My solution to healthcare reform

[ERCougar]

Change Medicaid eligibility from income to % of income spent on medical expenses. The percentage would be fairly high (maybe 10%?) and progressive (poor people qualify at a lower percentage than rich people). For example, a 200K earner might qualify for Medicaid once his expenses reach 30K in a year while a 15K earner qualifies once his expenses reach 1K in a year. It's enough that a family would feel it, but that no medical catastrophe would ever completely bankrupt someone.

Here are the advantages, as I see them:
1) Maintains the private insurance market - Not every doctor takes Medicaid, but most essential services are covered. People still would be interested in the additional benefits of private insurance.
2) Controls costs - people will be making cost-based decisions on their medical care, up to a point.
3) Controls insurance premiums - Insurance premiums get so high because of high-cost patients and catastrophes. The government acts as an insurer to the insurer.
4) Locally-controlled - Medicaid is state-run and actually does a decent job of "rationing". Patients don't get whatever they want, but get essential services. Each state is responsible to its own constituents for provisions, denials, income limits, costs, etc. I imagine Oregon's rules would look very different from Utah's rules, which is just fine. State bureaucracy >>> federal bureaucracy.

What do you think?

[RobinFinderson]

Change Medicaid eligibility from income to % of income spent on medical expenses. The percentage would be fairly high (maybe 10%?) and progressive (poor people qualify at a lower percentage than rich people). For example, a 200K earner might qualify for Medicaid once his expenses reach 30K in a year while a 15K earner qualifies once his expenses reach 1K in a year. It's enough that a family would feel it, but that no medical catastrophe would ever completely bankrupt someone.

Here are the advantages, as I see them:
1) Maintains the private insurance market - Not every doctor takes Medicaid, but most essential services are covered. People still would be interested in the additional benefits of private insurance.
2) Controls costs - people will be making cost-based decisions on their medical care, up to a point.
3) Controls insurance premiums - Insurance premiums get so high because of high-cost patients and catastrophes. The government acts as an insurer to the insurer.
4) Locally-controlled - Medicaid is state-run and actually does a decent job of "rationing". Patients don't get whatever they want, but get essential services. Each state is responsible to its own constituents for provisions, denials, income limits, costs, etc. I imagine Oregon's rules would look very different from Utah's rules, which is just fine. State bureaucracy >>> federal bureaucracy.

What do you think?

It isn't a terrible idea. The biggest problem I see is the maintenance of the private insurance market. Private health insurance is the devil in the details. Once we have gone that far toward total socialization, what benefit remains in floating the private insurance industry?

[ERCougar]

It isn't a terrible idea. The biggest problem I see is the maintenance of the private insurance market. Private health insurance is the devil in the details. Once we have gone that far toward total socialization, what benefit remains in floating the private insurance industry?

1) No plan will ever pass that eliminates or curtails the private insurance industry. The industry is simply too large and powerful.
2) Competition still works to an extent. We need to reward good doctors. We need to reward patients for healthy lifestyle choices. Private insurance markets can serve both of these ends.
3) There's no way to eliminate a market. Even in Canada, people purchase supplemental insurance.

[Swimmer]

Change Medicaid eligibility from income to % of income spent on medical expenses. The percentage would be fairly high (maybe 10%?) and progressive (poor people qualify at a lower percentage than rich people). For example, a 200K earner might qualify for Medicaid once his expenses reach 30K in a year while a 15K earner qualifies once his expenses reach 1K in a year. It's enough that a family would feel it, but that no medical catastrophe would ever completely bankrupt someone.

Here are the advantages, as I see them:
1) Maintains the private insurance market - Not every doctor takes Medicaid, but most essential services are covered. People still would be interested in the additional benefits of private insurance.
2) Controls costs - people will be making cost-based decisions on their medical care, up to a point.
3) Controls insurance premiums - Insurance premiums get so high because of high-cost patients and catastrophes. The government acts as an insurer to the insurer.
4) Locally-controlled - Medicaid is state-run and actually does a decent job of "rationing". Patients don't get whatever they want, but get essential services. Each state is responsible to its own constituents for provisions, denials, income limits, costs, etc. I imagine Oregon's rules would look very different from Utah's rules, which is just fine. State bureaucracy >>> federal bureaucracy.

What do you think?

Your idea is as good as almost any other that has been floated recently. The interesting thing about medicaid is that currently, almost anyone can qualify for medicaid if they are willing to pay the price. Basically it works like this:
There is a monthly income limit for medicaid eligibility. If your monthly income is higher than that limit, then you can "spenddown" to that level. So, if you make $5000 per month, and if the income limit for medicaid is $1500, then you have to pay the first $3500 of any medical bills that you accrue each month and medicaid will cover the rest. This is obviously only worth it for most people in the event of a catastrophic health care need. Those making $5000 per month likely have insurance already so it doesn't get used too often, but there are people who benefit from this. I like your idea better for the most part.

[RobinFinderson]

1) No plan will ever pass that eliminates or curtails the private insurance industry. The industry is simply too large and powerful.

Maybe not right now, but the day is coming when we can get rid of the health insurance industry. The health of the Republic can only be as fit as the health of its citizens. Eventually the people will come to their senses and realize that an excellent public health plan is exactly what this country needs to protect our national security. A healthy populous is not a luxury. It is a necessity. Once we all figure that out we will get tired of paying the middle men, and we will insure ourselves with our taxes.

2) Competition still works to an extent. We need to reward good doctors. We need to reward patients for healthy lifestyle choices. Private insurance markets can serve both of these ends.

Private insurance isn't the only system that can reward and penalize behavior.

3) There's no way to eliminate a market. Even in Canada, people purchase supplemental insurance.

No worries. We need to define a substantial baseline of health care which should be available to all citizens as a matter of right. If people want more than this let them buy whatever supplemental insurance they want.

[Mormon Red Death]

Change Medicaid eligibility from income to % of income spent on medical expenses. The percentage would be fairly high (maybe 10%?) and progressive (poor people qualify at a lower percentage than rich people). For example, a 200K earner might qualify for Medicaid once his expenses reach 30K in a year while a 15K earner qualifies once his expenses reach 1K in a year. It's enough that a family would feel it, but that no medical catastrophe would ever completely bankrupt someone.

Here are the advantages, as I see them:
1) Maintains the private insurance market - Not every doctor takes Medicaid, but most essential services are covered. People still would be interested in the additional benefits of private insurance.
2) Controls costs - people will be making cost-based decisions on their medical care, up to a point.
3) Controls insurance premiums - Insurance premiums get so high because of high-cost patients and catastrophes. The government acts as an insurer to the insurer.
4) Locally-controlled - Medicaid is state-run and actually does a decent job of "rationing". Patients don't get whatever they want, but get essential services. Each state is responsible to its own constituents for provisions, denials, income limits, costs, etc. I imagine Oregon's rules would look very different from Utah's rules, which is just fine. State bureaucracy >>> federal bureaucracy.

What do you think?

I'm surprised you as Doctor would be for Medicaid. Medicaid pays reimburses so poorly. I'm in a business venture and we checked with the state to see how much Medicaid would cover for Outpatient Occupational Therapy services. For the exact same service that BC/BS or IHC would pay $100 - $120 medicaid pays $20.

What does this mean? It means that states don't do a good job of rationing. Providers do the rationing by not accepting the insurance. It means ERs will be the primary care physician for the medicaid. It means that Outpatient treatment will have be done by overburdened government systems (school systems, state health offices). At least Medicare reimburses ok (not great).

Here again is my plan:

Medicaid is scrapped completely


1. High Deductible insurance is given to all residents of the state. The state pays health care providers once the residents of the state meet the deductible amounts (see provisos below) at Medicare rates and cover the exact same items that Medicare covers.

Here are the provisos to #1
A. Every person from 1-18 is completely covered no deductible
B. Single people from 19-65 have $6,000 deductible
C. Married people from 19-65 have $6k deductible per person or $8k per couple
D. People over 65 have a $2k a year from state to cover Medicare costs and deductibles
E. 100% of Preventative measures are covered
F. Employers must contribute 40% of Deductible for Full Time workers and 20% of part time workers that work 20 hours a week. If someone does not work 20 hours a week the employer is not required to pay anything. Conversely, an employer may only pay 80% of deductible each year.

G. Smoking cessation, Gym membership, or other weight loss programs all contribute up to $1500 of Deductible. Dental care can contribute up to $2,000 of deductible.


2. $2 a gallon Gasoline tax is affixed to pay for program. Michigan averages 4.5 billion gallons of gasoline consumed each year. That means 9 billion dollars to cover 7.1 million people. Reasons for a gas tax:

A. It’s easy to collect - http://freakonomics.blogs.nytimes.co...-a-guest-post/

B. It gives incentive to the designers, engineers and makers of automobiles to come up with gas saving cars.

3. 10% Fast Food sales tax. Average American consumes 159 fast food meals a yearhttp://answers.google.com/answers/threadview/id/779290.html. A 10% tax on an average meal of $6 for 7.1 million equals almost 700 million. These revenues would be used solely for Preventative measures and covering Children’s health. Reasons for this tax

A. Obesity and Fast Food consumption are correlated http://www.theyesword.com/obesity_and_fast_food.htm
B. Easily to collect.

4. Statewide system of Health care coverage that every provider in State must subscribe to track how much of deductible is used.

In conclusion, this plan makes sense on many levels.

A. It appeals to democrats as a way to broaden coverage to all Michigan residents

B. It appeals to Republicans as a Health Savings account provides market based solution

C. It appeals to hospitals and health care providers because as soon as a person meets their deductible amount ONE payer pays the reimbursement.

D. It appeals to business out of state to move to Michigan. Business’ where payroll makes up a substantial amount of costs are seeing the dramatic rise in health care costs.

[I.J. Reilly]

MRD, I think your plan is interesting but I see a few problems with it that I would like to address.

I'm surprised you as Doctor would be for Medicaid. Medicaid pays reimburses so poorly. I'm in a business venture and we checked with the state to see how much Medicaid would cover for Outpatient Occupational Therapy services. For the exact same service that BC/BS or IHC would pay $100 - $120 medicaid pays $20.

Medicaid can pay so low, and doctors can accept such low rates from them because they are guaranteed single payers. If you are billing insurance then you have the problem of splitting bills between corporations, who often dispute the bill, and private citizens, who often don't pay. With medicaid you avoid this problem. Non-emergency services often have to be cleared and the bills are paid promptly by the government.

1. High Deductible insurance is given to all residents of the state.

High deductibles often mean that the poorest among us do not get the care that they need. Those large numbers seem insurmountable to someone who earns 10/hr.

E. 100% of Preventative measures are covered

This is a good idea, and helps to change the model we have to a more proactive one.

2. $2 a gallon Gasoline tax is affixed to pay for program. Michigan averages 4.5 billion gallons of gasoline consumed each year. That means 9 billion dollars to cover 7.1 million people.

I see two problems here with this portion of your plan.
1. A bump this large in the price of gasoline would surely create a change in consumption habits, as we saw this last summer. This reduces your projected revenues.
2. This is not a sustainable model. The hope is that we will move away from fossil fuel consumption and so the more that we move away from those fuels the less we collect. As social security can teach us, government is not good at planning for eventualities.

3. 10% Fast Food sales tax. Average American consumes 159 fast food meals a yearhttp://answers.google.com/answers/threadview/id/779290.html. A 10% tax on an average meal of $6 for 7.1 million equals almost 700 million. These revenues would be used solely for Preventative measures and covering Children’s health.

Every time that this idea is raised it soon gets cut down by the language of "sin tax" it's a hard initiative politically to push through and the argument then becomes where you draw the line. If fast food why not junk food? If fast food why not all restaurants, Chilis has some meals that would blow the Big Mac out of the water? This quickly becomes a very divisive issue that can be a firecracker for any politician holding it.[/QUOTE]

[I.J. Reilly]

Change Medicaid eligibility from income to % of income spent on medical expenses. The percentage would be fairly high (maybe 10%?) and progressive (poor people qualify at a lower percentage than rich people). For example, a 200K earner might qualify for Medicaid once his expenses reach 30K in a year while a 15K earner qualifies once his expenses reach 1K in a year. It's enough that a family would feel it, but that no medical catastrophe would ever completely bankrupt someone.

Here are the advantages, as I see them:
1) Maintains the private insurance market - Not every doctor takes Medicaid, but most essential services are covered. People still would be interested in the additional benefits of private insurance.
2) Controls costs - people will be making cost-based decisions on their medical care, up to a point.
3) Controls insurance premiums - Insurance premiums get so high because of high-cost patients and catastrophes. The government acts as an insurer to the insurer.
4) Locally-controlled - Medicaid is state-run and actually does a decent job of "rationing". Patients don't get whatever they want, but get essential services. Each state is responsible to its own constituents for provisions, denials, income limits, costs, etc. I imagine Oregon's rules would look very different from Utah's rules, which is just fine. State bureaucracy >>> federal bureaucracy.

What do you think?

ER, this plan seems very sensible but I have some issues I would like to raise that maybe you could answer for me.

1. Where are the rewards/penalties for good/bad behavior? What I mean is, do we (through our paid taxes) shoulder the burden of the cost of those that choose to live unhealthy lifestyles?

I personally think that one of the cornerstones of a good solution to our healthcare problems would have to be well thought out rewards for preventative/proactive steps taken by the individual.

2. When catastrophes do happen who decides how much care is enough? I would assume the government since they are paying but this doesn't often go over well with people who are watching family members die when they know that there are steps that could be taken that would help prolong the family member's life and/or ease their pain.

3. Do you employ any cost adjustments for cost of living?

As anyone who has lived in places with high costs of living could tell you a dollar in NYC is not the same as a dollar in Des Moines. Perhaps you see this as the price one pays to live in a more desirable spot in the country.

All in all though, I think this is one of the more reasonable plans I have seen.

[ERCougar]

I'm surprised you as Doctor would be for Medicaid. Medicaid pays reimburses so poorly. I'm in a business venture and we checked with the state to see how much Medicaid would cover for Outpatient Occupational Therapy services. For the exact same service that BC/BS or IHC would pay $100 - $120 medicaid pays $20.

What does this mean? It means that states don't do a good job of rationing. Providers do the rationing by not accepting the insurance. It means ERs will be the primary care physician for the medicaid. It means that Outpatient treatment will have be done by overburdened government systems (school systems, state health offices). At least Medicare reimburses ok (not great).

Nearly every pediatrician takes Medicaid. Most PCP's take Medicaid. Most specialists in my town take Medicaid. I would love to get Medicaid-level reimbursements for all of the uninsured people I treat right now. It's not our favorite insurance, but remember--Medicaid doesn't even kick in until people reach their deductibles, i.e. they're truly in need. We would all feel a lot better about taking lower reimbursements for people who are down on their luck.

Here again is my plan:

Medicaid is scrapped completely


1. High Deductible insurance is given to all residents of the state. The state pays health care providers once the residents of the state meet the deductible amounts (see provisos below) at Medicare rates and cover the exact same items that Medicare covers.

You're just changing the name and the reimbursement levels. You can call it whatever you want.

Here are the provisos to #1
A. Every person from 1-18 is completely covered no deductible
B. Single people from 19-65 have $6,000 deductible
C. Married people from 19-65 have $6k deductible per person or $8k per couple
D. People over 65 have a $2k a year from state to cover Medicare costs and deductibles

This is hardly a safety net for many folks. Also, you're missing out on an opportunity to cut costs--why should I have the same deductible as some college student who's living on Top Ramen?

E. 100% of Preventative measures are covered

No problem with this in principle. There are definitional issues here though--should the state pay for the most expensive new blood pressure medication that works no better than the old generic? This is where Medicaid rules often work fairly well. Patients and doctors often complain, but it makes them consider costs--something we all need to start doing.

F. Employers must contribute 40% of Deductible for Full Time workers and 20% of part time workers that work 20 hours a week. If someone does not work 20 hours a week the employer is not required to pay anything. Conversely, an employer may only pay 80% of deductible each year.

Why are we still trying to stick with employer-based coverage? What happens when your medical catastrophe causes you to lose your job? When you're the most vulnerable, you lose your help? That's not right.

G. Smoking cessation, Gym membership, or other weight loss programs all contribute up to $1500 of Deductible. Dental care can contribute up to $2,000 of deductible.

Good idea.

2. $2 a gallon Gasoline tax is affixed to pay for program. Michigan averages 4.5 billion gallons of gasoline consumed each year. That means 9 billion dollars to cover 7.1 million people. Reasons for a gas tax:

A. It’s easy to collect - http://freakonomics.blogs.nytimes.co...-a-guest-post/

B. It gives incentive to the designers, engineers and makers of automobiles to come up with gas saving cars.

3. 10% Fast Food sales tax. Average American consumes 159 fast food meals a yearhttp://answers.google.com/answers/threadview/id/779290.html. A 10% tax on an average meal of $6 for 7.1 million equals almost 700 million. These revenues would be used solely for Preventative measures and covering Children’s health. Reasons for this tax

A. Obesity and Fast Food consumption are correlated http://www.theyesword.com/obesity_and_fast_food.htm
B. Easily to collect.

4. Statewide system of Health care coverage that every provider in State must subscribe to track how much of deductible is used.

I love these ideas.

[I.J. Reilly]

How would cost of care be affected if doctors had less loans to repay? Is medical school a profit center for universities? Is the cost of medical school something that should be reevaluated?

How about malpractice insurance? Lawyers, should there be reform in our laws to limit the liabilities of doctors?

What sort of margins do medical supply companies make? What sort of argument could be made for curbing these margins(thereby reducing the profit incentive?)?

Should the U.S. pursue some policy that tries to get some other countries to shoulder some of the burden that the U.S. has had for so many years in the area of prescriptions?

[ERCougar]

How would cost of care be affected if doctors had less loans to repay? Is medical school a profit center for universities? Is the cost of medical school something that should be reevaluated?

No, medical school is not a moneymaker for universities. I'm pretty sure they receive supplemental funds for each student enrolled to help fund the education. Yes, the enormous loans med students have to take out are a huge problem in that they drive students from the lower-paying but more cost-effective (in a public health sense) primary care specialties. I'm pretty sure that in Europe, the government pays for medical education; if not, I know that the costs to the student aren't even in the same ballpark as here.

How about malpractice insurance? Lawyers, should there be reform in our laws to limit the liabilities of doctors?

<Biting my tongue>
OK, I'll just say that this is a HUGE difference between the US and every single-payor country. Malpractice premiums and fears drive up costs considerably.

What sort of margins do medical supply companies make? What sort of argument could be made for curbing these margins(thereby reducing the profit incentive?)?

I have no idea.

Should the U.S. pursue some policy that tries to get some other countries to shoulder some of the burden that the U.S. has had for so many years in the area of prescriptions?

Connecting patients with the costs of their medicines would do something in this regard. With few exceptions, there are cheap generic equivalents to medications that work just as well. In the ER, I prescribe almost all generics, as do most ER doctors, because we're trained that way. One of my major annoyances is when I get a call from a pharmacy because a patient that my partner saw wants a cheaper drug. So we just always write for the cheapest drugs.
Opening pharmaceutical trade with Canada will help this as well.
Single-payor advocates also point out that governments can get special discounts on drugs because they negotiate as one. Walmart and some insurers can do this too, though.

[wuapinmon]

No, medical school is not a moneymaker for universities. I'm pretty sure they receive supplemental funds for each student enrolled to help fund the education. Yes, the enormous loans med students have to take out are a huge problem in that they drive students from the lower-paying but more cost-effective (in a public health sense) primary care specialties. I'm pretty sure that in Europe, the government pays for medical education; if not, I know that the costs to the student aren't even in the same ballpark as here.

Here's one reason why med school costs so much. U of U salaries:

John A Hawkins Professor Cardiothoracic Pediatric Devel - $1,129,370

Clough Shelton Professor Otolaryngology - $936,441
Eric R. Scaife Associate Professor Pediatric Surgery Development - $879,197
Earl C Downey Associate Professor (clinical) Pediatric Surgery Development - $854,190
Rebecka L Meyers Associate Professor Pediatric Surgery Development - $849,531
Christopher L Peters Associate Professor Orthopedic Surgery Operations - $844,602
John T Smith Md Professor (clinical) Orthopedic Surgery Operations - $837,521
A Lorris Betz Senior Vice President Office Of The President - $791,414
Payam Tristani-firouzi Assistant Professor (clinical) Dermatology - $790,926
Faizi A Siddiqi Assistant Professor (clinical) Plastic & Reconstruct Surgery - $775,407
William Bradford Rockwell Professor Plastic & Reconstruct Surgery - $743,437
William T Couldwell Professor Neurosurgery - $711,355
Carl Rasmus Kjeldsberg Professor Clinical Pathology - $705,002
Richard E Black Professor (clinical) Pediatric Surgery Development - $690,319
Dennis Charles Shrieve Department Chair RADIATION ONCOLOGY SOM - $677,593
Stephen Eugene Morris Associate Professor General Surgery Faculty - $672,355
Charles L Saltzman Professor Orthopedic Surgery Operations - $670,141
Nassir F. Marrouche Assistant Professor Cardiology - $647,793
Michael Lynn Hadley Assistant Professor (clinical) Dermatology - $643,360
Robert Lawrence Randall Assistant Professor Orthopedic Surgery Operations - $615,045
Sean J. Mulvihill Professor Surgery Administration - $614,795

This is not a criticism of how much they make, just pointing out the high costs of paying a dude almost a million a year to teach ENT stuff.

[I.J. Reilly]

<Biting my tongue>
OK, I'll just say that this is a HUGE difference between the US and every single-payor country. Malpractice premiums and fears drive up costs considerably.

Feel free to elaborate. Can anyone make a good argument for not having any sort of malpractice reform? How responsible (in dollar amount) should doctors be for their actions as a medical professional?

[CardiacCoug]

Here's one reason why med school costs so much. U of U salaries:

John A Hawkins Professor Cardiothoracic Pediatric Devel - $1,129,370

Clough Shelton Professor Otolaryngology - $936,441
Eric R. Scaife Associate Professor Pediatric Surgery Development - $879,197
Earl C Downey Associate Professor (clinical) Pediatric Surgery Development - $854,190
Rebecka L Meyers Associate Professor Pediatric Surgery Development - $849,531
Christopher L Peters Associate Professor Orthopedic Surgery Operations - $844,602
John T Smith Md Professor (clinical) Orthopedic Surgery Operations - $837,521
A Lorris Betz Senior Vice President Office Of The President - $791,414
Payam Tristani-firouzi Assistant Professor (clinical) Dermatology - $790,926
Faizi A Siddiqi Assistant Professor (clinical) Plastic & Reconstruct Surgery - $775,407
William Bradford Rockwell Professor Plastic & Reconstruct Surgery - $743,437
William T Couldwell Professor Neurosurgery - $711,355
Carl Rasmus Kjeldsberg Professor Clinical Pathology - $705,002
Richard E Black Professor (clinical) Pediatric Surgery Development - $690,319
Dennis Charles Shrieve Department Chair RADIATION ONCOLOGY SOM - $677,593
Stephen Eugene Morris Associate Professor General Surgery Faculty - $672,355
Charles L Saltzman Professor Orthopedic Surgery Operations - $670,141
Nassir F. Marrouche Assistant Professor Cardiology - $647,793
Michael Lynn Hadley Assistant Professor (clinical) Dermatology - $643,360
Robert Lawrence Randall Assistant Professor Orthopedic Surgery Operations - $615,045
Sean J. Mulvihill Professor Surgery Administration - $614,795

This is not a criticism of how much they make, just pointing out the high costs of paying a dude almost a million a year to teach ENT stuff.

These docs aren't paid with med school tuition. I would bet that most of these guys generate more money for the Med School through research grants, and certainly more money for the University Hospital through clinical revenue than they take home in salary.

You can go to any hospital in the country and they will gladly pay a new cardiologist $$300-400K per year and feel like they got a bargain. The hospital will make many times that salary through the additional revenue that comes by adding a new physician.

[CardiacCoug]

Connecting patients with the costs of their medicines would do something in this regard. With few exceptions, there are cheap generic equivalents to medications that work just as well. In the ER, I prescribe almost all generics, as do most ER doctors, because we're trained that way. One of my major annoyances is when I get a call from a pharmacy because a patient that my partner saw wants a cheaper drug. So we just always write for the cheapest drugs.
Opening pharmaceutical trade with Canada will help this as well.
Single-payor advocates also point out that governments can get special discounts on drugs because they negotiate as one. Walmart and some insurers can do this too, though.

Sometimes I wonder why I even write for a specific statin or ACE-inhibitor. It would be easier to simply make recommendations (e.g. "medium-dose statin" or "low-dose ACE-inhibitor") and then let the patient work it out with the pharmacist and insurance company. That would definitely cut down on the number of calls and paperwork..