Health Care, 10 Ideas

Health Care needs to be fixed; it’s a case of how and how much. It appears likely that the Supremes will gut ObamaCare and if they do we need a new fix.

20 years ago there were 256 mandates to insurance companies in terms of mandatory coverage conditions, today it is over 2,000 and will grow under ObamaCare. These mandates ignore age, condition and health status. The motivation was understandable as insurance companies were playing coverage games and there were clear cases of abuse. However, in the effort to justifiably protect some, these mandates accelerated costs for all. If you’re a 20 year old athlete in great health you are protected from a wide variety of circumstances that will, likely, not impact you for decades, if ever.

The question also looms: is there an appropriate role for government to play in health care? Yes there is!

The math? The most frequently quoted number is that 46 million Americans don’t have health care. 12 million of those 46 million are not Americans which leaves us with 34 million. Of the remaining 34 million between ages 18 and 65, 17 million had enough income to purchase health insurance if they chose according to a study by Barach College. That leaves 17 million uninsured. Of that remaining 17 million some uninsured were uninsured only temporarily, again according to Baruch College. So by any margin of error adjustment you might apply, over 90% of Americans are, in fact insured or specifically choose not to be.

We have, to some degree, universal coverage as hospitals are not allowed to refuse initial treatments regardless of insurance status.

Government run health care already exists in four high profile programs, Medicare, Medicaid the Veterans Administration and the Native American Health Service. Medicare and Medicaid have massive unfunded liabilities and the VA and the NAHS are abysmal failures.

So instead of jumping off the financial cliff let’s take a swipe at actual reform.

1. Mandate the guarantee of progressive coverage: as you age and your needs change the ability to adapt and convert coverage will reduce overall costs and provide guaranteed options. If you’re 20 and in good health you should be able to opt for a program that covers preventative intervention and catastrophic events, not the 2,000 conditions that will likely not affect you. As needs change so should coverage options.

2. Allow for a new definition of what constitutes a group. Small business especially start ups have encountered the “group” issue; the requirement to insure a minimum number of employees before qualifying for group rates. You’ve also faced the average age issue and limited choices based on employee population size and demographics. Vast numbers of small business cannot get over the “group” requirements. Mandate the recognition of new types of groups that will allow small business to participate at a reasonable cost; Chambers of Commerce, Trade Associations and groupings of similar type businesses with similar employee populations. Most small business can afford some coverage for their employees they simply cannot afford it outside of “group” rates.

3. Eliminate COBRA as it is currently structured. COBRA is a well intentioned idea that simply does not work for anyone without significant income or resources. The average increase in costs for health coverage under COBRA is 200%-300%. Your $400 a month contribution to your company provided coverage will result in $1,200 – $1,500 per month cost to maintain your plan under COBRA. COBRA is your option to maintain coverage if you lose your job. Following the logic, the loss of a job typically eliminates COBRA as an affordable option. COBRA should be transformed to a pooled national group allowing unemployed individuals to maintain basic health coverage at their prior contribution levels. Temporary government money to support what was the employer’s contribution would be an acceptable cost without the need for massive bureaucratic intervention. Employers would also be given the option to maintain their contribution and receive tax incentives for doing so simplifying the process.

4. Eliminate state based restrictions on insurance plan competition. Allow for national competition. Competition has always been the surest way to reduce costs to consumers. If a business in Florida can get the exact same plan in Nebraska, from the same company that offers the plan in both states but at a 45% discount, why not? That approach will actually reduce costs and expand the pool of covered employees. That idea will also tend to balance costs based on larger pools of participants. This option will require the states to agree to base line national standards for oversight and coverage options.

5. Allow surcharges for risky behavior. For instance, smokers pay more after a year of their plan being in place if they do not quit. Same for obesity, drug use, sky diving, mountain climbing, bungee jumping etc. If I smoke and don’t make the choice to quit I should pay more for insurance, my behavior should not be a drain on the entire insurance pool. We have already accepted the idea that life and liability insurance coverage considers risk, perhaps health coverage should as well, within rational boundaries.

6. Eliminate a vast majority of mandatory coverage requirements and allow a tiered system appropriate to age, condition and family size. Institute the requirement for clear guidance from insurance companies as to exactly what is covered under each option, and associated costs. This requirement should be executed at an eighth grade reading level, no fine print and no games. Take the social engineering out of health insurance coverage.

7. A large majority of Health Care costs are concentrated on early and late life. Create a privately managed, government supported insurance plan that supplements typical insurance plans and is focused on catastrophic health events, early life crisis and terminal care. Require all insurance companies to participate in funding a trust based on their number of subscribers, with government support for expense beyond the trust. Universal Health Care as currently structured demands rationing. It sounds rational, the pure numbers support rationing…………. until it’s your parent, wife, husband or child that is being denied care based on some decision being made somewhere by someone you don’t have access to.

8. Malpractice; There are in fact two forms of malpractice but only one carries a legal jeopardy. The first is obvious and a significant part of the current health care cost equation. There are clearly cases of medical malpractice albeit they are a very small percentage when compared to the number of individuals receiving care. The medical industry engages in massive spending associated with covering their legal liabilities. Two significant issues should be addressed. One, apply the “reasonable care” provisions that apply to all other types of liability to the medical industry. If two tests represent “reasonable care” in assisting with a diagnosis, Doctors should not feel the need to insist that six be performed so that potential liability can be eliminated. If you want six tests you’re going to have to pay for the extra four. The costs associated with physicians generating tests based on fear of legal jeopardy are massive. Two, reasonable standards that limit liability in the most commonly litigated situations would serve to limit costs both medically and legally. The second level of malpractice is more subtle and perhaps more costly and dangerous. When faced with complex medical situations you had better know enough to ask exactly the right questions. Short of asking exactly the right questions your physician will likely not volunteer information beyond the scope of your question, again for fear of liabilities. In other words you need to know a substantial portion of the truth to get the truth. If that sounds crazy it is. It is also expensive.

9. Elevate the status of and legal protections for medical personnel who are not physicians. Nurses, midwives and terminal care providers are among the most impressive individuals in the health care industry and capable of more involvement in the medical process at far less cost. Sergeants run the Army, nurses run the health care industry. We might want to consider recognizing the reality.

10. Preventive medicine and personal responsibility; it is easily agreed that preventative care is a significant path to cost reduction. Make scheduled preventative check ups a condition for continued insurance coverage. Make them extensive, we have incredible diagnostic technologies available, they could have a dramatic impact on ongoing costs related to reactionary versus preventative care. A government sponsored capital purchase program to get the technology out there and widely used, will reduce costs as well as patient pain and suffering. Motivate the provision of supportive services for weight management, smoking, drug use and alcohol abuse as a key component of all insurance coverage; that will reduce costs.

There are common sense, real world steps that can be taken to facilitate cost reductions and increase the number of insured Americans. They should be fully engaged in advance of another failed entitlement program. More Medicare and Medicade style corruption and inefficiency is not the answer.

We should pursue these types of ideas in the interest of real reform. We simply do not need a 15 ton fire truck to douse a campfire.

  • D.D.Mao


    You stated “The question also looms:Is there an appropiate role for government to play in health care? Yes there is.”

    Besides Medicare,Medicaid,Veterans Administration and the Native American Health Service the only mention I see of government involvement is in number 10 Preventive Medicine.A majority of the reforms you mention would basically be legislation changes of the state regulation nature wouldn’t they? Which we should KEEP IN MIND that most hospitals,doctors, and nurses are licensed by the state and not the federal government.The V.A.hospitals,Native American programs,and of course members of the military and their families being the exception.

    In item number 8 while generating test to cover the fear of legal jeopardy is probably a strong cause I’m sure they could also be accused of padding the bill which is covered by a health plan.When payed by a health plan the doctors feel the individual doesn’t feel the extra cost and as you stated the solution would be when two test are adequate if you want additional test then it comes out of your pocket.

    I know you and I are close in age and as a point of disclosure I am eligible for Medicare in November.

  • DD,

    I’ve still got a few years to go for Medicare and it would be nice if its still there since I’ve been paying for it for a long time. Most of my suggestions would require some form of government action, would it not be refreshing if legislation actually removed barriers and regulation instead of creating more?

  • Babs

    Hmmm, interesting, Landreaux. I work in the Health care industry as a CPC (certificed professional coder). You need to consider what constitutes “medical necessity” in caring for patients. If the diagnostic tests you’re referring to are not considered by the standard bearer of the industry – CMS – then providers cannot be reimbursed for those services.

    So let’s revisit this subject – no, it’s not the nurses who drive healthcare, it is still the government (CMS) who dictates what is acceptable of unacceptable for reimbursement. And if you can’t get reimbursed for it, take a guess at how many providers will “provide” the service.

  • Babs,

    Point taken, what I meant by nurses driving the process is the exceptional people and the exceptional care they provide. I don’t remember too many of my doctors names along the way but I still remember the name of the nurse that took care of my wife and I at the birth of our first child. It was intended to focus on who ACTUALLY delivers a significant portion of person to person care.

    The tests I refer to are those that are strictly focused on limiting liability as opposed to diagnostic necissity. Diagnostic necissity should prevail but will not until a change in the liability exposure is reformed.

  • Babs

    I’m not sure I understand you – what are tests that are strictly focused on limiting liability as opposed to diagnostic necessity? What does that mean? Medical necessity and diagnostic necessity – as you’re using it – are one and same tool. And what is “liability exposure”?

    I’d love to get into a real in depth discussion on exactly what is happening today, but I’m not sure where you’re coming from.

  • I am going to guess and say that Landreaux is referring to tests that physician order as a means to prevent them from getting sued, rather than ordering tests that they feel are needed.

    Example: People commonly come into the hospital with a complaint of abdominal pain. Even when there are no other relevant signs or symptoms, many of these people end up having a whole slew of diagnostic tests when the actual problem is likely only gastritis related to alcoholism or poor dietary choices.

    X-Rays (KUB)
    CT’s of Abdomen and Pelvis
    Endoscopy, Colonoscopy
    Perhaps even ERCP

    Desperately trying to find a problem that does not exist. We get those types of patients in frequently. You know; the frequent flyer patients who get tests done simply so it looks like the physician actually worked up the patient before discharging them with a prescription for protonix.

    Another example that we talk about lately are those patients who get admitted to the hospital simply because the E.D. physician is afraid to turn the patient away (knowing they don’t need to be admitted). Then the new “Hospitalist Physicians” we are using now, sees the patient and promptly discharges them….wasting time and money on a patient who didn’t need to be there.

    Is that the sort of thing you were intending to speak of Landreaux?

  • Landreaux


    Yes generally it was. But, based on personal experience, the reluctance for a physician to tell you the full story is also a major consideration for me. If you’re not knowledgable enough to ask the right questions, especially in an end of life situation, physicians will approve all manner of extreme treatments to occur based on the demands of loved ones even in the sure knowledge that it either won’t help or could even make other symptoms and conditions worse. All because you did not ‘hit’ the right question.

  • Babs

    Well, Kendale, first of all a patient admitted for observation or “obs” can only stay 24-48 hours without a determining diagnosis. What both of you may not know are the rules on reimbursement for such an admission – it’s restrictive and lower. And that’s what drives the financial problems of the healthcare system. Even the tests you refer to, Kendale, are driven by “allowable” vs. “noncovered” by any insurance company including your government healthcare programs. Sure, any manner of tests and procedures can be done – but if they don’t fall under the CMS and CCI edits for that particular diagnosis, they will not get payed for them.

    Landreaux, I agree with you on the integrity of healthcare providers. They’re like any other profession – good ones and bad ones. Some forget “Do no harm”. But they are also usually the ones you see looking for partners to ehlp pay the bills or closing their offices and becoming Hospitalists only. Because all of those tests and extreme treatments that are not “medically necessary”? Guess what, you do them for free – no payment.


  • Gen

    I love the 10th idea, personal responsibility is a must. Of course, its our own body to deal with. So, I guess its not questionable for being a responsibility.

    Gen from baignoire douche 2 en 1