Universal Health Care:From the Trenches

Universal Health Care: From The Trenches

The following proposal for universal health care was written by Milton Masur, M.D. of Westbury, NY , he will take responses at: blog site

As an internist, in practice for thirty-nine years, I have often pondered the health insurance problems the American people have to deal with. Our ability to provide and receive medical care has been curtailed by unfortunate influences which seem unavoidable: We have been subject to inflated costs, lack of proper access to health care for many people, and sometimes, the greed of insurers, pharmaceutical houses, suppliers, providers and patients.
We are subject to costly medical technology and excessive fractionation of care as we strive to deliver cutting-edge services. We find that funding by insurers often brings with it micro-management and undue political influence.
With all of this, there is the threat of a demanding and fearful public in an atmosphere of litigiousness applied with little restraint. All these have made medical practice difficult for both providers and recipients.
It occurred to me that by opening Medicare as an optional form of insurance to people under age sixty five, we might ameliorate considerably some of these influences. It would also be necessary to mandate public or private health insurance for all citizens to equitably enlarge the overall insurance pool.
Since then I have explored the subject and tried actively to participate in formulating improvements.
The proposals for universal health insurance by the Clinton White House administration provided a weather change but not a climate change. For so many years, people have advocated universal access to no avail. The fairness in such an idea seems to have been accepted by the public, the medical community and both political parties, but we have not formulated an acceptable vehicle.
A glimmer of hope came from an article in the Atlantic Magazine which jointly sponsored a symposium with The Annenberg Center for Public Policy. Two members of the House Health care Committee, conservative Republican James McCrery of Louisiana, and liberal Democrat James McDermott of Washington state, met, along with many other notables in the health care field. There was agreement on some principles, including mandated universal access, community rather than experience insurance rating, an income tax basis for premiums and tax credits for the poor to buy that insurance. Representative McCrery acknowledged that he made these concessions partly out of fear that a single payer system might otherwise evolve.
To insure the uninsured, the present Bush White House administration supports the Senate Health Committee Breaux-Frist proposals. These would allow the general public a wide choice of private insurance plans (as is currently available to Federal employees). However, employers would provide limited and probably lessening premium support with inflation, and costs would increasingly be shifted to the employee.
Many people cannot afford these premiums and will not buy health insurance with lessening financial supports. As has been stated, the financial rope offered is too short to pull many people out of the hole and would not provide universal access.
A government run single payer system should be more economical than one run by the private sector. For example, Medicare administrative costs average 2-3% compared to average private costs of 13% ("Rebuilding Medicare for the Twenty-First Century." http://www.medicare4all.org/report/med1.html/ ). However, the American people often reject and fear government control of their lives, especially if there is no recourse elsewhere.
Both government and private medical insurance can provide good health care insurance, but both can be inappropriately arbitrary, rigid and controlling with consumers and providers caught in the middle.
However, if both private and public are options, we can foster a beneficial competition between these sectors for improved services.
High deductible, medical savings accounts have been in evidence for years in the private sector, and recently, on a limited basis, some were created with a tax exempt status. Money set aside in such a high deductible policy remains in the consumer's hands, possibly to be spent on needed care, but also possibly to be saved and used for other purposes. There is a financial incentive not to seek medical care, especially preventive care. Conceptually, as the late Milton Friedman has endorsed, the support is for catastrophic care, not continuing preventive care.
In addition, the money put into MSA's is siphoned out of the health care system, especially when the consumer is healthy. Insurance by definition requires premiums to remain in the insurance pool to provide for those who need it. The position paper of the American Academy of Family Practitioners (Draft Health Care Proposal http://www.aafp.org/unicov) supports "assurance" of medical care, not just catastrophic insurance, a position which I think is necessary for people's well being.
In the scheme I am endorsing, employer based premiums could be converted to payroll taxes to capture the more than one hundred billion dollars in tax-free premiums and remove the employer control of choice of plans.
This money could be used optionally to buy Medicare or private health insurance which would both be open to people under age sixty-five. Low earners could have subsistence wages free of taxes and receive income tax credits and subsidies, if necessary, sufficient to pay premiums.
Those with greater incomes would pay a greater share of the insurance premium. Those of us who own our own homes benefit from tax deductible interest. Employer supplied health insurance for most of us is also tax deductible. Tax incentives are given to encourage corporate investment. Shouldn't the working poor who can't afford health insurance get something in kind?
Medicare premiums would have to be structured to attract healthy subscribers and expand its economic base. This could be accomplished by competitive premium rating as private insurance does, according to age, sex, and number of family members, geographical region and possibly other factors.
However, there would not be rating on the basis of prior illness and premiums must either be related to income, or government subsidies must be added for lower earners, in order to support uniform premiums.
Medicare currently insures 13% of the population but pays 30% of the health care bill because it insures older, sicker people. Some portion of the 46 million uninsured would opt for Medicare and some for the private sector, but the playing field would be more level once Medicare insured younger, healthier people and expanded its economic base. The people who opt for Medicare would get unlimited choice of physician, and hospital and the benefits of lower administrative costs and competitive premiums. Those who wish to opt for private insurance could do so, if they feel they are getting a better deal. There could be a true competition, with increased choice for the consumer.
A standard, basic but comprehensive policy would have to be offered by all insurance companies. Additional services could be optional at higher premium cost. The standards would be worked out by forming a quasi-utility, essentially a "Health Insurance Commission". There would be governmental and private insurance representatives as well as general public and professional provider representatives, even pharmaceutical and medical supply representatives, deciding what should and should not be included as benefits. This structure could provide information management, oversight and the opportunity for negotiation of relative value scales to aid in the assignment of proportional payments for goods and services as well as insurance premiums.
Here is the opportunity for the public, providers, pharmaceutical houses, medical suppliers and insurers to be represented and formulate policy by negotiation, rather than fiat. Here also is the embodiment of a strong governmental role in a market system to prevent damage from imperfect or inaccurate information to either buyer or seller. This idea has been championed by Nobel Prize winners in economics: Joseph E. Stiglitz, George A. Kirby and Michael Spence.
Because medical needs are huge and the wherewithal is limited, we must find a way to distribute medical care fairly. This means regulation is necessary, but if it is done on a negotiated level, this will be less onerous than compulsion by the purse-string or compulsion by all the traffic will bear.
If everyone in this country has to be insured, than both private and governmental insurance could enlarge to meet the need and benefit from providing expanded services; so could professional providers and hospitals.
I certainly have not addressed all the problems I mentioned in my opening remarks. However, I think that the opportunity to formulate universal health insurance brings with it the opportunity to ameliorate some of these problems: We hear so much about the excess cost of health care in the United States, with too little accomplishment in mortality and morbidity statistics. Part of that is related to exclusion of people from preventive care resources.
However, part of it is due to a remarkable waste of money in the pursuit of defensive medicine and excessive end of life care. Doctors feel compelled to promote the perception that no cost or procedure was spared in the patient's care. This causes a huge expenditure of money, time and effort, as well as demoralization of the medical profession and the public.
There is no question that providers must act reasonably and responsibly, as should the public and the legal profession. But we have to find a way to stop throwing away money uselessly, since we need more money for the legitimate costs of medical care.
We must find ways to adjudicate lawsuits more fairly and expeditiously and at lower cost. One way might be to mandate the testimony of expert witnesses in examinations before trial, rather than only at the trial itself. If both sides are fairly represented in a pre-trial process, we can take some of the coercion out of settlements made to avoid trial altogether. This probably would reduce direct financial and human costs related to adjudication and settlement, and perhaps eventually lessen inappropriate defensive care.
Efforts to reduce legal costs and demoralization of patients and providers should be part of the rejuvenation of our health care system and should be part of the universal health care solution.
I have not addressed the costs of expanding our system to universal access. There is evidence that the money to expand is largely already within the system, but has to be redistributed and used to better purpose. We might need additional money, but at this time in history, we in this country ought to have learned that community needs and ethical values must supersede narrow self interest and greed.
Dr. Karl Menninger termed the lack of purpose or ethical values in a person or society "the sin of anomie". This country is basically ethically and humanely disposed and we must give those ideas substance through proper health care. Universal health care access is a compelling idea. Now is the time to link soft hearts with hard heads to make it a reality.
Summary of Health Insurance Proposal:
1. Medicare as a governmental insurance plan should be optionally available to all citizens under age sixty-five. All citizens in the United States would be mandated by law to buy or have purchased for them basic, comprehensive medical health insurance, either public or private.
2. The premiums of Medicare patients under sixty-five should reflect age, sex, geographical location, number of family members and possibly other factors designed to compete with private insurance. However, prior illness would not be a factor. Income would be factored into the ability to pay for premiums. Private insurance carriers also would not be able to rate on the basis of prior illness and would have to factor ability to pay into premium structure.
3. A Federal Health Insurance Commission would be established with representatives from government and private insurance, the public, professional providers as well as the pharmaceutical and medical supply industries. A basic, comprehensive insurance policy would have to be established and mandated publicly and privately. Additional insured services could be optional at separate cost publicly and privately. Relative value proportions for goods, services and premiums should be established as guide-lines. Both public and private insurance entities would have to adhere to guidelines. The Health Insurance Commission would establish information management and oversight as well as the opportunity to negotiate guide-lines.
4. Premiums for those under age 65 would be collected from payroll taxes, in part made up by converting present employer insurance premiums into payroll taxes, in part by new payroll taxes and in part by tax credits and subsidies for low earners. Employers could no longer choose insurance plans for employees.
5. In order to lessen costly, unnecessary care given primarily to defend against potential law suits, we should streamline the handling of medical malpractice suits, making the process fairer, shorter and less costly financially and emotionally to both plaintiffs and defendants.
Milton Masur, MD