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Next steps on health care
Mixed messages from Trump and Ryan. Some indication that Trump never really cared about health care except "repeal Obamacare" as a campaign slogan, and he would be delighted to never hear the words for the rest of his Presidency; also some indication of an interest in "working with Democrats". It's clear that the Republicans don't have enough of a unified vision to pass any health care bill on their own, so any change from here on will need to be bipartisan. What if he/they actually meant it? What improvements could be made that would get a significant number of both Democratic and Republican votes?
I wouldn't shed many tears if health insurance were divorced from employment, and most Americans got their health insurance through an individual market rather than through group deals worked by their employers. (This would make cases such as Hobby Lobby moot: if your employer doesn't pay for your health insurance, your employer doesn't get to choose what your health insurance covers based on their religious views.) This could be accomplished by gradually decreasing the amount of employee health-insurance expenses that an employer can tax-deduct, making it gradually less attractive for them to offer health insurance. The effect would be to move a lot more employed, reasonably-healthy people into individual markets (including, unless changed, the state Obamacare exchanges) and make those markets more stable and sustainable. And it would arguably be a "pro-free-market" move that would attract ideological Republicans.
One of the problems with Obamacare as it stands right now is that in some states most insurers have pulled out of the market. A public option would guarantee that there IS competition in every state, which should bring down premiums... but it's competition by a gummint entity (even though it's not taxpayer-funded), so Republicans won't go for it. Never mind.
Perhaps the biggest possibly-bipartisan improvement would be clarity and fairness in health care pricing. At present, most of the financial benefit of having health insurance isn't the amount of your health care costs the insurance company *pays*, but the amount that the insurance company *negotiates away in a puff of smoke*. Providers have to give deep discounts to big insurers, or they'll be out-of-network and will never get any customers from that insurer.
So here's how we change that. Require health-care providers to publish price lists of their services, and limit the ratio (gradually decreasing over a number of years) between the maximum and the minimum they charge different customers. (Might want to allow large discounts based on personal income, but not based on insurance.) This would make illegal a lot of insurance-company "negotiations" with providers, and mean that uninsured and insured people paid more-nearly the same prices for things. Health care providers would compete with one another on price and quality, rather than merely on which ones are in-network for your insurance company. The whole idea of in-network and out-of-network providers would become less important; consumers would have more choice of doctors, and maximum prices would come down as minimum prices rose. I suspect most doctors would love this, but insurance companies would hate it, so there would need to be some other sweetener to prevent the latter from blocking it. Perhaps the first idea above would please the insurance companies enough to balance this. And it's a free-market reform, so it should get a fair number of Republican votes (although not those who see ANY government regulation as evil, even government regulation to open the markets).
I wouldn't shed many tears if health insurance were divorced from employment, and most Americans got their health insurance through an individual market rather than through group deals worked by their employers. (This would make cases such as Hobby Lobby moot: if your employer doesn't pay for your health insurance, your employer doesn't get to choose what your health insurance covers based on their religious views.) This could be accomplished by gradually decreasing the amount of employee health-insurance expenses that an employer can tax-deduct, making it gradually less attractive for them to offer health insurance. The effect would be to move a lot more employed, reasonably-healthy people into individual markets (including, unless changed, the state Obamacare exchanges) and make those markets more stable and sustainable. And it would arguably be a "pro-free-market" move that would attract ideological Republicans.
One of the problems with Obamacare as it stands right now is that in some states most insurers have pulled out of the market. A public option would guarantee that there IS competition in every state, which should bring down premiums... but it's competition by a gummint entity (even though it's not taxpayer-funded), so Republicans won't go for it. Never mind.
Perhaps the biggest possibly-bipartisan improvement would be clarity and fairness in health care pricing. At present, most of the financial benefit of having health insurance isn't the amount of your health care costs the insurance company *pays*, but the amount that the insurance company *negotiates away in a puff of smoke*. Providers have to give deep discounts to big insurers, or they'll be out-of-network and will never get any customers from that insurer.
So here's how we change that. Require health-care providers to publish price lists of their services, and limit the ratio (gradually decreasing over a number of years) between the maximum and the minimum they charge different customers. (Might want to allow large discounts based on personal income, but not based on insurance.) This would make illegal a lot of insurance-company "negotiations" with providers, and mean that uninsured and insured people paid more-nearly the same prices for things. Health care providers would compete with one another on price and quality, rather than merely on which ones are in-network for your insurance company. The whole idea of in-network and out-of-network providers would become less important; consumers would have more choice of doctors, and maximum prices would come down as minimum prices rose. I suspect most doctors would love this, but insurance companies would hate it, so there would need to be some other sweetener to prevent the latter from blocking it. Perhaps the first idea above would please the insurance companies enough to balance this. And it's a free-market reform, so it should get a fair number of Republican votes (although not those who see ANY government regulation as evil, even government regulation to open the markets).
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Personally, I'd be fine with a flag day, after which it's just illegal. I think we should criminalize making the paying of health insurance premiums or contributions to health care payments of any kind as part of a compensation package for employment, and I think we should do something like triple damages for employees who are required to take compensation in kind in health care, to motivate them to rat out their employers if they try to do it on the sly.
But that's just me.
Require health-care providers to publish price lists of their services, and limit the ratio (gradually decreasing over a number of years) between the maximum and the minimum they charge different customers. (Might want to allow large discounts based on personal income, but not based on insurance.)
Is there a reason to do this gradually? In any event, how about we criminalize offering discounted fees to third-party payers. (Contracting to so == conspiracy to price fix, 60 months Federal time.) That allows providers to offer sliding scales – or otherwise have creative price schemes[*] – directly to patients who are paying out of pocket, but not to insurers.
[* You may recall my three parter on demand for therapist time; a colleague has two-tiered pricing depending on whether you want a premium schedule slot, or a less desirable time slot. He reports it works great to load-balance his schedule.]
This would be hard to get right, because third-party payment can be sneaky. But that's the general direction we might want to go in.
(And a pony.)
Health care providers would compete with one another on price and quality, rather than merely on which ones are in-network for your insurance company.
While we're at it, let's make "networks" of "preferred" providers illegal, which, as obvious restraint of trade, they sure as hell should be. No health insurer has any business refusing to cover care provided by any health care provider in good legal standing: insurers don't get to save themselves the expense of paying for Essential Benefit care by making it so that no covered providers are available to their customers.
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When it comes to dismantling existing systems, I'm generally in favor of doing it gradually to minimize disruption to the markets. (Although a disadvantage to gradualism is that a future Congress changes its mind halfway through and reverts you to where you started.) For example, if you outlaw discounts to third-party payers, effective (say) six months after the law is signed, you now have tens of thousands of legally binding contracts, on which both parties have budgeted, that are now illegal for either party to fulfill.
I sorta like the idea of making networks of preferred providers worthless BEFORE making them illegal, because that spreads the pushback into two phases rather than concentrating it at the start.
And there will be serious pushback against the third-party-payer-discount ideas: insurance companies will tell their customers "Big Government in the pocket of doctors and pharmaceutical companies wants to take away the discounts we've negotiated for you, costing you $billions." Which, in a sense, is true, although if the market functions properly, nominal prices should come down so that total provider income is about the same as it is now. If you have any ideas on beating that predictable PR blitz, I'm all ears!
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That actually seems easy to me – and better yet mostly already done. Insurance companies have done a piss-poor job getting their customers to understand that the prices they see on their EoBs were deals made to their advantage by their insurance acting on their behalf. Meanwhile, everybody has heard lots of stories about "sticker price" hospital bills wiping out uninsured families. Somebody has to come up with the money and will to do the PR campaign, but the content writes itself: NO MORE $50 Q-TIPS, EVIL INSURERS HAVE TO GIVE EVERYBODY THE SAME PRICE.
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Eh, just outlaw new contractual agreements. Ta-da.
When it comes to dismantling existing systems, I'm generally in favor of doing it gradually to minimize disruption to the markets.
I have yet to be convinced to care about this, wrt health care. I mean, we do nationwide flag days for bullshit reasons all the goddamn time (e.g. the CPT code changes Jan 1, 2013, DSM-5 May 2013, the ICD-10 cutover Oct 20(?), 2015), I see no reason not to do one for the benefit of the consumer for once.
(Although a disadvantage to gradualism is that a future Congress changes its mind halfway through and reverts you to where you started.)
That's one disadvantage. The other, or more properly an advantage of striking quickly, is that, as so many people have recently observed, once you get the populace accustomed to having some benefit, it's super hard, politically speaking, to take it away. There's a big advantage to getting people used to good things sooner rather than later.
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And as the Dealmaker In Chief says, the worst way to go into a deal is desperate to make it. The other guys have to know that you're willing to walk away. The R's are currently betting that if they can get Obamacare to fall apart, they'll be more willing to walk away from fixing it than the D's will be, so the eventual deal will be on R terms. And they may be right: losing popularity with poor and sick people wouldn't cost most R's much, but it would cost the D's a lot.