It seems likely that Republicans in the House and Senate are going to have their way with the Affordable Care Act someday soon. Trump, for his part, has expressed interest in keeping the more popular provisions, like children 26-and-under staying on their parents’ insurance and not denying people with pre-existing conditions.
Those are two rules that are likely to survive. The individual mandate, however, is likely not going to. Which is a key part of the system working. It already had a big hole poked in it from the Supreme Court at its inception. Another poke is likely to be a huge undoing.
“Repeal and replace” isn’t likely to happen, either. But people say they want it. They just never say what should be the replacement. Paul Ryan has been leading the way on this “A Better Way” campaign. When it comes to healthcare they’re largely hands-off, saying what they always said, like “buy insurance across state lines”. This won’t fix anything because the operations aren’t transparent enough for consumers to make informed choices. It’s another cozy relationship with Washington that’s going to begat more problems.
So I thought about it. I have routinely said for healthcare to work for Americans you have to pick a “side”. Either full-single-payer or full-free-market. Any mix of the two and you have too many special interests mucking things up. We know what we get with single-payer, and it does have downsides, but it’s easy to understand.
I happen to think a free market system would be more uniquely American and healthier in the long-term. Here’s Hartercare:
First, we’re going to require hospitals, medical providers, and pharmacies publish their prices clearly and consistently for everyone. If Starbucks can put the calorie count on a muffin, you can tell me how much a pill costs. This will give consumers the critical piece they need to make informed decisions on non-emergency care.
Second, we’re going to have a debate about patent reform. The fact hospitals often don’t seem to know how much an MRI costs or how much a drug costs is part-and-parcel with patents. A $30 million piece of equipment costs $30 million because of patents. Patents are important for a lot of things, but healthcare seems to be an area where that profit is more problematic. If transparent pricing doesn’t work, then let’s setup patent reform. This could be government buy-backs of technology, front-loading the research grants (maintaining our status as a research powerhouse), limiting their duration for drugs and life-saving patents, or all the above.
Third, encourage employers to stop granting health benefits at all to their employees. This was always a weird hack from WWII and it needs to stop. No one likes it when their employer issues them a phone or a laptop because it’s usually a crappy one. Health insurance should be about the same. The pool is now “everyone”.
We can ween people off this by slowly reducing tax write-offs and other incentives for employers over a period of 3-5 years.
Protect low-income, the elderly, and everyone else with a universal emergency plan. When your heart stops beating it’s not a time to Google around for price lists. And no matter what kind of private insurance exists on the market, low-income people are likely never going to be able to afford it. If we as a country are going to do something about that, we must have a universal system. I propose a universal emergency plan that covers everyone with basic care, preventative care, and emergency room care. This is paid for through taxation and distributed to everyone.
To supplement that, private insurance carriers, complying with the same rules on transparent and consistent pricing can offer add-on services. We already do this for a bunch of stuff, like supplemental Medicare plans, supplemental deductible coverage, and other benefits like Aflac.
Plus, having preventative care available to everyone saves money in the long-run for everyone. And having a “Basics” system removes all debate over contraceptives, abortions, and other hot-button issues.
Forget state lines, let’s open this up to the world. Insurance carriers and pharmaceutical companies’ cozy relationships with legislators are over. Let’s open competition globally. Drugs in Canada cheaper? Buy ‘em there mail-order. Health insurers in South Korea think they can provide better service to Americans than Anthem? Bring it on. Doctors in Japan want to provide tele-health services to look at grandma’s bunion? Let’s try it.
If Samsung can manufacture dishwashers from Korea and sell them against GE, and Tylenol can be made in Mexico and sold here, so can anything else. We have the systems and incentives in place to ensure people stay no less safe than they are now.
Stop incentives for the wrong things. If you read “Reinventing American Health Care” by Ezekiel Emanuel, one of the architects of the ACA, you’ll discover two important things:
- The Obama administration didn’t know what impact it would have on healthcare. They assumed it would either cut the costs and we’d see a permanent decline, or, we’d take “a big whack” where it went down for a few years and would proceed back up again. Seems we’re on the big whack track.
- Medicaid and particularly Medicare is incredibly distorting to the health system. Hospitals, for example, get more money back on reimbursement rates from the government for the same procedures if they’re in a new hospital. Thus, every hospital in the country is consolidating and merging and building shiny new buildings. Shiny, expensive, buildings. Because the government is mostly paying for the construction through higher reimbursements. Stop. That.
There’s no reason a little bit of profit with some healthy competition can’t be a solution that brings affordable care for everyone. Yes, some people are going to have better care than others. But that’s always been that way and always will be. We’re talking about ways to sustainably build a robust system that can scale to everyone, on demand, and without distorted incentives. These steps would go a long way.
And, there’s always single-payer system, too. Which is what most carriers think we’re moving toward anyway. It’s also what Emanuel points out in his book as one of the Administration’s “That’d be nice” goals anyway.