Sunday, August 16, 2009

My 2¢ on Healthcare Reform

My 2 ¢ about health care reform reflects my experience as a healthcare consumer, a healthcare provider, a former administrator of a healthcare facility that both operated on healthcare payments and purchased healthcare for its employees, and as a parent of young adults trying to make their way in the world.

First, there are obvious and glaring problems with the current system. The worst of those is that too many people are uninsured and unable to purchase even a basic package of insurance coverage. Our current system of employer-provided insurance evolved in a time when people worked for one or two employers for their entire careers. It is badly out of adjustment at a time when people change jobs often, have periods of unemployment between jobs, and are often working as independent contractors rather than full-benefit employees. The business model has changed dramatically, but the insurance model hasn't caught up with it.

Next are a set of problems inherent in an industry that is set up entirely as a market: loss of coverage for high-expense illness and treatment, loss of coverage when changing jobs for "pre-existing conditions," refusal to pay because of narrow interpretations of policies, and, often, erroneous nonpayment because of sheer incompetence resulting from poor training and supervision of insurance company employees--which, of course, benefits the companies which don't pay benefits that customers are entitled to. This requires the customers to engage in lengthy and frustrating campaigns to receive benefits which they have paid for and are entitled to; often they just give up.

On the provider side, doctors and other healthcare providers have had to deal with increasing costs for repetitious claims submissions and wasteful, often idiotic, and sometimes downright unethical hoops that they had to jump through in order to receive insurance reimbursement for services they've provided to patients. (This got so bad in my clinical psychology practice that I withdrew from all third party payment several years ago.) With the exception of very brief treatment, the entire inpatient mental health system has been scrapped, except for the very wealthy. Coverage for extended intensive outpatient treatment, while less expensive than inpatient treatment and often preferable, is very rare.

Healthcare is trending toward unsustainable costs at the individual, family, and national levels. For children covered under their parents' insurance, finding an affordable policy that provides adequate coverage is impossible when they become adults, and can't find, or don't want to take, jobs that provide insurance. Meanwhile, healthcare gets more and more expensive, critically cutting into business competitiveness and government solvency at the state and national levels. All these problems are very serious and that is what drives the urgent need to reform the healthcare system

On the other hand, there are genuine reasons to be concerned about reform. The first reason is that whatever form it takes, reform is going to have to vastly expand coverage while managing costs, and that means that there will inevitably be some sort of a two-tier system, consisting of a first tier of basic care that everyone receives, and a second tier for those who can buy supplemental private insurance or pay out of pocket. Many people react to this situation with dismay, insisting that health care should be a completely equal right for all, and that everyone should receive the same level of care. The problem with that wish is that it's an economic non-starter, an example of "the 'perfect' being the enemy of the good." In fact, we already have a multi-tier system, except that the lowest tier is composed of some 50 million people with no coverage at all. Everyone will be better off if everyone is covered with a basic package, and costs for that package are going to have to be carefully managed if the system is to remain solvent.

It would be better if leaders of the national push for healthcare reform could say this forthrightly. Unfortunately, they can't. It would be politically very unpopular, unacceptable to many people, to acknowledge the need for a two-tier system, even if it addresses the worst problems in our current one. The result of reform leaders not being able to acknowledge the necessity for a two-tier system is that the reform leaders become hypocritical in asserting that all these uncovered people can be covered without the system becoming unaffordable if we just apply best practices and eliminate waste. That is bullshit, pure and simple, and anybody with common sense knows it. The reform leaders who know better are dissimulating, the ones who don't are deluding themselves.

How people react to it will depend on whether they are inclined to trust the government or not. Those who are inclined to trust the government will interpret the reform leaders' posturing as politically necessary to get the job of health care reform done. Those who are inclined to distrust the government will interpret it as a snow job in order to extend the power of government at the cost of the freedom of the people. That's a lot of what is happening now in the opposition to healthcare reform. It would be better if the reform leaders could acknowledge the issues. Of course, the genuine concerns of people who don't trust the government are being fanned by the usual parties for the usual reasons.

My own attitude, having been in all these roles with regard to the healthcare system, is that reform is urgent and necessary. And it seems to me that we finally have a climate in which most legislators are willing to say that publicly. However, a serious obstacle to reform is the feeling on the part of many legislators that we really have to take our time and get this right the first time. Simply put, I don't think we can. The systems are too big, the issues are too many and too intertwined, to get it right the first time. So my perspective is that we are just going to have to go ahead and fix what's most broken, understanding that we won't get it all right and we're going to have to keep correcting and adjusting and fine-tuning as we go along. I frankly doubt that the take-it-slow legislators have adult children who are, or will soon be, without health insurance, or family members whose care has exceeded the benefits in their policies, or who have been prevented from receiving necessary mental health or other services because they are excluded from coverage, or who haven't been able to change jobs for fear of being ineligible for insurance because of an illness they needed care for while working on their current job, or who perhaps even were not hired because they or a family member have an illness which would threaten to raise the company's insurance premium.

The bottom line is that the problems in healthcare are too urgent not to go after, even with the understanding that we'll have to adjust as we go. Reform will result in a two-tier system in which everyone has a basic care package and those who can afford to supplement can do so through the insurance marketplace. A marketing consultant might call it "basic care plus," meaning that everyone gets basic care and those who can afford supplemental policies can add a "plus." No, it's not perfect. But in healthcare reform, the way things are right now, the perfect is the enemy of the good.

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