Health Reform; Proposals, Questions, Answers,

Today I ran across two instructive articles on health reform:the first was was in the August 13 New England Journal of Medicine, “Health Care Reform 2009 at healthcareform.nejm.org”; the second was “Comparing the Health Care Proposals,” the New York Times, August 12, 2009.

1) Here are the questions raised in the New England Journal with my answers.

• Can we achieve health care coverage for all Americans?

Not this time around. I may be wrong. Everyone,i.e, all major health care players, it needs to be said, favors coverage for all at affordable prices. The question is: How? At the moment, the message of a center-left president isn't selling in our center-right country. In his town hall meeting today in Belgrade, Montana, President Obama demonized and ravaged private health plans as the devil and goverment reform as the messiah. Polls show the public isn't buying: somewhere between 70% and 90% of Americans covered by private plans are satisfied with their current coverage. Government snake oil, delivered in huge, overwhelming rushed doses to save the nation from global competition, is still being received as snake oil.

• Should we mandate that all citizens have health insurance and that employers cover their employees or pay a penalty?

I don't dismiss this idea. If car insurance is mandated for everyone, why not health care? Countries like the Netherlands and Switzerland have achieved universal coverage with individual mandateA administered through private plans. Why not America? Because Americans resist individual mandates imposed on citizens.

• Should Medicaid be expanded?

Probably. Needs are growing with the recession. But Medicaid is biggest part of most state budgets. States will need federal help to expand coverage without going broke.


• Do we want tighter regulation of the private insurance market?

It depends on who is doing the regulating. Keep in mind costs are escalating faster in Medicare and Medicaid markets than in private markets. Medicare has no cost controls, which is why it is hurtling towards bankruptcy.

• Should a public insurance plan be created to compete with private insurance plans?

No. Reason? No competition. Public plan could charge 30% to 40% lower rates. They have no overhead, can print money to cover losses, and would quickly destroy private plans. •

Is there a role for health insurance exchanges?

Maybe. Exchanges are worth exploring. Individual and small busineses need help, and grouping them in exchanges may help to lower premiums.

• How can we rebuild our dwindling primary care workforce, which be critical to a successful health care system?


I’m dubious this can be done, given the present medical student attitudes and skepticism and the complexity of our health system. Answers include: paying primary care more, forgiving education debt for those choosing primary care or agreeing to serve in underserved areas, rewarding medical home formation, expanding medical schools and primary care residencies, importing more foreign medical graduates, replacing primary care physicians with nurse doctors and nurse practitioners.

• How will we pay for reform?

Alternatives are “soak the rich” or raise taxes for middle class? Both will be necessary under the Obama proposal. Other alternatives – HSAs with high deductibles, and market-based competition are ignored by Obama administration, which is unfortunately because coverage could be expanded at little cost to taxpayers.

• Do we have the will to provide coverage for all while also reining in health costs, which continue to to increase three times as fast as wages?

Probably not, because reining in costs will involve cutting services for the elderly, a potent voting bloc.•

Can we sustain our health care system as the largest single sector of our economy?

Perhaps, if we recognize health care as the single largest employer and a positive economic force in the economy. Health care is a job-producing machine.

• Should we eliminate or modify the tax exemption for employers’ contribution in their employees’ health insurance?

No, because it won’t work politically. This was McCain's proposal, which Obama ridiculed. Americans still trust employers more than government.

• Should we move away from fee for service and instead adopt a salaried model or bundled payments?

Impractical. Besides implies mistrust of doctors, who remain more popular than government.

• Should the Medicare Payment Advisory Commission (MedPAC), be given explicit authority to control health care spending?

No. It ignores a fundamental American cultural trait – distrust of government czars and freedom of individuals to make choices. Americans simply don’t trust Big Brother in the driver’s seat.

• And can we, in the end, have a high-value health care system in which each dollar spend contributes to better health outcomes for patients?

No, one man’s meat in another man’s poison. One person’s health benefit is another person’s needed health salvation. Besides, you cannot judge outcomes on the basis of statistical data in such a personal, emotional, and individualist matter as health care.

So much for one’s man’s opinions. Let's move on.

2) Here is an explanation of an New York Times article,”Comparing the Health Care Proposals, August 12, New York Times. The Times says there are three House committees and two committees in the Senate working out the details of how to overhaul the nation’s health system. And it adds, only the Senate Finance committee is seeking a bipartisan solution; the others are pushing for a Democrat solution, no matter what Republicans say.

The article compares the proposals of the key players; The House, Senate Health Committee, the White House, and Interest Groups on these issues: individual mandates, employer contributions, .subsidies for individuals, tax credits for employers, expanding Medicaid, defining minimal benefits, what it will cost, raising revenues, and cutting benefits. The article does not mention the American people, who are making their voices heard loud and clear in town hall meetings across the land.