Republicans are struggling with their attempts to repeal Obamacare because they avoid addressing the fundamental questions about the role of the government in health care. Without defining the principles of what health care policy should do and how it should be executed, every petty issue becomes an obstacle that’s hard to overcome. It is almost like a poorly planned road trip without a defined destination, where at every intersection the bus stops as passengers -- with different ideas of what the destination should be -- cannot agree on which way to turn.
Below, in 19 points I outline what, in my view, that ideal health care policy should be. This list, with brief explanations, is not to convince others that I am right. It is to encourage others to challenge me. My position on these issues is of secondary importance. Please consider my points as opening statements in a sincere and, I hope, productive public debate about what health care policy should be.
Conducting public debates is not easy. Trying to overcome the typical problems of internet-based debating forums, I invented a new format, which can be found at www.virtualagora.net.
Please sign up, post your challenges, answer challenges of others. Also, please volunteer as moderators. Below is a list of my takes on various aspects of the health care issue, which I see as pivotal to reach any reasonable consensus. If, in your view, I missed some issues, please go to www.virtualagora.net and post your challenge.
1. I do not want government involved in my health care at all. As an able-bodied adult, I am convinced that I can afford to pay for my health care, under the condition that other Americans -- those who provide health care and health insurance -- have the freedom to prepare for me products that I am willing to buy. From the government, I expect only protection from bad actors; if someone tries to cheat me on the contracts I signed, I want the government to be an objective arbiter.
2. We should have guaranteed minimum medical care. It means that those who cannot afford or do not want to pay for their health care should have basic medical care that we agree is acceptable, but it should be of such a limited level that those who can afford to pay would not like to have it. With this approach, we do not need an individual mandate.
3. The government should not be focusing on providing health care to poor Americans. It should focus on securing an economic environment so that the prevailing majority of Americans advance economically and can afford to pay for their own health care. Presently, about 20% of Americans are on Medicaid, a government-sponsored health care program intended for the poor. That number should be 10 times smaller. We need health care that the prevailing majority of Americans can afford to pay for.
4. We should openly talk about the role of money in health care. We feel uncomfortable talking about how many dollars our health or life might be worth. We cheat ourselves if we discuss health care policy without openly talking about money. Often, a serious sickness within a family of modest means is a severe financial burden and a cause of bankruptcy. Many private insurance plans, as well as Medicare and Medicaid, do not cover all of the newest treatments or drugs because of their high cost. The rising costs of Medicare are a burden on the federal budget, and the expanding costs of Medicaid drain the coffers of many states. Eventually, we as taxpayers need to pay. In other words, despite not wanting to talk about it, it boils down to money.
5. The financial decision of which medical procedure or medication gives the most benefit for the money spent should be made by the patient under the doctor’s guidance. Currently, insurance companies collect a lot of money from us in high premiums and then pay for some of our medical services. Behind this approach, there is a belief that bureaucrats can better decide than you and your doctor how to best spend your money so that you can get the most benefit for every dollar spent. As a result, patients directly pay only about 11% of all medical costs. Experts estimate that in this system about one-third of all spending is wasted due to artificially high prices and unnecessary medical procedures.
6. We all cannot outsmart the system. In discussions about health care, often I am under the impression that many advocates of broad government regulations tend to believe that this is the way for them to pull from the system more in benefits than they contribute in cash. The truth is sobering: Most of us need to contribute more than we get back so that the very few needing extremely costly care can get it. We cannot be guided by illusions that we will be the ones who outsmart the system and others will pay for our care. Those others will be us because government can have money only when it takes it from us.
7. Prices of medical services should be transparent. This way, a patient, with the advice of his or her doctor, can decide which procedure or medication offers the best value for the money, within a certain budget.
8. Advanced technologies should lead to lower costs of medical services. Everywhere else -- cars, appliances, and cell phones -- with technological progress, prices go down. In the medical field, prices go up much faster than inflation. It is known that many expensive drugs and medical procedures are available abroad at much lower prices. This means that in the Unites States the market mechanisms, which push down prices of our fancy TVs and cell phones, do not work in the medical field. They need to be restored.
9. We have to define what health insurance is. The Affordable Care Act -- also known as Obamacare -- created rules governing health insurance but did not define what health insurance is. Meaningfully, the proposals prepared by Republicans do not do it either. Insurance, by its very definition, can cover only unexpected losses of a catastrophic nature. The law -- as we have now and as it is proposed by the GOP -- puts medical services that are, in fact, health maintenance under the umbrella of health insurance. They include preventive care as well as follow-up care for previously acquired conditions. It is as if our legislators felt so powerful that they could make laws deciding that sometimes 2+2=5, not 4. Nonsense, even if approved by both chambers of Congress and signed into law by the president, it is still just pure nonsense. We need health policy where the economic meaning of the term “insurance” is restored and respected. All medical services that have the character of health maintenance should be treated as such by law.
10. Our health insurance contract should be for the length of our life, not for one year. Our health is our lifelong affair. Yearly contracts make no sense for us but are convenient for accountants at health insurance companies. The basic question is: Should our health insurance contract satisfy our health needs or should it make life easier for accountants at health insurance companies?
11. Our health insurance plan should have a component insuring us against acquiring a health condition that requires ongoing costly care. If we see health insurance as covering our whole life cycle, as outlined above, then it should include protection in case we acquire what has come to be known as preexisting conditions under our current system of short-term insurance coverage.
12. Health Savings Accounts (HSA) should complement our health insurance. Health insurance, by definition, should not cover routine medical services and follow-ups on preexisting conditions. Those can be covered by health maintenance plans, structured in the same way as similar plans some of us have for appliances or cars. In the long run, these plans are not as financially beneficial as cash payments for repairs. Instead of buying health maintenance plans, we should be encouraged to put the same money into Health Savings Accounts (HSAs). HSAs give patients the power of the purse. Most medical services are not urgent situations. By being able to pay cash out of their HSA, patients will be able to consider the best service for the money spent and would be able to shop for the best price for the service needed.
13. People using subsidized health care should have their health insurance and HSA deposits coming from government subsidies or charitable donations. Poor people should have the same rules of accessing health care, giving them dignity and the freedom of making their own choices. As such basic services would be of substandard quality, it would allow charities to upgrade the quality of service in individual cases, when a donor can see the value in helping a particular person in need.
14. Government powers to regulate health care policy should be eliminated. At the time when the United States of America came into existence, the concept of the legislative powers of the government was understood that what was not banned was allowed. At that time, Americans proudly differentiated themselves from European powers where -- more often than not -- the concept of the law was that what was not explicitly permitted was not allowed. Today, in health care, the laws in the United States became what the founders did not want them to be; without government permission, practically nothing is allowed. This needs to be at least acknowledged and publicly discussed.
15. Health insurance should be purchased individually. Please provide me with one good reason why my health insurance should be purchased for me by my employer. It is patronizing. It limits my freedom in my very private matters. In this sense, it is un-American. The only reason for doing it this way is because it has been done this way for decades. It started during WWII as a way to circumvent some wartime government regulations, and spread to become the norm in American society. Employers should focus on exceeding their business objectives so that they can pay their employees more, allowing them to take care of their health matters themselves.
16. We need legal stability in order for any health care policy to function. In the current legal environment, no one will offer life-cycle health risk insurance to, let's say, a 20-year-old person with a guarantee to provide good health care 50 years later, when this person might acquire some illness requiring costly medical care for, let's say, an additional 20 years of that person's life. We need constitutional guarantees that, at their whim, politicians will not be able to change the rules of the game as they please.
17. We have to acknowledge that Medicare is the core culprit of most of our health care problems. Between Medicare, Medicaid, and health care for veterans and government employees at all levels, the government pays almost two-thirds of all of our health care costs. Medicare, being the oldest one and covering an expanding part of our society, is the driving force behind government-controlled prices and access to medical services. All private insurance companies follow the Medicare pricing scheme. Whatever the government’s bureaucrats approve or disapprove for Medicare becomes the industry standard. For this reason, any viable health care policy should have provisions allowing Medicare recipients to buy out of Medicare.
18. Republicans should go back to the health care policy that we had before Obamacare, analyze its shortcomings, and prepare an alternative solution. This is not what they are doing. They take the text of the ACA as the starting point and introduce changes here and there. By doing this, they accept the logic of the Obamacare approach. They sneer at their electorate.
19. If grassroots organizations representing the average citizen cannot agree on a health care policy, one will never be enacted – as politicians have proved they are unable to do it. Let us be blunt: Politicians in Washington do not care about finding and fixing the core problems of our health care system. Their objective is to be reelected. They will not seek to find what the source of our problems is; they will not ask fundamental questions, they will make no effort to educate the voters who might have unrealistic expectations. Instead, they will check the results of opinion polls and vote for whatever their misinformed voters lean toward. If we do not find a solution ourselves, outside the corridors of Washington, no one else will.
Please go to www.virtualagora.net so we can work together on finding a consensus on health care policy by bypassing the dysfunctional politics in Washington.