Thursday, November 13, 2008


Dr Don McCanne, Physicians for a National Health Plan - Obama's plan emphasizes increased government regulation and oversight of private and public insurance plans, leading to an incremental expansion of the existing system. As part of this, he would introduce a new Medicare-like plan for persons under 65 to serve as an alternative to private health insurance plans.

In terms of universal coverage, Obama's plan probably will not expand coverage very much, mainly because his plan doesn't do much to bring down the cost of health care. It continues to use the defective private insurance model.

The problem is that private insurers will not accept everyone in the risk pool, lest their costs go up. Even if regulations require them to do so, they still game the system through measures such as selective marketing. So people who are at higher risk will head for the new public or semi-public plans.

These plans, which under Obama's proposal would be available through a new National Health Insurance Exchange, would be required to accept people with pre-existing conditions. But they would still involve payment of premiums, co-pays and deductibles.

Obama says they would be patterned after the Federal Employee Health Benefits Program, but that may not be all that great. The plans that are offered to federal employees vary in price and a Senator can afford a plan that has far better benefits that his staffers. The FEHBP plans are not totally stripped down, but they still have deductibles, co-pays and other out-of-pocket expenses, and restrict people to a limited list of providers. In fact, 100,000 federal workers eligible for the FEHBP plans remain uninsured primarily because they cannot afford their share of the costs. Obviously that program wouldn't work for far too many of us.

Additionally, the program Obama describes will be costly. He says individuals who can't afford the premiums offered through the health insurance exchange plans will receive subsidies. But I think these subsidies will have to be much larger than estimated and will have to be provided to a much larger number of people than he currently estimates - not only low-income, but middle-income people and even those at the lower end of the high-income group.

So Obama's stated goal of universal coverage will be foiled by the lack of availability of affordable plans that have adequate benefits. His approach is flawed because the private health plans are not going to be able to have enough benefits if they're going to have affordable premiums.

The offering of a public plan option is not as simple as it would seem. Depending on the details and amount of funding, it has the potential to be the most important feature of his plan, or it could be a disaster. But even so, it alone won't lead to anything even close to universal coverage. Obama has stated repeatedly that he knows that single payer is a superior solution for health care reform.

It's likely that the public plan will be impacted by adverse selection - i.e. that individuals who are sick, or small businesses who have workers with costly disorders such as diabetes or cancer, will tend to seek out the public plans because the private plans would likely withdraw from markets that include high-cost individuals - markets in which they would be losing money. These individuals and small businesses will end up in relatively high-risk pools. It is essential those pools be adequately funded.

To fund the public high risk pools, either the private insurance companies would have to shift some of their funds into the public program through risk adjustment, or, as the public program uses up its funds, the government would have to make a greater contribution. To compete with the private plans, the public program and private plans would have to be funded at the same levels accurately corrected for the level of risk in their pools. That's not technically feasible. Nobody has a way to do that. So insurers are always able to game the system.

Even if you could get private insurers to compete with the public program on a level playing field, that still leaves a lot of problems. You still don't get the administrative savings you would under a single-payer system. Providers would still have to deal with multiple insurers. And both the Organization for Economic Cooperation and Development and the World Health Organization say systems that leave private plans in place are more expensive, less efficient and less equitable than a single public system. . .

The private health insurance plans of the 21st century have decided that they should cover only the healthy, putting an end to risk pools that enable a transfer from the many who are healthy to those with sickness or injury. They also realize that they should avoid competing with each other based on lower premiums, but should instead use their oligopolies to push premiums up to the maximum that the market will bear. . .

What we really need is a system that removes the financial burden from patients and more effectively pools our funds into a public program that is able to address costs more effectively by introducing greater efficiency and value into our health care system.

Such a system would guarantee comprehensive health care to everyone by replacing the private insurance industry with a tax-supported government agency or agencies that would pay all medical bills, similar to the way Medicare operates today, but even better than Medicare. People would have the freedom to choose their own doctors and hospitals.

That's a single-payer system. Such a system is embodied in H.R. 676, the "U.S. National Health Insurance Act," introduced by Rep. John Conyers. It currently has 90 co-sponsors in Congress, more than any other health reform proposal.

There are some in the political arena and health policy field who say the 2008 policy debate is over. They say single payer has lost out, and it's time to move on


Post a Comment

<< Home