A Compromise Health Care Alternative

Here is my idea for an alternative Healthcare plan that could theoretically pass Congress. In other words, a compromise that could theoretically attract support from both parties, if the Republicans could pass a plan that they weren’t unanimous about. And, of course, if Democrats liked the plan enough to support something that Republicans (especially Trump) would take credit for after the GOP spent Obama’s entire term sabotaging the ACA, refusing any compromise, and being colossal dickwads. It’s not single payer (GOP nonstarter), and I’m not saying it’s better than single payer. I can’t say it’s better than the ACA either, except it might be for some, and it’s designed with the same goal of making Healthcare affordable to all.

My compromise is rooted in the idea of providing more options. In short, to give both sides a version of the system they want. Envision two suburban neighbors, Bob and Sue. Bob has a cheapo catastrophic healthcare plan from a national corporation with a very high deductible, but it cannot drop him and it has to cover his kids until age 26. He also has a Healthcare Savings Account to cover at least half of his high deductible. These measures provide him some measure of protection from medical bankruptcy, as long as he’s managing his HSA responsibly. For routine medical needs, however, he pays a concierge practice about $150 a month, which doesn’t bill his insurance, but comes out of his HSA and counts against his deductible. They cover his checkups and routine visits and offer considerable discounts on testing and other services, for which the prices are published in advance. They also have an upgrade option which includes a number of additional specialists including mental health. They don’t cover prescriptions, but Bob can now buy them online more cheaply from reputable Canadian or European pharmacies and still use his HSA. Of course, Bob could also just buy a low deductible private health insurance plan (also from a national corporation) if he’s healthy enough to qualify and can afford the higher monthly costs.

Sue prefers the security of a public option. She pays the government for Healthcare and her monthly fee is determined by her income bracket. All medical services are provided for an affordable co-pay. The government pays medical providers on a salaried basis, not per-procedure, so they have no incentive to recommend unnecessary procedures to some, nor to avoid treating low-income patients out of fear they won’t pay their bill. The size of the program gives the government leverage when negotiating with drug providers, and its negotiations include MediCare, MedicAid, TriCare, and all federal employees. The government reduces costs by consolidating functions across those programs I just mentioned, especially MedicAid which is partly federalized. State spending on MedicAid is sharply reduced, as they have a much smaller role in administering it, and one federal MedicAid program is cheaper than 50 state grants. As for government medical practitioners, they make less annually on average than concierge docs (depending on patient volume) but they don’t have to worry about malpractice suits or paying someone to handle insurance stuff. They can be doctors instead of businessmen, if that’s what they prefer, and still be relatively highly paid.

People like Bob can have problems if they fail to manage their HSA wisely or if his concierge docs try to make up for a temporary shortfall in revenue by recommending tests that are probably unnecessary (“but hey, aren’t you glad we’re now 100% sure it isn’t cancer?”). Some will pay less for more, and some will pay more for less. It’s traditional capitalist medicine, but with fewer administrative costs, and with fewer opportunities for price gouging. And you can always opt out of having to make healthcare decisions based on finances by taking up the public option.

Seeking treatment from any government salaried provider without having any public or private insurance will require immediate enrollment in a public plan for a minimum of one year (MedicAid if eligible or otherwise), but will not require payment upfront. Those who are unable to mentally or physically consent (such as a drug overdoser dropped off at the hospital) will be given the option of being charged full market prices out of pocket or being enrolled in a public plan (including MedicAid if eligible, as above) for a minimum of one year. And enrollment automatically renews unless you cancel it. Non-payment will be applied to your taxes.

Obviously, the biggest loser in this compromise are the drug companies. Perhaps federal grants for pharmaceutical research and development, including cost-reduction research, could alleviate that. And the health insurance industry loses a lot of customers, though some of those include loss leaders. They also get to cross state lines, which is likely good for profits but at the expense of laid off workers.

Layoffs are unfortunate but that’s what happens when you take on an industry that is making big bucks from making people sicker and/or poorer. Taking on big tobacco leads to layoffs. Taking on pollution from coal leads to layoffs. And if you’re looking at this as a Republican, taking on “government spending” leads to… guess what? Layoffs. How to help laid off workers is another topic entirely.

Like I said, not better than single payer, not necessarily better than the ACA, and it would require willingness on the part of Republicans to actually compromise and put forth something compelling enough to get Democrats to forgive 8 years of absolute obstructionist bullshit and risk making Trump more popular. But workable? I think so. I could live with it.

About xstryker

Amateur poll reading enthusiast and blogger living in Wilmington, Delaware.

4 comments on “A Compromise Health Care Alternative

  1. I have to digest this, X. As I was reading I found myself nodding at some of your ideas and then frowning at others – unsure of how they would work.

    I think (and I have more thinking to do!) that your idea leads us to single payer – very clever of you! – but I have a few questions. If I missed your explanation, I apologize. Is health insurance mandated under your plan? I don’t like the mandate, but it is what made covering preexisting conditions possible, so I understood why it was there.

    Wouldn’t younger, healthy people choose Bob’s plan, while older people and those with preexisting conditions go for Sue’s public option? Wouldn’t all roads eventually lead to Sue’s plan? And wouldn’t the public option road turn into the single payer road?

    Okay… going back to read again!

  2. No mandate. It relies on income from premiums and savings from negotiations and streamlining. And obviously I have no way of guaranteeing it’s cost-neutral without research from the CBO. The question is whether or not Republicans still care about the deficit now that they’re in charge, because Trump certainly doesn’t. Private insurers can charge exorbitant rates for new enrollees with pre-existing conditions, but they can’t drop existing customers for getting sick (they can drop entire products or drop for non-payment). My preference would be for them not to be able to force people to a different plan or jack up the rates on individual policyholders (only on all policyholders for a specific plan product), but I’m not sure whether that gains or loses votes. Being able to lock in good rates puts a strong incentive for young healthy people to sign up, which helps lower costs, and if the insurance companies have to keep them onboard after they get sick, eventually they share more of the cost for older, sicker people.

    One could argue that any well-run public option system eventually leads to single payer if you don’t allow conservatives to destroy it. At the current moment in politics, Trump has flirted with a public option, and his grandiose narcissism tramples the logic and ideology of both the left and the right. If Trump thinks the people at his rallies will eat it up, and it lets his web of companies evade paying for employee health insurance, he might go for it, who knows. And if Trump goes for it, only time will tell if congressional republicans will have the fortitude to oppose him.

  3. Thanks for this propsal, xstryker. Is Bob’s option more or less what we had before the ACA, that is, with a wide variety of insurance plans, including point of service (PPO), or is it only concierge plans where you pay a subscription? My feeling is for this to be at all acceptable to Republicans, it would need to allow all types of plans, not only low-premium, high-deductible catastrophic but also the old-fashioned high-premium, low deductible plans (what I think of as the Uncle Dupy plan, like what my dad got under DuPont in the 60s and 70s), where you can go to any doctor and the plan pays according to whatever it has worked out with various providers.
    Sue’s plan sounds like an HMO run by the government, with a potentially narrow network (restricted choice of doctors). On the other hand, if this is a federal plan, then your network could include facilities and doctors across the entire United States. As well, I assume that the federal plan would have benchmarks for quality and covered services similar to ACA’s, with no annual caps or lifetime limits?
    My concern about this idea is that insurance companies will oppose government competition. I think it was the insurance companies who lobbied hard against the public option in the ACA in communities with limited insurance options. It’s a tacit recognition that they can’t compete against government efficiencies and of course the government doesn’t have to siphon off money to pay shareholders.

    My dream scenario is more like Medicare for all, with a basic plan for everyone with a fairly high deductible and the option to buy supplemental insurance that could either reduce co-pays, lower deductibles, expand networks, cover specialty drugs, whatever — depending on how much you’re willing to pay for it. The basic plan would require some participation — either taken from wages, or maybe payable quarterly like self-employment tax, or monthly premiums. Perhaps for very low income people that participation is waived, as it is in Medicaid. (Digression: Imagine combining Medicaid and Medicare and doing away with the stigma — that would already get more people to sign up.)
    I think that there’s room in this for salaried providers — I like that part of your plan, and I think some doctors would be glad to get a salary and not deal with administration and reimbursements. The thing is, if the salary comes with patient quotas, there’s a danger of the clinics turning into patient mills — not enough time per patient, stressed out doctors. Was that part of the problem with VA clinics? Too many patients, not enough doctors? (I’m really asking, I don’t know the details.)
    I also think that doctors should be able to operate as free agents, outside of insurance (while still participating in electronic record sharing). They have to be under supervision of medical boards and all, but I’m curious what a doctor would charge on the free market without having to set prices high because they expect to be negotiated down to 75% or less of their stated rates.When I went without insurance for a while, I was able to negotiate a fee with my doctors that was lower than their usual billed fees because I paid them directly without any insurance paperwork.

    For me the first fix of the ACA is to put Medicaid expansion back in as mandatory for all states, but allow states to experiment with charging premiums to adults above certain income levels. To allow adults to stay on Medicaid, paying premiums, until their incomes were high enough and stable enough to switch over to exchange plans. That would reduce some of the uncertainty and remove the incentive for people on the borderline to keep their income in Medicaid-eligible range (I’ve been there).

    I got off track. It’s interesting to think about it. One day I’ll tell you about my idea for getting young adults to sign on to health insurance without complaining so much. (Hint: works a bit like a pay-as-you-go cell phone plan.)

    • A lot of food for thought there, Paula. I don’t have definitive answers for any of them (aside from agreeing that the insurance companies would be able to sell a variety of products including a more traditional low-deductible employer-subsidized plan). The key thing is to have a starting place that catches the interest of Trump, congressional Republicans, Democrats, and health professionals. Something that gets both sides to the table to work out the details. And I’m not suggesting that Democrats make the first move (or even talk about being open to a watered down replacement) because that would signal that we would roll over for a minimal gesture.
      But Trump has suggested a public option, and if the GOP wants a replacement bill that can muster 60 votes, then they’ll have to put something appealing on the table rather than just blaming Democrats for not climbing aboard their legislative garbage barge.

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