When it comes to protecting the environment, I've been called a Democrat. When it comes to protecting the country, I've been called a Republican. When it comes to protecting ourselves from an overreaching government, I've been called a Libertarian. I mention all of this, in the interest of full disclosure, because if we are ever going to begin to solve the immensely complicated problem of health care in this country we are going to have to overcome all of these labels and ideologies and get back to reality.
Before we get into what can be done, first we need to break through a few myths:
1.) The U.S. doesn't have socialized medicine
Medicare and Medicaid account for almost a third of our tax spending on the Federal and State levels (see previous column, Health Carelessness for statistics.) While covering approximately 24% of the population, they amount for almost half of the health care dollars spent in this country. Established to cover the elderly and the poor, Medicare and Medicaid necessarily take the least desirable patients (from an actuarial perspective), leaving the less expensive young and able-bodied to the private sector. In essence we already have socialized medicine, but only for a quarter of the population and operating in one of the least financially expedient ways.
2.) We can never afford to insure the entire population
The U.S. spends over 15% of GDP on health care and yet approximately 14% of the population is uninsured. Most European countries with socialized systems spend between 7-12% of GDP to insure their entire populations. It is true that current Medicare and Medicaid spending are growing faster than our economy and as such are unsustainable. As designed, Medicare and Medicaid take the least economically desirable people thereby ensuring long term financial problems.
3.) Universal health care would create a massive new Federal bureaucracy
We already have a massive federal bureaucracy that administers Medicare and Medicaid. Even so, it is estimated that most HMO's spend 12-15 cents of every dollar in administration costs while Medicare and Medicaid spend less than 5 cents.
In order to solve the health care problem, much of the current system needs to be broken up and reorganized. This means no less than the moth-balling of Medicare and Medicaid, which are unsustainable anyway in favor of a system that can work for everyone. Some basic principles of a new national health care framework can look like this:
1.) National health insurance should compete with the private sector.
Instead of Medicare and Medicaid, we should establish a single government insurance plan that will compete in the marketplace. In order to prevent the current problem that the government insurance only receives the least desirable enrollees, we can pass a law making it illegal for insurances to "skim." By mandating that insurance companies must take anyone who wants to enroll we'll be eliminating the disadvantage that government insurance currently faces. Consumers would then be able to choose between government insurance and private insurance, and competition will ensure that the highest quality of care is being offered so as not to lose membership.
2.) Keep employer funding of health care.
Most health insurance in the U.S. is currently provided by employers to their employees. While many people are unhappy with their health coverage, some people are not. Employees should have the option of sticking with their company's plan or opting for the national system. Some companies have recently been gaining competitive advantage by hiring part time workers and not paying them benefits. Congress should pass a law similar to the "pay or play" proposals being offered in some states. The playing field needs to be leveled so that the burden of health care is borne by the entire economy and not by part. In this way companies who are happy with their health insurance can choose to keep things as is, while being offered a government sanctioned alternative. Companies who choose not to offer health insurance will "pay in" to the government insurance who will then cover their employees. The unemployed will be covered by the government insurance by default through the current tax system. No longer will we have so many "health care" bankruptcies that people are forced into so that they can qualify for Medicaid by losing everything they have.
3.) Keep health care providers private.
The U.S. health care network is, in many ways, the envy of the world. We have some of the best hospitals and some of the best doctors. Nothing should be done to jeopardize the quality of care. The government health insurance will be more insurance, less HMO. Furthermore, people will always have the option of paying more to receive care outside of the system, just as they do now.
4.) Tort reform - Reign in the lawyers
Besides huge administrative expenses, one of the biggest problems with our health care system is the massive cost of litigation. Laws must be passed to shield doctors and hospitals in what is, at best, the inexact science of medicine. Too many doctors' choices are influenced by a fear of lawsuits and not by good medicine. Removing some of that fear will not only bring down costs but allow for universal information systems and other good ideas that don't see the light of day in today's lawsuit crazed environment.
5.) Emergency Care
Some of the most expensive care offered by hospitals is care in the emergency room. Under our current system, emergency rooms are prohibited by law from turning patients away. With a national health insurance we can change that so that emergency rooms can take in those with insurance (which will be the vast majority since all will be covered in some way). In order to deal with the small number who are not covered (illegal immigrants, foreign uninsured, etc.) we can certify "authorized clinics" that can receive these patients at a fraction of the cost of our emergency rooms, thus lowering overall costs and significantly decreasing emergency wait times.
It can be possible to provide Universal Health Insurance to all Americans. Doing so, however, would require breaking through some sacred myths and cherished programs. Unfortunately most people when offered the possibility of change and uncertainty opt instead for continuity despite the problems. As Clinton's failed health initiative proved, it will be impossible to enact such a sweeping change in our system of government without very strong bi-partisan support. Health reform cannot be a pet project of one party or it is doomed to failure. Only together can we break through the entrenched bureaucracy and create a better system for all of us.