Our healthcare system is in crisis. Not only in crisis, but I believe the current healthcare situation is threatening the American Dream. The traditional idea of the American Dream is if you consistently work hard you will be able to make a better life for yourself and your children. In recent years the costs of health insurance premiums have been increasing in double digit percentages on a yearly basis.
A 2005 survey showed that 80% of people in the United States did not have health insurance at some point during the year. The same is true today, if not worse, and for many of these people their lack of insurance is not because they don’t want it but because they cannot afford it and by not having it they risk losing everything they have worked for. When regular hard working people cannot use the system to get what they need without sacrificing everything else that they’ve worked for, something is wrong. Even with good insurance through your employer it is still quite possible to end up during a catastrophic illness to have to spend down your assets and/or file for bankruptcy in order to finance your illness. This is a threat to the American Dream.
The healthcare crisis is a multifaceted problem with everyone playing a part. Some of these problems stem from the historical accident of WWII, where employers provide insurance and in the process decide what they are willing to cover. This has become a burden on employers and in some ways threatens their ability to compete in the global market. Combined with the fact that not all employers provide insurance, the individual often gets the short end of the stick.
Other problems stem from our litigious society and the cost of malpractice coverage. Too many players in the healthcare business have become far too greedy in the profits that they obtain, including personal injury lawyers, litigious patients, insurance companies, drug companies and even some healthcare providers.
Still further, the number of uninsured patients affects overall rates by causing hospitals to raise their rates to cover the loses they obtain by caring for uninsured patients.
Finally patients as with their other technology seem to want the very best no matter how much it costs, even if something less expensive would do just as well. It seems that the very best medical test or drug is synonymous with the very best TV, or computer.
There is a current movement of groups (ex. Physicians for a National Health Program, Kentucky Single Payer Healthcare, Massachusetts Nurses Assoc. UHCAN, etc) that argue we should have a single payer system like Canada.
While I agree that having everyone covered is vital and the only way to make our healthcare system work, I also believe that a single payer system, administered by the government, will be politically impossible to make happen in the United States. I believe this because it would be such a huge change from our current system that those whom it would significantly affect, would fight it to the bitter end. And I can understand why; it would put insurance companies out of business and put a huge number of people out of work and would have other far reaching affects on the healthcare industry. Additionally, the Canada system has it’s own well known problems and is not very well received by many Americans who don’t like to wait for anything.
I believe that the financing piece of the answer is in a tiered system but not like the one that is traditionally thought of; not like the one in the UK. I would consider the plan I propose to be a three tiered system. My inspiration comes from an article I read a year or two ago in the Courier Journal of Louisville, Kentucky, concerning some ideas of John Edwards and also information I obtained in a medical ethics class at University of Louisville. However, it takes those ideas further. The outline below details my proposed system.
First Tier: Financing
The federal government (or could be done by state governments if nothing done federally) would determine year to year what it has actually cost to pay for healthcare for the previous year for all of its citizens. Based on the previous year a safe estimate would be determined.
This safe estimate would both escrow the amount that it is estimated it will cost for the coming year and would also help recoup shortfalls of previous years.
- As such the amount would go up some years and down others.
- A line item would be added to the tax return and the cost of paying for healthcare would be equally divided among the citizens.
- This amount would vary year to year depending on the actual cost of care
- If citizens are educated as to the fact that what they spend affects this number it may help counteract abuse of the system by patients.
- This money would be collected with taxes just as Social Security is
- Employers may be expected to assist in paying this healthcare tax just as they do with social security if it can be done without significantly affecting their ability to compete in the global marketplace.
- Applications for subsidy could be filed just as with food stamps for those who cannot afford it.
- The government would assess the risk level of each citizen and create blocks of people with the risk burden as equalized as possible between blocks.
- If people are concerned about the government knowing their medical history then private companies separate from the health insurance administration companies could be developed with the sole purpose of assessing the risk of patients.
- The companies would only give a risk level to the government for developing the blocks. The government would not know the actual medical problems of a particular citizen.
- This risk level could be synonymous with credit scores, the difference being that people cannot and should not be sanctioned for their poor health risk score.
- These companies would contract with and be paid by the government.
- The initial administration costs may be significant with this piece but would likely even out over time given the computerized nature of our society.
- The insurance companies likely have much of this information already.
- Families should generally be kept in the same block to keep things simple.
- The health insurance administration companies would submit bids to insure these blocks of people (eg.100,000/10,000 people with a risk ratio of 60% low:30% medium:10% high).
- This would be much like the road construction companies do now to build our roads.
- The sick not just the well would be covered equally thereby spreading the cost between companies and individuals/families.
Second Tier: Administration by Current Private Insurance Companies
Once the insurance companies have contracted to cover a particular block it would be that insurance company’s responsibility to administer the insurance just as they do now but with changes from their current protocols.
Their mission from this point forward is to get and keep their patients/members well in the most cost effective manner possible.
- Cost effectiveness needs to be determined by the evidence of clinical studies and agreed upon by a governing body comprised of healthcare providers and insurance company representatives.
- Initial cost effectiveness standards would be agreed upon by the governing body with future changes based on clinical studies.
- Studies may not be funded or done by those with a conflict of interest.
- Clinically proven, medically necessary care may no longer be denied.
- Government guidelines would be developed so as to prevent abuse of this responsibility.
- Appropriate sanctions would be imposed where abuse is discovered.
- Preventative care is paramount to their mission
- Education will also be paramount
- Education programs would be developed to teach people ways to stay healthy particularly with children where the greatest long term promise exists.
- The insurance companies could even choose to give grant money to school systems that include nutrition/ health education and daily PE as a regular part of their curriculum.
- Education as to the importance of a primary care doctor should also be part of the insurance company’s education plan.
- Education that high tech healthcare while sometimes better isn’t always better, just more expensive.
- Education of the importance of vaccinations not only in childhood but in adulthood as well.
- Their secondary mission is to make reimbursement as easy as possible so as to put the focus of the healthcare providers where it needs to be, on the patients.
- Keeping claims and reimbursement simple will lower administration costs on both the insurance company end and the provider end, thus lowering the cost of healthcare somewhat.
Patient responsibilities:
- Participation in the healthcare system is mandatory
- All citizens must pay in.
- All citizens must be enrolled with an insurance company
- Co-pays would still be charged for office visits and pharmaceuticals
- Sufficient to keep people from abusing the system but not so expensive as to keep people from waiting until they are more expensively ill before they seek care.
- Patients would be expected to have a primary care doctor.
- Patients need to understand that having a trusted relationship with a doctor that knows everything that is going on with them will aid in keeping them healthier long term.
- Yearly check-ups with their primary care doctor would be expected or at least rewarded in some way.
- Check-ups will aid in finding problems early when they are less expensive to treat.
- Ideas regarding transparency of cost such as have been developed by Humana should be utilized so that patients are aware of how their healthcare spending habits affect the system and therefore their budget.
Third Tier: Additional Insurance
Insurance Companies would be able to sell additional insurance to their members for things that are not considered cost effective under the regular plan
- This may include but is not limited to newer higher priced drugs which have an older/cheaper counterpart that has been shown to be just as clinically effective but may have more side effects than the new drug, new treatments that show promise but have not yet been proven to be clinically effective and/or cost effective, alternative medicine treatments that show promise, private rooms, etc.
- There could be multiple levels of coverage to choose from just as with other types of insurance.
- Quality Control - Government would do surveys on an ongoing basis These surveys need to be kept brief to encourage participation. Surveys of patients to assess the insurance company they are with, the primary care doctor they are with (if feasible) and the system in general Do they believe that their insurance company and primary care doctor assist them in getting and staying well? Do they feel they get the care they need? Are they treated in a respectful manner? Is the system in general working? Surveys of healthcare providers to assess the ease of filing claims and the system in general. Is what is considered cost effective care accurate in terms of what they feel will really aid in the treatment of their patients? The results of these surveys will be taken into account when making new contracts with the insurance companies, when comprising the cost effectiveness governing body, and making other changes to the system. This will in theory promote quality care.
- The system should be regularly tweaked to make sure that the overall mission of a healthy population is being served.
- Each year possibly in April (tax time) or maybe October there would be an open enrollment period just as there is with employers now Each citizen/family may do nothing and stay with the insurance company they are with or choose to be put into a pool of people who want to change companies, be reassessed and put into a new block. It is possible that people would have to be put into a new block because of too many changes to the overall risk level of their block even if they want to stay with their current insurance company. This could be done within the insurance company possibly.
- Incentives for insurance companies as well as healthcare providers should be developed for those doing a good job at getting and keeping their patients well and in the most cost effective manner possible.
- EMTALA will be retained in order to cover those who for whatever reason fall through the cracks who may or may not file a tax return. Situations where an accident occurs and the person doesn’t have any identification on them. Illegal aliens who are seriously ill.
While I know that I have not come close in this document to addressing all of the issues that have contributed to our healthcare crisis, I believe it is a beginning. My goal in this system is for everyone to make a small sacrifice for an overall benefit to everyone. There are a lot of details with this system that would have to be ironed out in order to make it work, it is my hope, however, that you agree that this is a system that is a good compromise between those who want a single payer system and the insurance companies who want to use market base solutions to fix our healthcare system. One thing is certain something has to change as our healthcare system is becoming more of a problem every day. Though our choices obviously do make a difference in our health, sometimes poor health is not due to poor choices but just bad luck. The American Dream of a better life should no longer depend on whether we are lucky with our health.
About The Author
My name is Carol. I am a 2nd degree nursing student at University of Louisville and a mother of two. My first bachelors degree is in psychology. I have worked in numerous areas of healthcare over the last twenty years including inpatient psych, drug studies, medical editing, etc. I have personal experience with the difficulties of healthcare finance due to the fact that we cannot currently purchase insurance through an employer and I cannot buy individual insurance due to being rejected by insurance companies for some minor but nevertheless chronic conditions. Additionally my husband is a healthcare provider for whom I did scheduling for several years. As such I have seen first hand and hear about the numerous problems that providers deal with. Revised 5/6/08 Earlier versions should be discarded
