Sep 17, 2009

The Baucus Bill isn't that bad.

Here is the link to the Senate Finance Committee's "Chairman's Mark", released yesterday and supposedly the starting point for the compromise bill that will be acceptable to a wider range of congress.
All in all, I think it is a good framework for reform, except for a couple of things. The most important problem is that it allows private plans to charge very different amounts to different populations of people. If you're, say, 60-65 years old (too young for Medicare and too old to train for a new lucrative career), you'll have to pay a LOT for health care coverage (5 times more than for younger people). Say you're a single person 60 years of age making $50K a year. You'd be excused from the requirement of either having to buy insurance or pay a fine to IRS only if the lowest premium available to you was more than $5000. (You wouldn't be eligible for a tax credit to help defray the cost, because you'd be too rich.)
That's simply too much for most people I know, and because the 60-65 year olds will shoulder the greatest premiums, it basically says fuggedabout relief. You'll just be penalized if you don't buy coverage, and you still won't be able to afford coverage.
Let's get real. We need to provide a fair insurance system for people who can't get it through the workplace. Those same people must have incentives to be frugal about how they use their covered care. A system of COMPETING regulated health plans offering benefits with a standardized value is the best way to change the health care system to be more efficient in the delivery of care. Nothing is ever perfect, but consumers can vote with their feet by changing plans when they find one or the other not meeting their needs.
I started working on health care issues in 1971. Over the years, I would ask physicians, nurses, and other health care professionals with whom I worked on committees and panels to estimate, off the top of their heads, what percent of health care costs is wasted. It varied, but the most frequent response throughout the years was 40%. (20% also was suggested a lot.) And, it didn't get any lower as I got older.
Right now the system isn't organized to capture those savings. As patients, we all know the problems. Duplicative tests, doctors not communicating, incentives to test and prescribe too much, etc., etc. To change things in the culture of medicine, you need to change the organization of medical care. My two years working at the Mayo Clinic in Minnesota in the mid 1990's taught me that medical culture is very important, and that the organization needs to have incentives to make their practitioners change behavior.
Mayo was organized better than any system I've ever seen. They were most efficient in the conduct of individual services (xrays, lab tests, visits, etc), but they provided a very intensive set of services. Mayo is still paid largely on a fee-for-service basis. Imagine the innovation that would be forthcoming if the majority of its patients signed up as HMO members in the "Mayo Clinic HMO." Mayo would be a leader in deciding if and when services were justified on medical grounds (let alone costs). Under a competing system, Mayo might have incentives to build its HMO into an offering for most people in southern Minnesota.
So, we need the Baucus framework, with some tweaks, but we need to have the young subsidize the old (young-old, non-Medicare). The young will be old someday too. Keeping the young in the pool with the old will keep premiums more affordable to those most vulnerable. The 50+ crowd who start succumbing to chronic and debilitating disease.
If you agree or not, you can find out how to contact your congressman or senator in my recent post, How to Contact Your Congressman or Senator. They need to hear from you. Here's a good news article that shows how important your voice can be on this particular issue.

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