I have two issues with your screed, the first being…
Michael Long
1

Your first issue concerning “end of life” health care is above my pay grade as I said. But they have to be addressed by people that are able to deal with them. Call them “death panels” or whatever you like, but someone with medical knowledge needs to get involved in managing end of life care and assisting families in the difficult decisions associated with them.

For example, all over America we spend billions on people that are in permanent comas and life support. The annual cost per person exceeds $100,000. Eventually their bodies wear out from being on life support and they die. In the past, the lifetime benefit limitations on health insurance policies caused families to say that after a few years when the $1 million dollar mark was reached on the patient’s lifetime benefit limit, that the doctors should “pull the plug”. Now thanks to the ACA there are no limits. Do I think a flat dollar limit is the right answer no… but neither is unlimited care without question the right answer.

The European health systems all have mechanisms to deal with this. In Germany hospitals turn away elderly patients that they do not believe they can materially help since those patients consume to much of their limited budgets. If they can’t “treat” the patient, the patient is not admitted. They do not see their role as one of “housing” dying patients. Is that wrong? I don’t know… it just is… We don’t do anything similar and so we can run up a Medicare bill of $100,000 or more in thirty days of a hospital stay and then patient dies.

But my point is if you want to cut health care expenses to European levels, you have to address these issues. It is not a matter of single payer. It is a matter of ethical decisions that our health care system has not figured out how to address and so we just spend the money.

Your point about young people misses the point. Many young people are faced with college loans, trying to form of family, buy their first home, and they earn less than older people. When you look at the cost of health insurance under the ACA, there are three pieces. The first piece is prepaid Medical expenses, which for a young health person are almost nothing. The second is catastrophic health insurance and again for a young person is almost nothing. The third piece is a massive subsidy or income redistribution from the young person to the older or sick person. This component for young people forced to buy health insurance makes health insurance a financial burden given all their other issues.

So if as a society we decide we want to tax people to subsidize health care for the poor and sick, we should just tax them. By embedding the cost in health care premiums and then forcing people to buy the product or pay a penalty, you get the behavior you are getting today. Many young people that previously went without insurance still do only they pay a penalty for doing so. So what you have done is effectively raised their cost of health care and provided no coverage. When for the same amount they pay in penalties they could have purchased catastrophic health insurance and had coverage. Is that really fair? Even worse, the government pockets the penalty and the health insurance companies get saddled with the cost of the sick and that explains why premiums are soaring.

Now your single payer system answer leads me to believe you are a Democrat. Democrats have been arguing for this for years and it is simply a dumb idea. France with a system similar to our Medicare system found that the utilization rates of the French people were spinning out of control and so has begun to cut government benefits and encourage the French people to buy private health insurance supplemental or alternative polices. Over 85% of the French have private health insurance today. We have “single payer” systems in America: Medicare, Medicaid, and the VA. None of them have effective tools to manage health care and in the case of Medicare, the government estimates over a third of the care provided is unnecessary.

But in case you are a Republican or know one, the idea that insurance companies selling across state lines or the “free market” can work to hold down health care costs is a similar pipe dream. Health care is not a national market. It is a patchwork of micro markets rift with monopolies and oligopolies and as such the pricing power of these providers mean that “free markets” competition will not work to lower health care costs. On top of the “natural” monopolies there are numerous government created ones included drug patents and state CONs.

So if single payer is not the answer and the “free market” does not work, what is the answer: a hybrid system. In simple terms, the power of a single payer system is that the government sets reimbursement prices. Let’s use that. Let Medicare set the price for all health care products and services and make those prices available to individuals, employers, private health insurance companies and government programs.

Likewise the power of the private health insurance market is there demonstrated ability to better manage care than the government does. So make sure every American is under a private health insurance managed care plan where their utilization is monitored by a company that “profits” from doing so.

My recommendations are based on a career that included being an executive for the largest government health care program administrator, an executive for one of the largest private health insurance companies in America, and an executive for several very large regional and national health care providers in various states. The ACA was flawed from the beginning. The Republican solutions are equally flawed. At the core of both is ideology and not real experience in understanding how the health care system really works or in some respects why it does not work.

In summary, you and I both agree “price controls” are necessary to get health care costs under control. But a lot of your other comments are based on misinformation and you miss one of the biggest driver of health care costs and that is the over utilization of the health care system driven by patients and providers.

A few of your statements are sadly Democratic rhetoric, which while inflammatory are frankly untrue or insignificant. For example, if you average CEO compensation for health insurance executives over health insurance premiums they average $8 per year. Is that really going to move the needle? I agree CEO compensation is to high mainly because of Boards unable to effectively deal with it, but that is a separate discussion and not relevant to the cost of health care. I also think if we had “price controls” that slowly pushed down reimbursement part of that excess compensation would be dealt with as part of cutting costs.

In fairness, part of the problem for Washington fixing health care is that the answers are not very popular politically. Putting Medicare under “managed care” or setting up price controls is not going to sell to large segments of the public. Directly taxing people to fund care for the poor and sick is efficient, but politicians prefer to hide the tax somehow (in the case of the ACA in premiums for young and healthy people). So we will stumble along until the cost is so out of control that the government is forced through sheer desperation to do the right thing. As someone who spent a life time in health care fixing broken parts of it, I can say the pain will be far greater when we are forced to fix the system the right way… but I think it is human nature to avoid a little pain now even if it means greater pain later.

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