A clean slate for healthcare: starting over

Great Debates
1

As I watch the debacle called healthcare.gov, I find myself wishing that we could somehow just wipe the slate clean with regard to health care, and start over from scratch. It isn’t enough to repeal Obamacare, although that would be a good start. Large parts of the system were broken before then.

I hereby propose the following steps:

  1. Repeal Obamacare.

  2. Repeal HIPAA.

  3. Repeal COBRA.

  4. Outlaw all employer/company-related health insurance. Get employers out of the business of having anything at all to do with health insurance.

  5. From henceforth, every person living in a given state, regardless of their age, sex, marital status, etc., will automatically be part of that state’s insurance pool. The only exceptions will be people in the military, veterans, and people in federal prisons.

This is not to say that everybody else will automatically get insurance–that decision will be left up to each state. Everybody will simply be part of their state’s insurance pool, regardless of how that pool is treated.

A person moving to a new state shall have the option to be covered by their old state for 30 days. After that, they are automatically moved over to their new state’s insurance pool. This includes out-of-state college students.

A state with fewer than 2 million residents shall have the option of creating a joint insurance pool with any other state with fewer than 2 million residents.

There will be no more employer-sponsored health insurance plans of any sort. There will be no more privately-arranged insurance pools. The only insurance pools will be entire states.

Each state shall have absolute control over the details of its health insurance marketplace. If Vermont wants a single-payer plan, that’s fine, but nobody can force that on any other state. If a state wants to make health insurance optional, that’s up to them.

2

What if I am travelling, and need care in another state?

3

Are we also repealing EMTALA, while we are at it?

4

No. Extend the same tax deductions granted to employer-sponsored health insurance to health insurance bought on your own. Going one step further and banning health insurance as a fringe benefit would be excessive. Banning all private health insurance is insane.

5

Why is the Single payer option for the whole effing country so absurd? I mean other than Americans are ignorant and stubborn that is.

6

–Reminder that some of the state exchanges, including their websites, are doing just fine.–

In other words we’re back where we started, if not worse. What problem has been solved?

7

Good point, and one that I hadn’t thought of. Since my plan would put health care completely under state control, I suppose that the “full faith and credit” clause might apply. I’m not sure of the details, however.

Wikipedia says that it’s part of COBRA, so yes. The idea is to radically re-design the whole health care system from the ground up.

I never hinted at banning private health insurance. My plan would simply ban private health insurance pools, which is another matter all together.
If a state wanted to get out of Medicare and Medicaid entirely, and turn the whole thing over to private companies, that would be perfectly fine under my plan.

What part of “clean slate” do you not understand? You have to tear down before you can rebuild.

If you bought an old, rickety house, would you rather spend a great deal of time and money doing very extensive repairs, or would you prefer to tear it down and get a new house for possibly the same amount of money and certainly far less aggravation?

8

How do you determine when someone has moved to a new state?

What if I take a 31-day vacation to another state. Do I somehow now have to research what kind of health insurance is offered just to travel from state to state? That seems awful.

9

Leave it up to one of the parties in today’s government, and that’s where the “reform” would be considered complete.

10

The central problem is that we care about how healthy people are. Even if they are stupid, or lazy. We don’t want them to die of gangrene from complications of diabetes. We don’t want them to die from tuberculosis.

In a perfectly free market, such people will probably buy health insurance. Unfortunately, health insurance is an incredibly complicated product. It is more complicated than buying a house. And for a big percentage of the population, it is too complicated for them.

And even if the market for insurance worked perfectly, insurance isn’t a perfect match for health care. The most obvious example is people with pre-existing conditions, who lose their insurance for one reason or another. The insurable event has happened, but they still need care. Which gets us back to the central problem.

So your options are either a highly-regulated insurance market (which is Obamacare, and you pretty much end up with the basics of Obamacare no matter what policy principles you start with if you want to cover everyone) or government-run insurance and/or healthcare.

We’re America, so we chose highly-regulated private insurance.

But don’t get it twisted. The number of decisions to get us to that point are actually not that many: you decide that we care about how healthy people are (including people with chronic conditions), and you decide that you don’t want government paying for or providing care for middle class sick folks. That’s pretty much all you need to get something very much like Obamacare.

11

You’re tearing down everything and it seems to me that you might end up with even more uninsured people than we have now. What is being built for them in this scenario?

12

I ask why we are going to insure people at all. Why the focus on artificially propping up the industry of administration of health insurance on the backs of Americans?

I counter with the following proposal:

Medical Care: Medical care is directly paid for by the government. Medical care is expanded to include Dental, Eye Care, and Chiropractic/Massage care (last bit is as-prescribed).

Prescription coverage: Prescriptions are all paid out of pocket. Additionally, no prescription may cost more than $150 per 90 days supply (or $50 for 30 day supply). If you have to charge some insane number (like $3,000) per dose, your medication isn’t worth it in a cost:benefit analysis.

Cost controls: Doctors will be put on a direct salary from the government and all practitioners at each segment will get a certain pay scale, adjusted for local cost of living. (Example: $100,000 a year as a PCP base, modified up but not down for cost of living where they are practicing). Education may be directly subsidized for certain areas to help control supply (e.g. our looming PCP shortage. Offer to pay 50% of med school costs for anyone who is a PCP for 15 years after exiting school.) All costs of the doctor visits are applied against the doctors’ costs, coupled with support costs to rationalize the expense of having the doctor there.

So, if a doctor’s visit is considered $150 and the doctor’s support costs are $250,000 a year (his salary, building, equipment, etc), then he will be publicly graded yearly, based on taking the 1,667 patients required to “pay” for his practice each year. Example is simplistic and used for illustration only.

Actions against doctors based on these metrics (Which should also include malpractice claims, malpractice determinations) will be done at the county level. If a county wants to eject poorly performing doctors, that is their perogative and should not be centrally managed.

Performance controls: All malpractice claims will be investigated. A “malpractice board” will be setup at 1 per 10,000,000 people of population, not to fall below 1 board per state. The board will contain two local politicians from each service area (each segment of 10,000,000 people) duly elected by that area to serve on the board, two local administrating doctors, and three lay persons, randomly selected by a jury-pool-like system to serve for 2 weeks at a stretch (notified 3 months in advance and paid at their normal pay rate but tax free plus expenses related to the boards business and employers cannot negatively impact the employee for serving).

“Costs”, being absorbed by the taxpapers, will be regulated by a central authority in each state that is to compare the cost of all facilities, equipment (with appropriate life and replacement schedules), consumables, personnel needs and etc factored into the “cost of service.” This will be used as the metric by which paid doctors and support staff are graded against.

Taxing: If we assume that we are spending too much per-capita for health care, then if we take the 2nd, 3rd, and 4th spots of per-capita spending (in 2010) and average them, we get a target of $5,238 per person as our target, which translates to $1.6 T. To raise this funding, we would roll the roughly $1T in spending from medicare and medicaid and raise all federal income tax brackets (personal, business, and capital gains) by ~2.5% to make up the other 600B.
Yes, it’s single payer. But if we do it right, we won’t have the bull crap we are putting up with, now.

13

I’m not sure what problem this is suppose to solve. But whatever it is, couldn’t it just as well be done by itself, rather than at the same time all these other controversial changes are going on?

If the US is going to move to a mixed jury, don’t limit it to medical malpractice. But I have no problem with starting there.

Personally, I do think there is a medical malpractice problem in terms of defensive medicine. My modest proposal is that in each metropolitan area, a few hospitals should be allowed to set up no-malpractice HMO’s. In return for giving up my right to sue, by using the HMO hospital for all my non-emergency care, I would, I think, get friendlier and cheaper care in a open atmosphere where docs admitted to, and then learned from, their mistakes.

There would have to be some financial adjustment for the poor so they didn’t feel monetarily forced to give up their right to sue.

14

Do what Taiwan did, have a bunch of the brightest leaders in the field redesign your health care system from scratch. It would likely include things like

Comparative effectiveness built into the system
Heavy regulation along all lines of the industry for price negotiations and price controls
Universal coverage
Incentives for efficiency and productivity
Run the system with the goal of the most (productive) health care per dollar spent irrelevant of how you achieve it
Streamlined administration
More efforts to promote labor saving technologies within health care

I can dream. In the real world I get to pay larger and larger amounts for more and more useless insurance.

I don’t know if single payer is that big of a deal. Lots of nations have multi payer and they do fine.

The two big reasons our system is so expensive are supposedly a lack of efficient administration (Taiwan spends 2% of health spending on administration, the US spends about 30%) and the lack of price controls/negotiations of price. A lot of prices are set by the market or set in secret to avoid negotiations. My understanding is neither the public or private sector has any real power to negotiate prices down in our health care system.

If you fixed those two (ideally) you’d probably reduce health spending 40%+ and our costs would become pretty much in line with other OECD nations.

15

The problem I am addressing here is the same problem that we have with police: Doctors don’t want to speak ill of other doctors. On top of that, many malpractice claims get settled out of court with both not admitting blame on the part of the doctor and gag orders for a lump sum of money to the victim.

Thus, it’s hard to know if your doctor is good or not. This system would allow you to see both the number of claims against them and the number of decisions pro or con versus those claims. So if you went to a doctor that had 15 claims over a 15 year career, and, say, 10 of those were adjudicated against him, you could see not only what those claims were (He gave me the wrong meds that gave me a rash vs he shot my testicles off with a pressurized oxygen valve) but what sort of culpability he had maintained. You then have a path to a thorough review of your area doctors. If they are all scum, you could move to have them excluded from practice in your county.

Within the board itself, the doctors can speak to how bad the effect is and how easy it was to make that mistake. The politicians can be theoretically impartial (though I expect that doctors that were on the panel would slowly ooze into the political positions). And the lay persons can bring understanding of the victim and the social milieu that exists within that area.

A Texan version of the board might not care much, for instance, that the guy got a rash from the wrong meds. Whereas an Oregon version of the board might take that doctor to the poor farm and dump him in a ditch. But at least it’s not beholden to some magic number dispensed by bureaucrats that are removed by 14 layers of government.

16

I think your idea will make this worse, since every malpractice case now gets played out in public. I’d think it would be harder to turn in your fellow doc knowing that if he or she did lose the malpractice case, it would mean publicity that would ruin the physician’s career. Note that even if he or she won, the record of the accusation would be public, and thus look bad for the doc and hospital*. This would be yet another reason to circle wagons.

This is indeed a problem.

It is today extremely rate for a doc to have a statistically significant malpractice history. Under your plan of having every case go to trial, the cost to an attorney of filing a case goes way up. So the number of malpractice cases will decline, making the history even less likely to be statistically significant.

As for knowing if your doc is good, the best you can do may be to have a long-time family doc, who you go to because he or she is a good listener, recommend a specialist when the need arises. I realize this is a partial answer at best, not least because it is hard to find such a family doc who also has friends in many departments of an outstanding hospital.

The insurance company pays, not the doc. And more and more, the hospital pays the insurance premiums, not the physician. Or are you going to outlaw malpractice insurance?

  • Malpractice lawsuits frequently target nurses and hospitals as well as docs.
17

Sorry, that would end up breaking mrAru and myself - it costs me around $3000 a month for all my medications and a fair amount for testing to make sure my organs are not being killed off by some of my medications … [thankfully I no longer take one that is $25 a pill … ] $800 a month is what we pay for the mortgage on the house. we couldn’t scrounge up an aditional mortgage payment a month for meds unless we stopped eating and mrAru found a job around 10 miles from home.

Now if you just put everybody on the same Tri-Care plan that mrAru earned for us with 20 years naval service, I would be down with that. It runs me $20 co-pay per doctor visit, 20% or so for hospital stuff, there is some sort of catastrophic dealyo and we get our meds on base. They could ‘nationalize’ hospitals, and people get their meds gratis at the hospital dispensary or at the governmental equivalent to the state run liquor stores [state run drug stores?]

18

If and only if it becomes a witch hunt. I’m sure in some areas it would work very well, other ares it would work somewhat well, and in some areas work like a rusty gate that hasn’t seen oil since 1936. But it would be a better system than what we have now.

This isn’t a trial. It’s adjudication. The board reviews the facts of the claim and all evidence related to it and any pertinent witness statements. They then vote on the severity of the event and the action to take for remediation. It could be as simple as training on technology or as severe as criminal charges that gets referred to the real court system.

As for malpractice history, it depends. A lot of malpractice is settled before we would see anything. The basic formula is: Issue reported, lawsuit filed, insurance settles. This tends to happen within 3-6 months and never sees the inside of the court room. Since the lawsuit is then dropped for the settlement, you have no real record.

So this would bring to light issues that may be relatively minor, but it would also illuminate those issues that were crap to begin with that now just get settled with a nuisance payout check.

And these doctors are also getting further in between. Wouldn’t it be nice if you could review their record and decide for yourself?

Malpractice insurance would only cover civil suits, but would not be able to suspend the board or settle before the board’s ruling. it would also not cover any fines the board may issue directly to the doctor.

Yes, but that’s a litigation tactic to get to the deepest pockets you possibly can for the largest payout. If you are a doctor worth $500,000 then $50,000 seems like a lot. If you are a hospital worth 1B, $50,000 doesn’t seem like so much.

I would think it would save you money. On this plan (of $50 per month maximum per script) to maintain $3000 a month, you’d have to pay for 60 different prescriptions. I don’t pretend to know your situation, but I would think that taking at least 60 pills per day would make you more prescription than person. :slight_smile:

If I assume you are like my wife and have 8 prescriptions, it would drop your monthly cost to $400 a month, assuming they are all the bling-bling prescriptions and none of them are generics.

All lab work and doctors visitations (and hospitalizations) are free under my proposal. It’s only prescriptions you pay for. And the prescription cost is not allowed to be whatever pharmaceutical companies want it to be simply because they want to use Americans to pay off their R&D.

I get the R&D is a large cost, but Americans pay more for all of our prescriptions compared to any other country. Is there a good reason France pays 44% of our cost on average for prescriptions? Australia - 49% of our costs? Canada, our next door neighbor, pays 77% of our prescription cost. A few drugs, like Norvir are around $8,000 in the US and under $1,000 in Canada.

19

I take 18 drugs, and then have syringes and test strips [and holy fuck test strips are freaking expensive:eek:] and one of the drugs comes from a compounding pharmacy because the commercial version has acetaminophen and if I took it I would be perilously close to killing my liver so it is more expensive than the bling-bling nongeneric version. 3k is what it costs before co-pay, if I was getting it at a local pharmacy instead of on base at the hospital dispensary [which I can tap for free, except for the one I get at the compounding pharmacy - I still have a co-pay on that one.]

I am ripping pissed at the FDA for the crap about the colchicine - the unapproved drugs initiative had some drug company run colchicine through trials as if it were a new drug, and then they got a monopoly on it, renamed it colcrys and popped the cost per pill up from 2 cents to FIVE FUCKING DOLLARS per pill. I go through around 600ish pills a year depending on how bad my CPPD is hitting me. The only decent thing is the cute light purple enteric coating they gave it. [yup, if I were paying full price for it, that would be $3000 per year as opposed to the original $12 a year.]

20

In your situation, according to my plan, you’d pay $900 per month, for 18 prescriptions. :frowning: But they wouldn’t be able to charge you $5 per pill, at the very least. Also, the cost would be based on the prescription (If you need 3 pills per day, that’s still not over $50 a month versus 1 pill a day), not the packaging, for a small ray of light in your situation.