Feeling particularly peevish one morning a few weeks ago, I crafted an aggressive letter and sent it to all of my national government representatives as well as to the president. I asked each of them to simply stop all of the initiatives regarding health care, cap and trade, etc., and let us all catch our breath.
The U.S. government had, after all, in a stunning few months, embarked on an unprecedented multi-billion dollar spending (“stimulus”) program, acquired a major insurance company and two very large automobile manufacturing companies, and assumed effective management control over the banking industry. All this at enormous and incalculable cost. I, like many of my fellow citizens, was feeling a serious sense of overload and wanted some time to digest these initiatives.
With the exception of my representative, Congresswoman Nita Lowey, neither of my senators nor the president did much more than electronically acknowledge my communication and direct me to their websites where I could witness them performing adulatory acts and read the usual pap regarding their support for the administration’s programs. I do, after all, live in a very blue state.
Ms. Lowey, however, replied with a 2 ½ page response in which she detailed her understanding of the need for health care reform and presented a case for the plan as it now stands in the House version. I was impressed and pleased with the thoroughness of her response and grateful to have an opportunity to engage in what I hope to be a meaningful dialogue absent much of the hype that so often passes for discussions.
Here is my (somewhat edited) response to her. There is so much more to say but one can only cover so much at a time. Perhaps there will be more to report as she and I may engage in further discussions.
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Dear Ms. Lowey,
Thank you very much for your thoughtful and comprehensive response to the concerns that I had expressed regarding the health care “reform” proposals that are currently under consideration.
I would be pleased if you would consider the following observations and suggestions regarding this effort as I believe that they may better inform your considerations of legislation as it may develop over the months ahead.
First and, I believe, foremost, is the financial condition of Medicare. Without reiterating the facts that are well known and confirmed by all of the analysts and budget watchers, this program, by itself, is broken and will bankrupt our nation within the next generation or two. Congress and previous administrations have been urged to institute significant changes to either increase its revenue or decrease its services but there has been no political will to address the matter. Instead, the issue has been “kicked down the road” for future legislatures and administrations to address.
Medicaid suffers from a similar problem. Before introducing an enormous restructuring of our entire health care system as is being proposed, prudence dictates that we fix the problems that we now have. I do not find it credible to believe that the proposed legislation will ever be “revenue neutral.”
Supporters of the existing House proposed legislation contend that the introduction of a government-sponsored insurance program (included in the “Exchange” as you referred to it) will enhance competition in the health care insurance market. If one can predict anything from history, the political process and various special interest groups will surely suborn a government plan and more subsidies will be provided. (I observed the president’s town hall meeting in Colorado this eve where he strongly asserted that this would not happen. Count me as a skeptic).
Under these circumstances, choice will mean very little since the sheer economics of the plans that will be presented to employers and individuals will drive them to the less expensive, government-sponsored programs. This program will, inevitably, spell the death knell of competitive health insurance.
The concept that all patients pay the same rates for their level of coverage regardless of age or medical condition is embedded in the proposed plan. There is no equity at all in such a proposal since risks vary widely based upon genetic inheritance, life style, age, occupation, etc. The assessment of such risks are made daily by the hundreds of insurance companies underwriting fire and automobile risk coverage, life insurance, disability and even, yes, health insurance. While these underwriting efforts are regularly, to some extent, inhibited by state and federal legislation, there is an underlying concept that is, in my judgment, sound, i.e., one should pay for the risk that one presents to the insurance company.
Among the serious consequences of the proposed concept is that the patient will have no apparent financial interest in monitoring his or her medical costs nor will the benefits of life-style changes accrue to the patient in any tangible way. To the extent that individual citizens are indigent and require public assistance, direct subsidies or vouchers might be provided that may not distort an efficient and effective system.
Even those plans that operate under the provisions of the Employee Retirement Income Security Act (ERISA) will, after five years (assuming no changes to the underlying plan), be forced to offer “approved” plans, imposing even more conformity in the market. These and many other details essentially call into question the assertions that one may “keep his current plan.” The government-sponsored plans will most assuredly crowd out all other insurers and self-insurers as operate under ERISA.
With regard to one’s freedom to choose one’s own physician, the plan will introduce a concept called “medical home” or, in other words, an HMO-type program where the primary care doctor acts as a gatekeeper and determines what specialists one may see or what tests one may be given. Such a structure will, among other things, introduce incentives for the doctor to withhold certain tests and reduce costs. This will present a forthright conflict between the physician’s and the patient’s respective best interests because the primary care physician will earn more money based upon the savings that he or she produces.
In addition, since there will always be the ability to “join up” (remember, this is universal coverage), many individuals will remain in the HMO-type program until there is a serious illness when they will switch to a “fee-for-service” program. The latter will die very quickly when that happens (as has been the recent experience in Massachusetts).
Of particular concern to those of us who are opponents of using public funds to pay for abortions and for many family-planning programs is the continued insistence that the legislation permit such expenditures. In spite of protestations to the contrary, the efforts that have been made to offer amendments that would forthrightly limit such expenditures have been rejected by the relevant House committees. The existing language will, undoubtedly, be interpreted as to require these services when the plan is active.
When our legislature is faced with an issue that so many citizens view as abhorrent and, for many, immoral, it is not asking too much that public funds not be used for them. Continued rejection of these efforts will only strengthen the sense of estrangement from fellow citizens that many have grown to have.
There are many other serious concerns that accompany this effort, but, rather than occupy you with more “complaints,” I would like to make a few positive suggestions, not necessarily in order of importance, that will start us on the road to the goal of providing health insurance for as many of our citizens as possible at the lowest cost and without creating a new health care world.
- Remove all legal barriers that presently prevent citizens from purchasing health insurance across state lines and, at the same time, encourage Health Savings Accounts, etc. This will permit the insurance companies to assess and price for health risks using large pools of insureds. Just as we benefit from the spreading of risks for our homeowners’ policies, we would also benefit from such large risk pools in the health insurance market. Equally important is the anticipation that many variations on the levels of insurance, levels of deductibles, etc., would evolve offering the consumer many options from which he may select as he deems best for himself. I, for example, may prefer to have a large deductible and smaller premium while you may prefer more “first dollar coverage” and are willing to pay more for that choice.
- Effect meaningful tort reform. A number of proposed legislative solutions are in the hopper and should be passed as soon as possible. There’s not much good that can be said for a legal system that encourages fraud and the legal “blackmailing” of physicians and their insurance companies while, all the while driving the defensive medicine which we all bemoan. This alone would reduce the costs of health care dramatically.
- The subsidy currently offered to employers via the tax exemption of health care premiums must be extended to individuals that purchase their own health insurance. It is only fair to do so.
In short, let’s try to “free up” the market and see if the benefits that will accrue will be of such a magnitude that there will be no need for such an overhaul of the system as is proposed.
The amount of federal (and state) debt that is piling up should strike fear in us all. We will soon reach a tipping point where the only recourse will be to monetize the debt in such amounts that will create something akin to Weimar-style inflation. The government’s profligate spending, combined with our unwillingness to address such obvious problems as Medicare, sends a message to our international partners that we are fast becoming a nation of little discipline and no foresight.
I urge you to do all in your power to stop the introduction of any new programs and work to get our financial and regulatory house in order before we embark on any new adventures such as the complete reformation of health care.
I suspect that our world views are quite different and that you may not share my deep concerns. Should you have the time and be interested, I would regard it as a privilege to have some time to discuss these matters with you in person. No doubt I would be enlightened by your views and, perhaps, you might find mine of some interest.
Cortes E. DeRussy