So not everyone is happy with the Senate's health care reform bill, I understand that. I won't debate the merits of the bill here but will instead focus on what progressives can do regarding health care reform in the future. Something resembling the Senate bill will undoubtedly come out of conference and that is what I'm assuming will become law. Here are some ideas and policies that progressives can push to improve upon what has been accomplished.
These ideas and policies will aim at the following:
- sustainability (cost containment)
- equality (equity in coverage regardless of age, income, or location)
- freedom (portability of policies, choice of a public option)
Federalize Medicaid and SCHIP
Medicaid and (S)CHIP are currently funded jointly by the federal government and the states and are administered by the states. Sometimes they are separate programs. Sometimes they are rolled into one. They focus on providing health care to (very) low income families, especially children, their parents, and the elderly in nursing homes. There are vast discrepencies in eligibility and benefits across states, lack of participating providers (due to low rates paid to providers), and underfunding. By rolling these numerous state programs into one national social insurance program called "Medicaid" (administered by the Centers for Medicare and Medicaid Services) you would see the following benefits:
- economies of scale (reducing waste)
- consistent eligibility and benefits regardless of state
- ability to set rates on par with Medicare--this will increase the number of medical options available to participants.
http://voices.washingtonpost.com/...
It will be easiest to push for the federalization of Medicaid during the next recession when state budgets are tight and jettisoning Medicaid costs would be a gigantic relief to strugling states.
Decouple health insurance from employment
Tying health insurance benefits to employment restricts individuals careers and personal freedom. Along the lines of Ron Wyden's Health American's act (now defunct), I would like to see employment based health insurance ended. Instead individuals would purchase insurance from the new health insurance exchanges directly. Employers should be required to increase the wages/salary of their employees by the amount previously paid to subsidize their group plans.
Break provider monopolies
In many metropolitan areas, large health care providers create near monopolies and drive up costs to increase profits. So at the state and local level progressives should pursue anti-trust action against these providers.
Establish a national medical loss ratio (say, 90%)
Essentially medical loss ratios are a set percentage of revenue that health insurers must pay out in the form of care. If a company is going to provide a social neccessity like health insurance, we should at least require that a certain portion of the money they get from individuals (and the government through subsidies!) goes to paying for actual care and not overhead and profits. This may not hold down costs much (according to the CBO) but its a simple matter of fairness to those of us required to buy their product.
A single national insurance form
One cost driver in US health care are the numerous insurance codes and forms and the armies of coders and billing professionals required to parse through them just to bill the insurance companies. What we need is a single form and a single set of billing codes for all insurance providers. This will hold down overhead costs for health care providers and simplify interaction with health care overall. Yes, we'd have a single form under a single payer system, this would at least allow to approximate that efficiency with our current system.
Improve and expand Medicare
You could fill an entire diary on its own with ideas for holding down costs in Medicare and making it sustainable. The health care reform bill in congress implements many necessary cost-containment measures for Medicare. I won't look at cost containment in Medicare here, instead we should consider how to expanded Mediare coverage for those who are eligible. For starters, we need a public option for Medicare Part D and public Medigap coverage (see the "Medicare Part E" idea from PNHP http://www.pnhp.org/...
Merge the various federal health care programs into one
Another idea that I've seen floating around is to roll all the various federal government health care programs (Medicare, Medicaid, VA, TRICARE, Indian Health Services, etc.) into one single program--let's have it be the improved and expanded Medicare outlined above. This would streamline the various programs, would create equity between them in terms of coverage/etc and would put us one step closer to a single payer system. The only problem with this idea is that some of these programs also run health clinics while Medicare only deals with payments and not running clinics. This would have to a detail worked out. Perhaps the clinics could be run by (a) separate program(s) or private providers/local governments could step in.
Allow purchase of new Super-Medicare in the Exchanges
If we have our health insurance exchanges (like in the current bills in congress), our subsidies (also in the current bills), and our Super-Medicare single-payer type plan (outlined above), we should then allow individuals to purchase this plan (with subsidies) from the exchange. This would be a true public option, not like the watered down version that was recently struck from the Senate bill or is still present in the House bill. Admittedly this will be the most difficult idea to implement. As we saw recently, this is immense opposition from large corporate special interests with large amounts of money to spare. This will be easiest to pass if health insurance costs continue their stratospheric climb over the next 15 years or so. At the same time that we open the super-Medicare program to the exchanges, we could end the current age-based (65+) Medicare program. Current enrollees could be grandfathered in (pun intended) with no one new eligible for automatic enrollment at 65. Instead they would continue to buy insurance through the Exchanges.
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The end result, if all these ideas are implemented, will be a health care system where everyone purchases their insurance through the exchange, subsidised on a sliding scale, with a strong public option based on Medicare available to everyone. Health insurance will be portable, affordable, and equitable regardless of age, sex, income, or location. Strong competition in the exchange should drive the weaker carriers out of business with the public option eventually dominating. These ideas are doable and once the health care reform fatigue wears off in a couple of years we should again push for further reforms along these lines. We must also keep a long-term focus for reform and be willing to accomplish things incrementally instead of all at once.