June 19, 2012
Universal Health Care Conservative StyleBy Thomas Davidson
Republicans did not participate actively in the design of ObamaCare and for this reason the bill does not reflect conservative values. The current Republican slogan is "Repeal and Replace." -- a good idea perhaps, but problematic. ObamaCare is now the law. As such, its repeal will require a 60 vote Republican majority in the Senate and a Republican president to sign the bill. The Republicans are not going to pick up 13 Senate seats in the upcoming election. They might not even win a majority. And while the presidency is a possibility, it is far from assured. So, unless the Supreme Court rides to the rescue, how realistic a slogan do we have?
It depends. ObamaCare can be repealed and replaced. However, that can only happen if the new bill gets substantial Democratic support. How can a Republican bill do that? Simply, it has to offer the Democrats something that they very much want, but that that ObamaCare does not provide: universal coverage. But, can we Republicans ever support universal coverage? I suggest that we can, if, in exchange for that, we get features that reflect core conservative values, specifically:
I understand that, at first reading, a proposal to provide universal coverage sounds like another wasteful, not to mention massive federal expenditure. I will argue, however, that the opposite is true. We already have a health care system that is massively expensive and wasteful, and that is further characterized by levels of complexity that only a government program can achieve. At this point, comprehensive reform at the national level is the only realistic way to reduce its cost and minimize its inefficiencies.
The core of the approach that I would propose would be a universal system of voucher support for insurance premiums. This suggestion builds off of Congressman Ryan's voucher proposal for Medicare and Medicaid reform. His plan has important merits that deserve to be part of any larger plan. The first is that it provides a framework for cost management and regulatory relief that traditional Medicare does not. Under traditional Medicare and most private insurance policies, hospitals and physicians are essentially reimbursed on a fee-for-service basis. This system sounds fair and maybe it is -- for the providers, but it has one important drawback. It encourages hospitals and physicians to provide services. Whether all of those services are necessary or even desirable is not always clear. And, for this reason, there is an ongoing battle between government and private insurers on one side and hospitals and physicians on the other to determine whether the bill for this or that procedure is going to be paid. Thus the massive Medicare regulatory maze.
Congressman Ryan's proposal settles these issues neatly. If the government is simply providing the funding for a private healthcare policy, it has no interest or need to micro-manage patient treatment decisions. That whole area of contention becomes the health insurer's problem. Just as importantly, the government can actually budget its expenditures. It offers the health insurer X dollars for Y menu of benefits - take it or leave it. It then becomes the job of the insurers to figure out how to make the funding work and generate a profit.
However, for all of its merits, Congressman Ryan's plan is not enough. It is a fix for programs that serve people who are already insured and thus by definition does nothing for anyone else. In order to capture the public's imagination, the Republican plan has to be bigger and more ambitious in its scope.
To this end, I propose that the Republican Party expand on the Ryan plan with a national solution that addresses the real needs of all the people, while concurrently advancing the values of principled conservatism. In broad outline, the program would look like this.
The federal government would issue every American citizen and legal alien a voucher that would be used to purchase a basic health insurance plan. The benefits of the basic plan would be precisely defined and all insurers would have to offer such a plan for the money available from the voucher. Insurers could also offer supplemental coverage that individuals or employers could purchase, but the minimum level of care spelled out in the basic policy would be available to everyone.
Insurers would be responsible for all covered patient care costs after a moderate deductible -- say $1,000 per year per person. Low income persons would be exempted from the deductible through tax credits. This model would apply to Medicare patients as well as to younger patients. The voucher's value would vary based on age. All insurers would have to accept all patients. There would be a few refinements, but this is the basic picture.
Now you may be asking yourself: is this really a conservative proposal or is it socialism in disguise? It is conservative. It meaningfully advances the general welfare, and it does so in a cost-effective manner that does not involve burdensome regulation or restrictions of personal liberty. For this reason, it is consistent with the traditional values of principled conservatism. I will address some of these issues in more detail below.
Patient Choice and Market Competition
Although the program is national in scope, it avoids the worst flaws of a true single payor system. The government would not limit or even attempt to manage patient care. Patients and employers would have the right to purchase additional coverage for more comprehensive services if they so desired. Of equal importance, insurance companies would be compelled to compete to provide the most attractive bundle of services for their customers. In this way, physician and patient preferences would retain a major say in determining the scope of care and services provided.
The program would actually reduce the day-to-day role of the government in health care. The government would be involved only in its one area of acknowledged core competency -- collecting taxes and paying the insurers. The program would eliminate most government regulation of health care fees and utilization review. All of those obnoxious duties would be transferred to the insurance companies. More importantly, the government would have no legitimate interest in micro-managing physician and hospital practice patterns and would have not need or right to insist on access to patients' medical records. (And If there is one truly scary attribute of the modern government insurance programs it is the fact that the government has full access to the medical records of its citizenry.) The only residual role of government monitoring would be quality management -- a role that would place it squarely on the side of the citizenry, where it belongs.
But what about the expense? Am I not proposing a massive expansion of federal spending? How can such a proposal be squared with conservative values? Well, that I suppose depends on what one means by conservative values.
Conservatives cannot be reflexively hostile to government. Governments are necessary and are sometimes positively good. The test of a government program cannot simply be its size or the mere fact that it is being proposed in the first place. The program must meet certain tests. It must advance the general welfare, but it must do so at a cost in dollars and imposition upon citizen liberty that is consistent with the benefits it extends.
Health care falls under any fair definition of the general welfare. It is a fact that few individuals can afford a major health care episode with their own resources. So it is also a fact that the financial risks of catastrophic illnesses must be pooled. So let us acknowledge that the costs of our health care system are inevitable and must be shared. The remaining question is this: does our current system effectively and efficiently address these realities? It does not. Many individuals are uninsured. The system that insures the rest is terribly complicated and wasteful.
The people of the United States already spend more on health care as a percentage of GDP than does any other country in the world. We spend about 17 percent of our GPD; no other advanced countries spend more than 10 to 12 percent. Sadly, we do not really get much benefit in improved outcomes for the extra 5 to 7 percent of our GDP that we spend.
By consolidating the health care insurance budget in the manner I am suggesting, there is good reason to believe that the total cost of care would eventually be brought down over time. Why? It would happen because the pool of dollars available for patient care would be capped each year. Insurers and providers would have to develop models of care that would fit within those caps. Because all providers would be competing for the available patients and dollars in the system, those providers that developed the most cost-effective approaches to the delivery of quality care would thrive, and their models would be adopted and improved upon by their competitors. This dynamic would reduce costs over time.
The program would have to be funded by new taxation. But, those taxes would be offset by reductions in the health insurance costs that individuals and their employers already bear -- whether directly, in the form of insurance premiums, or indirectly, in the form of the cost of corporate products or services.
So would patients sometimes not get every service they might want? Yes. I will concede that the system that I am proposing would tend to encourage economy of care. The current system is the direct opposite of mine and, in fact, encourages unnecessary activity. That is why we spend 17 percent of our GDP on health care when the rest of the world spends 10. Unfortunately, we cannot continue to fund the current fee-for-service model for an aging population forever. And, if the continuation of business as usual is unsustainable, well, we might as well get used to the idea that it is going to be replaced by something less generous. I would prefer to let the market model the changes in practice than the government.
In the long run, the nationalized model that I am proposing would provide a mechanism for reducing health care costs and would serve important social and economic purposes besides. It would free corporations from the burden of insuring their employees. It would free individuals from the possibility of losing their insurance. It would eliminate the nightmares of pre-existing conditions, exhaustion of benefits, and predatory premium hikes that mar the private insurance industry.
Again, let me reiterate the core rationale for this proposal. Health care expenditures must occur. The current system is a tangle of regulations - published in thousands of densely typed pages that carry the force of law. It is inefficient at best and it positively encourages wasteful spending and unnecessary expenditures. It is incomprehensible to the layman and for that matter to most professionals. It must be reformed radically and at the national level if there is to be any hope of making it simpler, cheaper and more humane.
A Republican candidate standing on this platform of comprehensive reform would dance circles against anyone defending either the status quo or ObamaCare. The Republicans are campaigning now on a platform of "Repeal and Replace." In fact, there is no need for them to wait for the election. The Republican majority in the House could write and pass a reform bill next week and send it to the Senate. The Senate might just pass it too. It would, after all, fulfill the Democratic dream of universal heath care a lot better than ObamaCare does. But it does so with a conservative accent. It shrinks coercive bureaucracy and regulation. It makes American corporations more competitive. It lets the market work. It is a winner.
Thomas Davidson is a health care management consultant living in Faber, Virginia.
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