This article by Kevin Sack in the New York Times provides an excellent description of person-on-the-street reactions that explain why change in health care is hard to do. Note, this is not ideological stuff. It is just normal people's reactions.
The President tried hard from the outset to sell the proposition of providing access, controlling costs, and enabling consumer choice. He decided he had to stay away from terms like rationing and general tax increases. But people understand that you can't give everything to everybody without taking something away from somebody or asking for general sacrifices. As the debate over health care reform continues after the summer, it will be interesting to see how the various plans are modified and explained.
Some people have asked what I would do if I had the magic wand. Here's the simplified list of my major recommendations. My goals would be: Providing access and security to people; covering the costs of that access in a broad-based manner consistent with a national priority; limiting the expansion of uneconomic new technologies; and shifting the payment regime to the part of the health care system best able to control costs in the long run. I have tried to pick ideas that are properly jurisdictional at the national level, only preempting state jurisdiction where necessary for the sake of uniformity.
1) Eliminate the nasty practices of insurance companies by requiring them to take all applicants, eliminating pre-existing condition restrictions, and the like. In essence, provide a preemptive overlay of national regulation of health care insurers above state regulation. This would provide assurance to people that, when they changed insurance providers, they could maintain coverage. Do not create a public insurance plan.
2) Provide subsidies to people, based on income, to enable them to purchase insurance. Under the national regulatory scheme mentioned above, require a spectrum of insurance packages so people could have choice of several levels of coverage, from basic to advanced. Require people to enroll in one. (These provisions are the core of the Massachusetts access model.)
3) Pay for the subsidies by eliminating the current pretax treatment of insurance benefits and applying new taxes in areas that would, themselves, contribute to a healthier population (cigarettes, sugar content, and the like).
4) Create a national standards board that would review new medical diagnostics and therapies and equipment for cost-effectiveness, to supplement the efficacy determinations made by the FDA. Do not prohibit non-cost effective remedies, but make them ineligible for insurance coverage.
5) Revamp the payment system to shift emphasis to primary care providers so that they no longer serve in a mere triage function, but in fact have the time to properly manage a patient's care. Whether this is done by shifting payments within the fee-for-service environment, or moving to capitation, or a combination, would be subject to regulation by each state for the private insurers. For Medicare, the determination would have to be for the country as a whole.
I am not wise enough to judge the political acceptability of this package in Congress, but friends I have talked with so far have indicated that they like the themes. I'm happy to get your comments.
