This is a second part in a series where I am looking at the “parsing” process I go through in evaluating stated policy positions from the various candidates or interest groups. The direction of healthcare will be front and center in the 2020 election, and we are finally beginning to see some proposals with meat (and a lot of proposals lacking substance). Which bring us to:
Parse #1 – Is there any substance to work with?
The long-time Republican mantra of “Repeal and replace Obamacare” was always a no-substance position. There never was any serious “Replace” part of that proposal that had any widespread support, and what was proposed was mostly seat-of-the-pants ideas from various congressmen about how the “free market” was going to take care of the chaos resulting from a repeal of the Affordable Care Act.
At the same time, I have noted in a prior post that the Democratic “Medicare-for-all” advocates have been pretty skimpy on specifics to-date, especially specifics that survive any basic application of healthcare math. We need to get past personality politics and get some specifics on the table. I have little patience for those who say that we can work out the details later.
Parse #2 – Do they address the “three-legged stool”?
I have not been able to track back to give credit to the first writer who trotted out the “three legged stool” criteria for evaluating healthcare proposals, but it does a great job at “cutting to the chase” and addressing the most basic complexities of healthcare reform. This is the assertion that anything close to a universal healthcare system needs to address three realities that are often at cross purposes:
- Universal coverage demands that someone must insure the access to affordable healthcare to traditional “hard-to-insure” individuals, such as those with pre-existing conditions (although actually this will be almost all of us at some time during our lives unless we get hit by a bus). If you are not going to hand this off to a “public option” of some kind, then there needs some incentive or coercion with teeth for private market insurers to adequately cover these individuals.
- Universal coverage can’t be voluntary. This is the unavoidable coercion on the customer side. If you are going to treat this like other forms of insurance, then some segments of the society, mostly young, healthy males, need to pay premiums into the system in order to help pay for those who need the coverage now. Young, healthy males do need healthcare insurance, but their risk profile is different from older adults or children. They are all one motorcycle accident away from million-dollar healthcare expenses, yet the odds of that occurring are low. But that is what “insurance” is all about. However, the current U.S. system has mashed together “true insurance” with “medical pre-payment,” filtered through a complex system of tiered provider discounts.
- No matter how you structure premiums and co-payments arrayed across risk groupings, there will always be a substantial portion of the population who cannot afford the cost. The cost of single, unsubsidized care for older adults now exceeds $12,000 per year in premiums and an equal amount in co-payments in much of the United States. There needs to be some graduated form of governmental subsidy based on ability to pay that matches the reality of the current U.S. populace.
It is easy for a politician to propose mandating these “three legs,” but the reality on the ground has proven difficult in the implementation (against often-crippling opposition) of the Affordable Care Act insurance exchanges. For instance, Washington state Governor Jay Inslee has proposed a “Medicare-like public option” that would allow Americans younger than 65 to get coverage through a state exchange-contracted plan that will reimburse providers at established Medicare rates. However, the “buy-in cost” does not appear to yet be fleshed out, and it may prove difficult to convince doctors to accept patients at lower-than-market Medicare reimbursement rates without the “big club” wielded by the federal government in administering the age 65+ Medicare plans.
Parse #3 – Can you cite anywhere else where this plan has worked in practice?
The worst proposals are hung on the politician’s promise that “I have this great new idea about healthcare that no one has ever tried before!” I tend to dismiss these claims pretty quickly.
There are at least 20 viable near-universal healthcare plans in other industrialized nations around the world worth comparing and contrasting to the U.S. system. I highlighted three different ones, beyond the usual lazy citing of United Kingdom or Canadian programs, in a post from last September. Americans of all political stripes often think that they are the only ones in the world who can figure out the complexities of social problems like this. In reality, we are pretty bad at it, especially when it comes to healthcare. Others have been there before you.
We won’t be implementing a United Kingdom-like National Health Service anytime soon, and even the Canadian plan, which as some great features, would be very difficult to implement in the United States. But the three countries I highlighted, Germany, Switzerland and Austria, each have elements of similarity to the United States healthcare market. The most successful parts of their plans are worth examining and adapting to the U.S. system.
It is worth noting that some of these systems get dinged by critics for problems with “waiting lines” for services or facility shortages. The relevant follow-up question to this criticism is “What do you think the waiting line would be like if they spent the same amount per patient as we do in the United States?” In just about every case, any wait for services would become minimal at U.S. spending rates.
Needless to say, I am still waiting for a healthcare proposal that survives my three-layered parsing strategy. But let’s get some real plans on the table!
The first part of this series, about parsing top-line governmental revenue plans, is found here. You can subscribe to this blog by entering your email address into the box on the left side of the screen, or alternatively clicking on the Facebook or Twitter icons to be notified of new posts.