Under Leader Reid’s amendment, in the year 2019 about 16 million U.S. citizens would be uninsured and be forced to pay a penalty tax of almost $800 per year.

About eight million illegal aliens would be uninsured and would owe no penalty tax. Both groups would get their health care through a combination of out-of-pocket spending and use of uncompensated care in emergency rooms and free health clinics.

Fair’s Fair!
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“As in every industry dominated by monopolies, innovation will shrivel.
The medical equivalent of more chrome and styling will be trotted out each year over the same old chassis.”

…but us Land Shark’s will still have fins!

So true.

I think the 2,000 pages just floated over the transom or appeared one morning next to the porcelain throne. I think it has less literary merit than a Mickey Spillane novel, that arguably took less time to write than to read. If you dropped it on someone it might qualify as a cheap alternative to the Gas Passer.

I suppose there are ways to game the system I propose, but it only took me ten minutes to put it out there. How long did it take to write either of the 2,000 page bills we have ready to cram down our throats? And, do you think they won’t be gamed, eventually?

Back when all doctor were in the AMA and fees were standardized, that is to say fixed, you chose your Dr based on the quality of their National Geographics.

I would propose the following set of principles to consider for the the reform of health care. Take ‘em or leave ‘em.

First, with respect to people and institutions who provide the services that we call health care, let them set whatever price they wish for whatever service they provide. However, they can only charge that price, or zero. That is, they can have a certain price for a service, but that can’t be different for the person who has insurance and the person in the next bed who doesn’t. If they want to take pity on someone and do it for free, that would be fine, but if it costs $200 to sew up a laceration for Joe the Insured, then it will cost $200 for Jane the Not-Insured in the next bed. Not $120 for Joe, and $600 for Jane. If the provider wants to say “I feel sorry for you, so I will give you a break,” then let it be done for nothing. This principale would hopefully get rid of the phenomenon where the insured patient goes for a service and is charged $1000 for their care, and the uninsured patient is on the hook for $3500 or whatever. This would bring the costs of individual services to some equilibrium that people may not like, but they couldn’t cite the example of the two patients with radically different charges for the exact same treatment.

If a care provider performs a treatment for free for a charity case, let them deduct some multiple of that prospectively set price from their taxes (a deduction or a tax credit). This would greatly encourage provision of indigent care if a heart surgeon could deduct $60,000 from his adjusted gross income if he did a heart operation “worth” $20,000 in terms of his labor to a poor person and could have a real financial subsidy from the government for doing this charitable deed. By the same token, maybe “non-profit” institutions that provide health care and don’t pay taxes should pay taxes on their gross revenues and have the same sort of incentive to provide indigent care as the doctor in the example above. Think about it.

Next, lets REQUIRE that all health care service providers advertise the prices of their services. Yes, require them to advertise. They could provide their fee list for service to the .gov who could do the public the service of posting those prices, and let the consumer shop for a health care provider in part on the basis of price. Yes, make health decisions in part on the basis of what it costs. The consumer could look up what it would cost to fill the prescription at the local pharmacy, and maybe drive a few miles to get the medicine for less. Or not, if the price is competitive. But let the consumer know what it will cost for a gall bladder operation, or a 100 Coumadin pills, or an hour of psychotherapy. In advance of the visit, not as an afterthought when the damage is literally already done. Doctors competing in part on the basis of price? Shocking! No, not really. The myth that providing medical care is some mysterious religious rite (a view that is held by many, and encouraged by, well, doctors, duh!) keeps people from acting in rational ways, when it comes to medical care. Doctors could still distinguish themselves from their competitors on the basis of their bedside manner, reputation for diagnostic acumen, superior surgical skill, etc, and hospitals could compete on the basis of marble lined halls and walnut furniture, or whatever, or offer a cheaper alternative with less frills.

Let any ‘entitlement’ to health care not necessarily correspond to the ability to see an MD about a runny nose, or the high cholesterol. These things can be dealt with quite satisfactorily by a physician’s assistant or a nurse practitioner. Save the more expensive diagnostic or procedural issues for the more highly trained MD.

For the consumer, ban all first dollar coverage of anything, including the “Mom and apple pie” sacred cows of vaccines, or Pap smears, or cholesterol checks, or prenatal care. All of these things have value, and we should not be shy about assigning a fair value to it, based on what people are willing to pay and what providers are willing to take to provide the service. For too long, we have acted like medicine is some sort of sacrament whose price cannot be passed on to the recipient. If something is truly valuable and is of benefit to a patient, then the patient should be made to pay something for that service. The payment from the patient need not be the same for all, but could perhaps be based on some factor times the adjuste gross income, for instance. Maybe I, a fairly wealthy doctor, should pay a fairly high co-payment(maybe $100 for a brief ER visit to get a few stithes for my next table saw accident), and unemployed Bubba could pay something much less ($10 for the same service). This would serve to shift some costs from the poor to me, but not make me the sucker who has to pick up the entire check. This is a fundamental point of equity. If people feel that they are entitled to have unlimited access to expensive things with no skin of their own (figuratively speaking) in the game, it leads to abuse. Not because poor people generally like hanging out int he ER, but because if it is easy to do so, and there is no penalty for getting care in the ER, it is naturally what you will do in lieu of getting a personal physician to take care of you. I remember a man who came to the ER with his wife and two kids at 2 AM when I was a resident in training. He wanted to get tested for gonorrhea. He had no particular shame about acknowledging it right there in front of his wife and kids. I cautiously asked why he came to the ER in the middle of the night, rather than going to a doctor in the civil hours of the day. With no particular shame he said that it was convenient for him to come at that time, and what was my problem. This was at a time when the evolving standard of care was that the patient determined what was an “emergency”, not the doctor or triage nurse. So we have come a long way down that road such that illegals come to the ER for any and all manner of care, and the only way you can seemingly limit the damage is to refuse to feed them.

For the vast majority of patients, their care should be provided under the auspices of private insurance, with stringent regulation by the government. This can take the form of forbidding denial of coverage for pre-existing conditions, and regulated rates for certain basic levels of coverage that can be agreed upon. For people with medical conditions such as cystic fibrosis, or sickle cell anemia, or hemophilia, or in need of transplantation procedures for leukemia or liver failure, etc, let the government “superinsure” their medical care above some lifetime cap; maybe $100,000, or $250,000, or $500,000, whatever (I don’t have a specific number in mind). But the principle would be that people with devastating medical conditions would not be financially destroyed. It is criminal that someone without insurance who has a serious medical problem is forced into bankruptcy through no fault of their own. This would permit private insurance companies to offer lower premiums for standard levels of medical care, with the assurance that for the super-costly, they would be off the hook.

Let the private insurance companies be regulated so that people who are extremely high risk for medical problems be allocated to insurance companies proportional to the number of insured lives they have on their books. That way, the government could play the role of honest broker in terms of assigning each insurance company a proportion of bad risk patients to insure. This could be adjusted so one company couldn’t game the system by cherry picking the healthiest amongst us as their customers. The business model would become competition for the total number of patients and care providers on the basis of how well they serviced claims and what level of services they provide for a given price. They are not doing things that require medical judgement; they are distributing risk and making loans on the basis of future claims. Just like auto insurance.

Let the government grant dispensation to companies to develop common electronic medical records, and coordinate amongst themselves how to ensure security and accuracy without fear of anti-trust implications. The government has some decent systems for electronic medical record keeping that could be put in the public domain. For instance, I have not used it, but the people I know who have used the Veteran’s Administration electronic medical records have all given it good reviews. Let private companies take the .gov systems and build on them, and cooperate amongst themselves to generate a common standard.

Let the data that derives from medical care be deposited in secure databases in anonymous format for evaluation of outcomes to decide what is effective, and what is not effective. Let the decisions about what treatments to cover be based on what works, and what is ineffective. If the consumer wants to obtain a medical treatment that is of marginal effectiveness, or risky, then let them pay for it out of pocket. Enough of the arguments about how the government should pay for something that is not very effective and offers a remote chance of benefit. Let individuals decide if it is worth $40,000 to extend their lives by 5 months when they have cancer at age 40, or 50, or 60, or… It may make sense for the individual, but it may not make sense for a third party (goverment or insurance company) to do it.

Providing greater supply of doctors, nurses, respiratory therapists, dentists, etc: let people get a meaningful subsidy from the government for their time spent studying medicine or their healing art, in return for some time spent in service to the indigent at a fixed salary, or working at the VA or a military medical facility. One year of medical school paid for by .gov could engender a one or two year commitment to work for .gov at a salary comparable to the private sector less some fraction.

Tort reform: no limit on actual damages, but strick limits on “other damages” and the cut administered to the successful plaintiff’s attorney. A doctor or hospital can do an immense amount of damage to a patient, and there is no reason to limit the actual damages assessed. But there is no reason for more than some agreed upon multiple of the actual damages (treble?) for “pain and suffering”, and that could be capped at some prospectively agreed upon amount. The fraction of the damage award to the lawyer could be capped with the same reasoning that applies to capping reimbursement for MDs.

I would hope that a private insurance system that has disincentives for first dollar expenditures, a regulated playing field in terms of insured patient risk and limits on maximum payment to be made could offer much more affordable risk distribution for the average person than we now have.

It would be preferable to what is proposed now, and certainly would not take for than a hundred pages or so to codify.

Just some ideas. You should consider reading two books on this topic by Dr. Nortin Hadler (“Worried Sick” or “The Last Well Man”) for some perspective on why a lot of medical care constitutes “type 2 malpractice” (doing something very competently that didn’t need to be done, as opposed to type 1 malpractice, which is doing something incompetent like cutting off the wrong leg).

Unless we come up with a plan to help those who are hurting through no fault of their own, especially cancer survivors and other high-risk individuals, then, from their perspective, it serves no purpose to simply cast stones at the flawed plans promoted by big government advocates.

The conservatives did little to address the topic during the previous administrations. Now it has come home to roost with a vengeance.