Portablity- People change jobs, careers, locations etc more than ever now. Insurance benefits need to be able to transfer between insurance companies without a loss of benefits. Within this is the concept of competition. Another reason we need portability is it will allow for more competition between insurance companies. An example, my company is with ABC insurance for three years and have just decided to raise my rates for the third time. So, I decide to shop my companies health insurance. I find that XYZ insurance will save my company significant money without loss of benefits. So, if I am smart I will move my companies insurance. Now if ABC knows that XYZ is out trying to get my business, don't you think that ABC might not want to increase me this year in order to maintain my business? This is competition and this is a good thing.
3) Pre-existing conditions- We have to eliminate pre-existing conditions from our vocabulary. Medical insurance should cover any legitimate condition.
4) Care for the uninsured- There are far too many uninsured out there for a variety of reasons. I do think by eliminating Pre-existing conditions and improving portability, many more would be insured. However, what about those who are not working, don't want to work or kids who need medical care? I hope to address this below.
So far all I have done is to state the most obvious problems with out any answers...so here it comes...my concept of what healthcare should be like in the near future.
MY HEALTHCARE PLAN
There are systems already in place that can be the basis for healthcare without the government being involved or taxing us further. Health insurance should take care of major catastrophes and preventative care first and foremost.
The system that I prefer is a high deductible healthcare plan with a health savings account (HSA). The deductible can be determined by the family income. For example, people who make 50K or below we limit to a $1000 deductible; those who make 75K, $2000 deductible; those who make $150k might have a $5000 deductible. OF course the premiums for high deductible insurance are much lower than most plans now offered. Add on top of this a Health Savings Account-each month you can take pre-tax dollars and put aside money to cover your deductible costs to the limit of your family deductible. For healthy families, once you reach the maximum, you do not need to add money into the system unless you use some. Ultimately, the money belongs to you and not the government or an insurance company, you control it as long as it is used for a medical cost. Furthermore, your company can choose to match part of your contribution to this HSA. What needs to be added to the current system is portability and elimination of the pre-existing condition clause. This could cover the largest percentage of the population.
The un or under-insured: There have been several proposals that have been put out- the government option, expansion of medicare and expansion of medicaid. These government options are all fatally flawed as those systems already have significant financial limitations-especially in the current economy and would end up taxing all (don't believe when they say they will tax just the rich--the middle class will probably get it the worst). The other problem that exists is that there just aren't enough primary care physicians out there to serve the people we would have to put in this system. So any proposed system will have to fix the problem of too few physicians at the same time that it provides cost-effective care.
A system that can work is a system modeled not after medicaid or medicare but instead the Veterans Administration (VA). OK, pick yourself off the floor, its not that simple--but it does have some things within that system that are very useable. I am not advocating expansion of the VA system but instead another system similar to the VA that can be run privately if we so choose (and I would personally choose a private system).
So here are the things within the VA system that can be effective:
1) Community health clinics: They have clinics set up throughout the country to serve the needs of the veterans. In a new system, community clinics can be set up to serve the needs of the un-insured/under-insured. The current problems with the community health clinics in the VA are that people have to travel to them and sometimes they have to be triaged for care. Truthfully, "free" health care" should not be an easy thing or everyone would want it. We need to make it somewhat difficult but not impossible to access the care so that people will strive for getting out of this system and into the HSA based system. A triage based system makes the most sense for community health clinics.
2) Many of the doctors currently in the VA come out of school in significant debt...oftentimes that is why they choose a setting like a VA. The VA has programs that will pay off the student loan debt in place. So, this would solve a few problems...most docs choose to specialize so they can make more income so they can pay off their high debt loans (at least initially). So, why can't we put together a similar plan for doctors coming out of school to pay off their student loans for at least 5 years of service in this system. They would also receive a reasonable compensation on a similar level to what VA docs make for that time of service. This will also allow many more docs to go into primary care because they won't have to worry about their long term student loan debt.
3) Who could run this: There are many models of clinics out there that are privately run that can run a system similar to this...they can be hospital based community clinics, insurance company based clinics, private company based clinics that can be part of this system. My last choice would be the government but this is possible too (although they haven't proven to me that they can run anything effectively- See- post office, amtrack etc.).
4) How can it be paid for? This is the most difficult part. But these clinics can be run at low cost due to economies of scale and can be supplemented by government, religious organizations, charitable organizations etc to keep the costs down and so that it doesn't significantly effect our economy. This part requires people much smarter economic people than myself to figure out...but it can be done...cost effectively and provide the care that is needed so much.
Ok here is a general model for the future of medical care...it too is not perfect but I think it is a lot better than anything being proposed in Washington. I open it up to debate...maybe someone out there will be able to take some of these ideas and run with it.
Thanks for listening...my best as always,
Charles Shidlofsky, O.D.
