There’s no question that the health care system in the United States needs to be changed in several fundamental ways. However, the political debate surrounds what specific changes to make and how to go about making those changes. Complicating the issue further is an underlying question that has framed American political discussions since the founding of our country: What is the role of the government in society? Some people think that government should be involved and others think that government should not be involved. With respect to health care, the language of the debate is largely useless, because the government is already largely involved. As I see it, the question now is not whether the government should be involved; instead, it is to what extent should the government be involved.
According to Barack Obama, in his August 16th Op-Ed in the New York Times, there are four objectives of his reform proposal.
1) Insure the uninsured
2) Cut costs through eliminating inefficiencies in Medicare and unwarranted subsidies to insurance companies
3) Make sure more tax dollars go directly towards care, rather than to insurance companies
4) Provide American health consumers with protection by regulating insurance companies
However, one of the ways that Harry Reid's bill, passed in the Senate, would eliminate inefficiencies in Medicare would be to set up an independent Medicare advisory panel of unelected members. According to Senator Tom Coburn (also an M.D.) in his Op-Ed in the WSJ on December 16th, however, this panel would have the explicit authority to deny treatment based on cost. He additionally points out that "Medicare refuses claims at twice the rate of the largest private insurers," and that this is already a form of rationing, in that some doctors "restrict access to Medicaid patients, and therefore ration care." He ends with a story about one of his patients who, had Coburn been unable to do an uncommon test due to government restrictions, would likely have died ten years earlier from cancer.
It seems to me that insurance companies must have the same sort of advisory panels, without a doubt. And if its not to specifically deny payment for a particular treatment, then it may be to pay less for one treatment compared to another. Because I know that "rationing" is already happening in our current system, arguments like Coburn's make me think that the insurance system is beyond reform and that a single-payer system would be much simpler, although I haven't done extensive research on which system is actually better.
The insurance system itself and having to pay for health care raises questions about how doctors should should make treatment decisions. Should doctors practice as if insurance/cost was not an issue, in efforts to deliver the highest level of care to every patient? Or should doctors tailor the level and quality of careto the insurance/financial situation of each patient?
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Scott Gottlieb's WSJ Op-Ed on December 23rd points out a serious problem with the Senate health carelegislation, namely that it exempts Medicare from judicial review. This would take away the right of patients to sue the government. In his words "patients won't have the ability to appeal any of the decisions of this new Medicare Commission." Indubitably seen as an efficiency-gaining measure, it seems to me that this cuts down the checks and balances system of government at its knees. He next points out that increased regulation ironically requires insurance companies to "comply with new patient appeals rights. The government has exempted itself from the same sort of protections."
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As I've been thinking about this issue, I've thought of a few alternatives to the legislation currently on the table. I absolutely agree that Medicare needs reform and that insurance companies need regulation. I don't think it is the solution to require health insurance purchase and to bar companies from not covering people with pre-existing conditions. That seems like it would drive up costs, as the companies risk-pool increases. Also, people will pay the tax penalty and then buy coverage when they get sick, only to drop it once they are well. One needs to look at Massachusetts to see what would happen, which has the highest average premiums in the nation as of 2008 (LA Times).
However, what if we kept the most essential components of Medicare and insurance company reform, and additionally established grants that set up more free/reduced-cost clinics and created tax-incentive programs for more people to buy insurance? We could also use the tax on so-called "Cadillac" insurance plans to pay for programs for those with pre-existing conditions, etc.
