The Public Health Insurance Option

The public health insurance option is a component of the House health care reform bill (HC 3200) created to, in the words of the President, keep the insurance companies "honest" by engendering price competition. It has been criticized by some as unfair competition, and others believe it to be creeping socialism.

We don't know, of course, what impact the public option will have. We can be sure that there will be significant unintended consequences arising from the public option if it survives public debate, and currently it looks very much like it will not survive in whatever final form health care reform legislation takes.

The President betrayed his true feelings about the public option when he so quickly signaled, at the first sign of stiff opposition, that he was willing to surrender on that point. Current posturing about the public option is an exercise in backpedaling designed to unruffle the fur of the far left. The Senate bill does not contain a publicly funded, government-sponsored insurance plan, opting instead for non-profit cooperatives, a clear signal that the public option won't survive a Senate vote.

On the outside chance that the public health insurance option does make it into whatever legislation is finally passed, let's review what HR 3200 actually creates.

What's good about the public option:

• The public plan will allow physicians to participate on the same two levels currently seen in the Medicare plan; that is, they can participate as "preferred" providers, who will accept the payment rate as set by the public option plan (analogous to "accepting assignment" in Medicare), or they can sign up as "participating, non-preferred providers," analogous to Medicare participating providers who do not accept assignment. This latter designation allows the non-preferred physician to charge more than what the public option allows, but caps that additional amount, probably at the same rate as Medicare, which is, I believe, 120% of Medicare's rate.
• Physicians will not be forced to participate. There will be an opt-out clause.
• Physician reimbursement will increase at least 1% per year. This is in contrast to Medicare, where physician pay rates have been scheduled to be cut significantly each year, according to a schedule created by Congress years ago, which Congress has overridden every year since.
• Premiums will be set according to actuarial realities; that is, contrary to what many fear, the Commissioner of the plan will be required to charge premiums at rates set to actually cover the cost of providing insurance. This means premiums will not be artificially low, consequently gutting the insurance industry, as well as causing market disequilibrium (artificial supply/demand construct).
• The public option will exist only on the individual health insurance exchange. It will not compete with group health plans. This is good because individual plans are currently priced to favor the insurance companies (oligopoly market, creating economic profit at the expense of the consumer). The public option will move the market toward perfect competition. On the other hand, the group insurance market is probably too fragile to compete with the public option, mostly because employers would leave their current plans in droves to purchase cheaper rates from the government.
  
• Perhaps the best aspect of the public option is that the Commissioner of the plan will have the freedom to experiment with reimbursement mechanisms in order to incentivize improvements in quality and patient outcomes; for instance, increasing reimbursement for primary care physicians who create "medical homes" (that's a whole 'nother blog).

What's wrong with the public option:
Aside from the general caveats, which, prejudiced as they may be, are probably accurate , there are specific problems I can point out. In terms of the general caveats, they are the charges being lobbed at "government-run" health care by its detractors; for instance, the government has a penchant for breaking everything it tries to fix. In attempts to make health care more efficient the government will create layers of bureaucracy, and run the business like a courtroom or a legislature instead of like a business, ironically increasing the cost astronomically rather than saving money. Charges like these are unsubstantiated only because they are predicting a future as yet unrealized. However, the government's track record is dismally clear. Even President Obama himself pointed out that the government-run postal service is imploding while private enterprise mail delivery (FedEx, UPS, DHL) is thriving.

Now onto the specifics:

• The legislation sets initial reimbursement rates at current Medicare rates. The government really believes that Medicare reimbursement is generous. I know because I read the outpatient hospital payment updates published in the Federal Register every year (you think HR 3200 is bad at 1018 pages . . . the proposed 2010 updates to the outpatient prospective payment system was over 1800 pages this year!). But I can tell you that no physician in his/her right mind will accept 100% of Medicare. Most contracts with private insurance plans peg reimbursement as a percentage of Medicare, usually somewhere between 110% and 130%. Why would a provider, who successfully negotiates with Aetna and Blue Cross for, say 115% of Medicare, agree to accept straight Medicare rates from the public option? Unfortunately for the public option, the law creates a provider escape clause, and I predict most providers (at least the good ones with full waiting rooms) will exploit.
• Providers other than physicians (e.g. hospitals, nursing facilities, ambulance companies) have a take-it-or-leave-it reimbursement option: they can agree to accept Medicare rates or they can opt out. Big providers like hospitals are used to taking Medicare rates, and they will generally feel intimidated by the government's market dominance to accept these rates.
• From an economic perspective, setting rates artificially at Medicare reimbursement levels will cause supplier shortages. As I said above, Medicare rates are too low already. In a real free market, suppliers would stop producing if the price was set artificially below the cost of production. In the whacky health care world, we adjust our losses by shifting costs onto our paying customers, in this case, the private health insurance plans. This in turn creates artificially high prices for these customers. Or, another way to look at it is as a hidden tax tacked onto your health insurance premium.
• The plan will truly be run by the government, including the Dept. of Treasury creating a special bank account for the plan. As we said above, the government does not know how to do anything efficiently. It creates additional layers of bureaucracy, and regulatory hurdles, and a slavish devotion to process with complete disregard to outcome. The government would be better off hiring private insurers as contractors to deliver these services, just as they already do with Medicare (NOTE: you may think Medicare is a pure-bred government-run health care plan, but in all actuality, it's only government-funded. CMS pays private companies, like Blue Cross, to administer the program for seniors).
• I am afraid the the most devastating unintended - but certainly not unforeseen - consequence of the public option will be the demise of employer-sponsored group health insurance plans. American industrialists are a creative bunch, getting where they are in part because of their problem-solving skills and their stick-to-it-iveness. Employers will find a way to bump their employees off of group plans and into the individual insurance market, where they will pick up the public option. Let's face it: the dreaded 8% (of payroll) penalty that will be levied against employers who do not provide health insurance to their employees is a BARGAIN compared to the true cost to employers of providing health insurance in the first place. For this reason, if for no other, I would prefer the Senate's solution of creating non-profit coops to compete against the private insurance industry.

The Public Option introduces some good ideas to the health care reform debate, but as a complete package, I am afraid that the dangers outweigh the promises. This is probably a moot point, since I predict the public option will be excised from the final bill.

Don't Crush AEtna!

IN my last blog, I mentioned that the constellation of restrictions placed on for-profit health insurance companies by HR 3200 create the risk of imploding the health insurance industry. Not that the industry doesn't need - and deserve - some regulation! Still and all, for these companies to flourish, they must be able to operate in the marketplace. And investors will flee from their stock if they adjudge that these companies will no longer be able to make a profit.

In addition to the restrictions I discussed in my previous blog; namely, setting limits on out-of-pocket responsibilities for policy purchasers, HR 3200 seeks to create other restrictions on the health insurance industry:

1. Individual policies that aren't grandfathered will have to be offered on the Insurance Exchange, which will be sort of a comparison-shopping website or program where all plans can be compared to one another, much like Medicare Advantage plans can now be compared one to another on the Medicare website. This will engender competition among the plans, driving costs down and reducing variation in the benefits offered. But it will also limit an insurance company's ability to restructure pricing for its product. Overall, however, I think this is a good thing, because individual insurance policies currently are all over the place, with regard to price and quality.
2. Exclusion for pre-existing conditions will be prohibited. I mentioned this in my last post. This is a good thing for the consumer. Of course, for the issuer of the policy, it increases risk and provides no method of escape.
3. Guaranteed renewal of coverage - insurance plans will not be able to drop customers because their risk profile intensified. The only legitimate reason for dropping a customer is non-payment of premiums, and even then, the insurance plan has to notify the client of the impending cancellation and offer a grace period to re-activate coverage. Overall, this is a necessary improvement, since this has been one of the most common ways that insurers have shed themselves of expensive clients.
4. Variation of rates based on age of the insured person is allowed, but limited to a 2:1 ratio; that is, the higher rate for an older client cannot exceed twice the lowest rate for a younger customer. Again, this limits the insurer's ability to minimize its vulnerability to risk.
   
5. Insurers must provide coverage for mental health and substance abuse. Traditionally, insurers have reduced benefits for these two elements within their plans, to reduce their expenses for what many people don't even consider an illness in the first place. I believe this "discrimination" against mental health benefits was a reaction to the unrestrained avarice of the mental health/substance abuse facilities of last decade. I think these facilities learned their lesson . . . at least those that didn't go bankrupt in the ensuing response from insurers to the overutilization of the 1980s and 1990s.
6. The federal government will regulate the allowable medical loss ratio. This is perhaps the biggest threat to the insurance industry. If the government sets, in effect, a ceiling on the profits an insurance company can earn, it will drive investors away from the industry. The medical loss ratio is the percentage of revenue that is paid out in medical claims. If the government sets this amount too high, the profit margin will be erased (there is very little risk that the government will set the ratio too low).
7. Coverage for services can only be restricted based on medical necessity. That means that an insurance plan cannot decide to exclude coverage for a particuar medication or treatment that is FDA approved. If a drug is very expensive and the insurance plan doesn't want to cover it, the plan cannot create a bogus exclusion for the drug. It will have to find a way to provide the drug, because it is medically appropriate. The insurance plan is allowed to use the cost-share (copayment, co-insurance) to reduce demand for the drug or treatment. This is a common form of rationing currently used by the private markets. Ironically, many conservatives are worried about rationing of health care by a "government-run" system; yet this law will outlaw rationing based on anything other than medical appropriateness of the treatment.
8. The government will define a minimum set of services that must be covered. Insurance plans won't like this because they won't have the freedom to exclude certain services in their fine print. This is another trick that individual plans, especially, use to get out of paying for health care.
9. Annual and lifetime benefit maximums will be prohibited. This is another dirty trick used often by individual plans; for instance, the man I wrote about in my last blog whose insurance plan limited coverage for chemotherapy to $1000 per day. Or the patients we've seen with Mega Life policies (a division of United Health Care) that have a $25,000 annual cap, which is typically used up in the first two weeks of catastrophic care.
10. Cost sharing (deductibles, copays, coinsurance) will be limited, and altogether prohibited for preventive care. This increases the financial liability for insurance plans; on the other hand, it incentivizes individuals to seek out preventive care, which is always cheaper than treating late stage illness.

Taken together, these ten elements may very well hobble the private insurance industry, perhaps even erasing any profitability. This would be a big mistake, and I would urge the Secretary of Health and Human Services, who is charged ultimately with the regulation of health insurance plans, to protect the viability of the industry. The game will be played at the margins; that is, all of these changes may be implemented, and if they are implemented to the right degree, they may restrain the insurance industry without destroying it.

If these changes are implemented appropriately, the industry will survive, though not as profitably as it currently exists, and the consumer will be able to purchase a fair and reasonable product. Some plans will go out of business: the ones that need to go out of business. Most of these doomed plans are individual and small group plans - the plans that are poorly regulated today. Plans that charge exhorbitant premiums but end up paying out very little in benefits, through a mixture of exclusions, limitations, caveats and fine print. Plans that routinely drop patients when their loss ratio climbs too high, or exclude coverage for pre-existing conditions, or set unfair coverage limits . . . all these plans will go away. And that is as it should be.

HR 3200, Division A, Title I: What's Right; What's Wrong

Many pundits are talking about the Health Care Reform bill in Congress. Very few people have actually read it, including me. In actuality, there are three bills (not just one) currently wending their way through the two houses of Congress.

The piece of legislation that everyone is talking about is HR 3200. It is the longest, and the most liberal of the bills. So I thought that was a good place to start reading. House of Representatives Bill 3200, the 1,018-page behemoth passed in the House, is composed of three large divisions, each having a number of titles. I have slogged through the first section (Title I) of the first division (Division A), which is about affordable health care choices.

Title I sets out to standardize health insurance plans - both individual plans and group plans. While large group health insurance plans have been more highly regulated, historically, individual and small group plans have been flying under the radar for many years, and this is where I personally see the most abuse of consumers by the insurance industry.

The very first thing HR 3200 does is guarantee your right to maintain your current coverage, as long as you continue paying your premiums. So the plan won't scrap anybody's gold-plated plan already in existence. Or for that matter, if you currently pay for a crappy plan, your right to maintain poor coverage will continue for as long as you pay your premiums.

For people who currently do not have adequate insurance coverage, the bill creates a classification entitled, "Qualified Health Benefits Plans" (QHBP) and then sets out proposed regulations to standardize plans and protect consumers from mechanisms used by the insurance industry to avoid payouts.

Standards Guaranteeing Access to Affordable Coverage: Insurance plans will be limited in how much out of pocket expenses they can foist on their clients. Even then, the deductible limits are generous to the insurance industry, with caps on deductibles of $5,000 per individual and $10,000 per family, adjusted upward for inflation in future years. There will be three levels of QHBPs. The standard plan with the least expensive premium, will be allowed to shift about 30% of total cost of care on the insured. The next level up will be allowed to shift around 15%, and the top, or premium, plan will shift only 5% of total cost on the consumer.

Health plans will not be allowed to drop customers who become too expensive, as long as the customer pays his premiums. Nor will plans be allowed to exclude coverage for pre-existing conditions, nor raise premiums drastically on "high-risk" consumers to drive them out of the plan.

Here's what's good about it: in my line of work I have seen dozens of cancer patients who have lost their insurance because they lost their jobs and their group health benefits. If they were able to afford COBRA payments, their COBRA coverage eventually ran out and they were forced to convert to individual policies or lose insurance coverage altogether. Prior to the Stimulus Package, COBRA was unaffordable for most people, as group health plans were allowed to charge up to around 102% of the premium directly to the individual (the extra 2% or so was to cover the administrative costs incurred by the company). While most companies don't take this extreme option, they still shift most of the premium burden onto the individual, often making insurance unaffordable, especially when the individual is unable to work because of the illness.

When a patient's COBRA is converted to individual insurance (or if the patient was a small business owner or self-employed and already had individual insurance) then all bets are off. Because the protections built into group health regulations don't exist in the individual insurance market.

Individual plans are allowed to increase premiums annually (sometimes more frequently) based on the individual's history of claims. In most states, individual plans are allowed to exclude coverage for pre-existing conditions, often for more than a year, and in a few states indefinitely. Thus, if you were a cancer patient who was dropped from her individual insurance plan, you might attempt to purchase another plan on the open market, only to find that you lived in a state where the insurance company was allowed to exclude your cancer diagnosis for a year. Or forever. Health insurance, at that point, isn't worth the investment, since the main driver of your health expenses - your cancer - won't even be covered by the health plan.

Under the proposed reform to health insurance practices, insurance companies will no longer be allowed to discriminate against consumers based on pre-existing conditions. And premiums, as well as premium increases, will be regulated so insurance companies can't use premiums as a back-door way of firing their expensive patients.

What's bad about it: By itself, the prohibitions against excluding and dropping patients and against charging exhorbitant out-of-pocket rates aren't bad at all, and are prohibitions that the insurance industry can probably absorb. The problem is the number of restrictions that this bill places on insurance companies (and we'll visit more of these restrictions in later posts). Insurance companies are still for-profit businesses, and they have to be able to thrive and pay dividends (or at least grow in value) . If the government increases the regulatory burden on insurance companies to the point that they all become unprofitable, we will face a crisis in the health care financing infrastructure.

Some of my readers believe that the more liberal elements of the Democratic party secretly want this to happen, in order to usher in the Golden Era of the Single Payer Health Care System (or in their minds, the return of Stalinist centralized socialist economy). Well, truth is, some liberal Democrats do want this. But I don't believe President Obama or most of Congress really want to sneak in a single payer healthcare system by decimating the private insurance industry. Doing it in an underhanded way as this would only create chaos and anarchy for a period of time before a "government-run" health care system could rise from the ashes.

No, if this bill triggers an economic crisis in the insurance industry, it won't be because of some dastardly secret plan to destroy the free market. It'll just be the government's uncanny talent for creating more formidable unintended consequences than intended outcomes.

We have a good bit more to cover on Title I of Division A, but I'll save that for another night, as this post is already getting overlong.

Coming up:

Subtitle C—Standards Guaranteeing Access to Essential Benefits - the Health Choices Commission standardizes benefits
Subtitle G—Early Investments - reinsurance plan guaranteed by a $10 billion trust fund provides security for group health plans covering retired employees who are not (yet) eligible for Social Security (or "Rick Waggoner, couldn't you have held on two more years?")
. . . and much more!

Death Panels

Newt Gingrich and Sarah Palin have something in common . . . they both have attacked the end-0f-life planning section of the House's health care reform bill. Newt was more sophisticated in his attacks, refraining from using Sarah's term, "Death Panels," but called it the same in so many words. Sarah really believes it. Newt is too smart to believe it, but too Machiavellian to pass up the opportunity to terrorize the simpler-minded in our country for his own political gain.

Have you read the "Death Panel" clause? It begins on page 424 of the House bill (the version authored by Rep. Dingell, et al.) Before you start hiding your grandparents and your children with Downs Syndrome in the cellar, just take a look at this section of the bill amending Sec. 1861 of the Social Security Act. When you actually read it you'll discover that it is, very simply, an amendment that requires Medicare to pay for "advance planning consultations" not more than every five years.

And what is an advance planning consultation? It's an opportunity for a Medicare beneficiary to sit down with his or her physician and have an honest conversation about what is often inappropriately called "end of life" issues. In fact, these are issues we all face every day, but those of us who are young enough to be in denial about our mortality successfully avoid. They are decisions that every one of us should already be thinking about, in case we get hit by a bus, or get diagnosed with leukemia, or suffer some other trauma or life-threatening disease.

There are several elements to an advance planning consultation. The practitioner educates the patient about these issues, and then the patient asks questions and thinks out loud. The practitioner provides resources to the patient. The patient might make some decisions during the consultation, or he might go home and think about all these issues. The patient is not required to make any decisions regarding end of life care. Here are the things you talk about:

• Advance directives (living wills, durable powers of attorney for health care, etc.)
• What kind of life sustaining treatments you want - or don't want - in the event that you get really sick and you are not able to speak for yourself (you're unconscious or on a ventilator, etc.).
• Health care proxies: the person who will speak on your behalf in the event you can't speak for yourself, to make sure your wishes are carried out.
• Palliative care and hospice. These are not the same thing, by the way. Palliation is treatment that eases your symptoms, like pain management. You can receive palliative care while being aggressively treated, as well as when receiving only supportive care. Hospice is "end of life" care for the terminally ill. It is not euthanasia. It's symptom management when cure is no longer possible, allowing nature to take her course, and death to come naturally.

Is advance planning morbid? In the mind of most people, yes. That's because most people are afraid of death and don't want to think about it. Ever.

I don't have the luxury of living in this denial. In my work, I have seen many people die. I have been in the patient's room a hundred times - in the ICU, in the oncology unit, in the Emergency room. I have seen people die good deaths. They were prepared. They knew they were dying, and so did their families and loved ones. These patients are usually the patients who made these difficult decisions about the end of life. And because they faced the difficult decisions, they were able to die peacefully, surrounded by family, often in prayer, sometimes even singing hymns.

I have also seen patients die horrible deaths. I have seen patients coded over and over again, shocked with defibrillators, their ribs cracked from chest compressions. I have seen patients kept in the dark space between life and death, tethered to ventilators and dialysis machines, with no hope for survival, but trapped by loved ones who can't let go or won't let go. Sometimes they're trapped by the guilt of a survivor who didn't make amends for hurts inflicted long ago. Other times patients are kept in literal purgatory because a husband or wife or adult child has been asked to make a decision - a decision they never before considered - to "withdraw care"; that is, to stop treatment. And he can't. Because it feels like he is actively taking the patient's life.

The common denominator in these terrible deaths is that these patients, and often their physicians, avoided those difficult end-of-life discussions, hoping to escape the necessity. And then the crisis arrives like a thief in the night, leaving them no time to make those decisions.

In the House bill, advance planning consultations are purely voluntary. The patient must request it from the practitioner. All the bill attempted to do was to provide payment to the doctor for taking the time to have these conversations. Because right now, your doctor does not get paid to sit with you for an hour and talk you through these difficult but necessary decisions. And with what Medicare pays your doctor, he or she can't afford to give up six paying patients to spend an hour with you for free. This bill was going to enable your doctor to make time for you.

Alas! Because of intellectually challenged people like Sarah Palin, and morally challenged people like Newt Gingrich, the odds are now that the advance planning consultation clause will be struck from the bill.

Now let me say one more thing about "Death Panels." The purveryors of scare tactics want you to believe that a government-run health care system will ration care, focusing on the brightest and best of society and putting the weak and old to death. Don't you know that this is already happening? And not at the hands of the federal government, but under private health insurance and market driven health care.

When I was a case manager for oncology patients in the hospital, I could not count the number of times I was pressured by an insurance case manager to talk to their beneficiaries about hospice. I would call the insurance company to give them an update on the patient's condition. The nurse on the other end of the line would often say something like this: "Well this patient has cancer. She probably doesn't have long. Why is she getting treatment? Don't you think she should go on hospice? You need to bring up hospice with the patient." Sometimes the patient really was near the end of life. Sometimes the patient had just gotten diagnosed. If the patient's cancer had just recurred, or if it had spread, I was sure to get the hospice "option" pushed onto me.

Let me say this about hospice: it is a wonderful service for somebody who needs it and wants it. But the decision to choose hospice care is a philosophical decision, not an economic one. And it's the patient's decision, not the payer's.

Advance planning consultations - are they Death Panels? Not at all! They are actually Life-giving conversations. Because, in the words of a great prayer, until we are prepared to die, we never really are prepared to live. The issue, friends, is not whether the big bad government is going to take the decision of life an death away from us. The issue is whether we choose to exert control over that decision ourselves. The enemy is not the government, and it isn't even the insurance company. The enemy, in the words of Pogo, is us.

Freedom of Speech and the Responsibility to Listen

At this point I want to depart from my usual theme and talk about this recent phenomenon, driven by a grass-roots conservative movement, where public forums about health care reform are being dirsrupted by an unruly crowd that shouts down the speaker at the podium. Their purpose is to prevent any meaningful discourse from occurring, and to create the impression in the media that there is a groundswell of opposition to health care reform.

First, I find it somewhat ironic that this ultra-conservative group is using tactics made popular by leftist radicals in the 1960s. But more to the point, I'd like to make these observations:

• When a person resorts to yelling and dirsrupting reasonable discourse, it usually means that the person has nothing useful to bring to the discussion. It becomes an indictment, therefore, against conservative forces, who betray that they are "agin" reform, but have nothing better to offer.
• These people were raised in a barn, and their mommas never taught them any manners.
• It's a sad day in the body politic when we cannot have civilized and rational discourse on the issues at hand. It speaks sadly to the deterioration of civilization in our nation.
• It behooves us to engage one another, even with wildly divergent views, in order to find a place where we can meet. Because we can't stay where we are, with regard to health care in this country.
  

Health Care: Right or Privilege?

Part of the reason we find it difficult to have rational discourse on health care reform in this country is that we all speak different languages. What I mean by that is we hold different assumptions and beliefs from which we operate, and therefore we can't figure out why the person who disagrees with us is such an idiot. Well, he or she is probably not an idiot; he or she simply holds a different set of beliefs than we do, causing them to see the world differently.

One of the basic issues that we have to be at least aware of, if not in agreement with, is whether health care is a right or a privilege. If health care is a right, then, ultimately, we have to provide a certain level of health care to everyone, regardless of their ability to pay for it . . . which means government-run health care. If health care is a privilege, or perhaps more accurately, a responsibility, then we can allow the free market to provide financing options for health care and people may choose to purchase coverage or to pay as they go. And if they end up needing more health care than they can afford, they just have to live (or die) with the consequences of their decision (not to buy health insurance).

I happen to think that virtually every American actually agrees on this issue. Virtually everyone I speak with about health care believes the same thing: that he (or she) has a right to health care, but as far as everyone else is concerned, it's a privilege. Even the most die-hard libertarians who rant about being coerced by the government to pay taxes to fund social welfare programs suddenly become very nearly socialist when, for instance, after smoking two packs a day for 30 years, they develop lung cancer, find themselves somehow uninsured, and turn to Medicaid to pay for treatment. I have never seen a free-marketer turn down government-run health care when his own life was on the line.

The truth is that we are schizophrenic about this issue, and our actions betray our confused beliefs. As a nation, we seem to believe that some basic level of health care is a right, as borne out by the Medicare and Medicaid programs, and EMTALA legislation that requires emergency departments to treat patients with life- or limb-threatening illnesses, regardless of their ability to pay.

On the other hand, we also seem to believe health care is a privilege, as evidenced by the different levels of health insurance that we can purchase, or choose not to purchase at all. The fact that 15% of our nation's citizens have no health care coverage, and we as a society tolerate this inequity, is further proof that we consider health care a privilege.

I think we would be best served by putting this issue squarely on the table, and coming to some sort of majority agreement (consensus is impossible in our current environment) as to what level of health care is a civil right, and create the infrastructure for providing that level of care to our citizens. Then, persons who want more than the basic level of health care coverage can choose to purchase additional coverage. In a sense, this is what we already have for the poor and the elderly with Medicaid and Medicare, respectively.

NOW A COROLLARY TO HEALTH CARE AS RIGHT OR PRIVILEGE

Americans, in general, confuse the right to health care with the financing of health care. A popular argument currently being bandied about against reform goes something like this: "I don't want some unelected bureaucrat making my health care decisions for me. That's for my doctor and me to decide."

Here's the problem with that argument: you can already decide for yourself what kind of health care you want. The question is whether you can afford it. If you're worried that you are going to lose the freedom to make your own health care choices under "ObamaCare," you should open your eyes. That train left the station years ago!

The fact is, your freedom of choice has already been limited by the private sector! If you are uninsured you'll discover that you can't afford anything beyond the most basic care. If you are insured you will discover that your insurance company will have the last say on whether they will pay for your choices, in which case, if you choose a plan of action that your insurance company considers medically unnecessary, you're back to the first scenario . . . you're basically uninsured.

Let's use an example from my world - cancer care. Let's say you're a man, and you get diagnosed with prostate cancer. You and your doctor decide together that the best option for you is proton-beam therapy . . . the most expensive form of radiation therapy, available in only a handful of centers. In this case, you'd be lucky if you were the victim of government-run health care (i.e. if you were a Medicare beneficiary) because Medicare pays for proton-beam treatments.

But let's say you decided to purchase the cheapest insurance you could find, with a low monthly premium. You know that the insurance company can charge such a low premium because they make up the difference with high deductibles and copays. At the time you bought the policy, you weren't planning on getting sick, and so you didn't think much about it. You also didn't bother to read the exclusions and conditions and the other fine print.

Now you have prostate cancer. And you want to go to Loma Linda for proton beam therapy. You make the appointment and fly out for the consultation, only to be told that you will have to pay $50,000 (or more) up front because your insurance plan doesn't cover proton beam therapy.

Read this next part very carefully: Your insurance company never said that you could not get proton beam treatments. You are perfectly free to get proton beam treatments if that's what you and your doctor think is best. All your insurance company said is that they aren't going to pay for it. And they don't have to. Because health care, at this level, is a privilege, not a right.

At this point, you might beg or plead or even demand that the good folks at the Loma Linda facility treat you for free, or for a greatly reduced price. But they are not obligated to give you a price cut. Just because you are free to choose this expensive treatment doesn't mean the provider has to give it to you.

So you are free, in theory, to choose whatever health care you and your doctor think is best. But if you can't afford the treatment, are you really free? And if your insurance company refuses to cover the treatment, are you really free?

We are in a place in this country where we can't speak to each other rationally or, for that matter, civilly, about health care reform. And we will never get out of this place until we can find some common ground, or as they say in the music biz, sing from the same sheet of music.

One of first issues with which we have to come to terms is whether we believe there is a basic civil right to a minimum level of health care. If we do, how will we provide that level of care? And if we don't, how will we be able to turn those people away at the Emergency Room door who can't afford to pay?

You get what you pay for . . . NOT

We are not getting value for our health care dollar in the United States.

In 2007, we spent $2.4 trillion on health care, or $7,900 for every man, woman and child in America. That's more than any other country on the globe spent on health care, as a total sum, or as per-capita spending.

To put it another way, we spent 17% of our gross domestic product (GDP) on health care. The GDP is the sum total of all production - in terms of goods and services - generated by our nation's economy. That means for every $1 of wealth that we as a nation created in 2007, 17 cents went to pay medical expenses.

Again, to put our health care spending in perspective, we are spending 4.3 times more on health care than we spend on national defense. And what are we getting for our money? The U.S.A. ranks 50th in the world, according to the CIA, in life expectancy, behind Portugal and just ahead of Albania (our average life expectancy, if you were wondering, is 78.11 years). And at 6.26 deaths per 1,000 live births (again, according to the CIA), we rank 46th in infant mortality -- behind Cuba and just ahead of Croatia.

Let me repeat that, so it sinks in. We spend more than any other nation on earth, per person AND in total, and yet we have Third-World rates of infant mortality and life expectancy. And for all that money we spend, we still leave 46 million people uninsured.

Let's now compare American health care value with some of our neighbors in the community of industrialized nations. These figures come from the Organization for Economic Cooperation and Development: Switzerland spends 10.9% of its GDP on health care, and ranks 16th in the world in infant mortality and 11th in life expectancy.
Germany which spends 10.7% of its GDP on health care, ranks 15th in infant mortality and 32nd in life expectancy. Canada spends 9.7% of its GDP on health care. Canada ranks 36th in the world in infant mortality and 8th in life expectancy.
France spends 9.5%. France ranks 8th in infant mortality and 9th in life expectancy.

The USA spends almost twice as much on health care as these four industrialized nations, yet they all rank higher than we do on these two measures of health. To top it off, all four of these countries provide universal coverage for their citizens. Clearly, we are not getting our money's worth. In future posts to this blog, we'll explore some of the reasons that American health care costs so much but delivers less than promised in terms of value. Right now I mostly want you to realize that it is very possible to spend less on health care and expand coverage to all Americans at the same time.

Are the French smarter than we are? Are the Canadians more efficient? Are the Swiss just hardier people? Do the Germans live healthier lifestyles than we do? The answer to each of these questions is NO! If these nations can do provide universal health care cost-effectively to their citizenry, certainly we Americans can do it at least as well, if not better.