Monday, February 8, 2010

Health Care Meeting Feb. 25

President Obama has announced a meeting Feb. 25 with Democratic and Republican members of Congress to discuss health reform. It makes good sense to not start over, but to start with the bills that have passed the House and the Senate. And then discuss how to move from that toward some compromise. I suggested this outline of a deal last week. Ezra Klein has a list of compromises already in the Senate bill that Republicans tout as desiring.

Biggest political issue that also has policy merit is bringing in med mal. But, there also needs to be a shift away from adversarial dealing with malpractice toward patient safety approach. I wrote about this last year.

Biggest political issue that is mostly fake from a policy standpoint is the selling across state lines as a panacea. Of course, the Senate bill that passed on Christmas Eve allows states to form compacts and do this. This meeting on February 25 needs to walk through the steps of the general sell across state lines. Meaning I would give McConnell and Boehner the floor and tell them to tell us how it would work. First, you pass a law that reforms McCarran-Ferguson, then you....that sort of thing.

There are really two choices as I see it if you are after blanket across state lines: (1) set national insurance regulation of insurance. Big problem then will become fact that insurers don't have networks everywhere and that practice patterns render health care costs per capita so different across locales, so premiums won't work nationally. Or (2) make insurance like credit cards and allow insurance companies to all set up shop in a few states with low regs and then sell anywhere. People will get cheap insurance that will be fine if they don't get sick, but which will be filled with back end exclusions and there will develop a cottage industry of telling the stories (I thought I was covered and then I got Cancer...). The sell across state lines is a brilliant political slogan, but not much else as a mainline health policy.

Biggest policy issues that the country really does need to focus on and decide are:

1. Individual mandate or not? If no mandate of any type, there is no way to get to universal coverage. Even with it, you can't get there immediately. If we are going to decide we will not have a mandate of some sort (covering everyone via a catastrophic insurance of some sort is a type of mandate), I think we really have to then decide whether it makes sense to say that person's get care when they are uninsured. It makes little sense to say they do, which implies some sort of notion of right to health care, but then not put in a practical way to get the financing straight. We are in no man's land at this point.

2. Will we alter the tax exclusion of employer-paid insurance or not? There is good agreement across health policy types. This will take bipartisan support for sure. The President has been pretty bold on this, insisting on the tax on high cost insurance plans, which is the beginnings of a de facto capping against the wishes of Labor. It would be better to simply limit the exclusion, on the route to repeal. There are lots of Republicans for this, so simply adding this as a financing mechanism/reform to any bill should make them like it better if they are deciding based on policy.

3. Will we admit that there are limits to what can be done? Not rationing is everyone getting everything they want. We don't have that now. We need to put the rational into our rationing and begin to purchase health care with value in mind. Paul Ryan's Roadmap provides an interesting foil/approach that can help bookend the choices in a manner that is good for the country. He says voucher the Medicare program beginning 10 years hence, fixing the federal government's contribution and assuming the rest works out (with extra resources for low income persons). I would prefer a muddle through approach that would be based on expert assessment and practical interpretation of guidelines that also begins to have a policy punch. Eventually deciding some types of care don't make sense in certain circustances, and then say public money won't pay in some cases, or will pay less.

I would rather have an honest discussion and have my point of view not prevail than to continue our hysterical 'discussion' that we typically we have around rationing.

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