Page 21 - Delaware Medical Journal - December 2017
P. 21
OPINION
As we come up with answers, we’ll need to also consider ethical questions. Should some people have less care, and maybe poorer be economic issues, not just who pays, but will preventive care and access to early care for problems and health conditions (e.g., is a growing body of evidence for this question having positive answers. And will we take the savings from a healthier population
Sometimes conversations about this question are stalled when the issue of undocumented or illegal aliens is raised. At some point we’ll need a yes, no, or sometimes answer for providing health feeling that they don’t belong here, or that it’s too costly to cover them. A “yes” might be from a moral, Hippocratic, or economic view (after all, like other uninsured patients, undocumented people receive care that is costly and is ultimately paid for
by society). A “sometimes” might mean they are covered for catastrophic care or child health care, but not for other services.
WHAT ARE MEDICARE FOR ALL AND SINGLE PAYER SYSTEMS, AND WHAT ABOUT THE INDIVIDUAL INSURANCE MANDATE?
If, as a society, we decide to embrace universal coverage we’ll next need to determine how to structure the system to pay for it. At this point, we will already have worked out the questions about what’s covered, for whom, and who pays for what part of the coverage and care. Clearly this will be an iterative process as decisions about the type of system will interact with cost and
One common theme for any system we choose is the basic
of-mind, and the costs are shared through an insurance pool by
a larger population. In each individual’s ideal world he/she will never need health, home, auto, or life insurance. Okay, maybe the use of the latter would just be delayed. But we would be paying premiums that are helping subsidize others who experience less fortunate events. Or, maybe we’re better off by needing to use our insurance frequently, knowing that someone else’s premiums are helping offset our direct costs to the insurers. When only the sick, or reckless drivers, or the old, have coverage, the premiums are higher. There is little or no sharing in the actuarial pool.
that health care premiums for many would be lowered because more healthy people would be in the pool. Many other countries use the individual mandate as a building block of their universal coverage. That’s how Switzerland does it3 with subsidies (as
in the ACA) for those with lower incomes. Their citizens buy
and generally choose their own doctors who are paid by a fee for service model, though on a national fee schedule.
What about Medicare for All, a version of which is the Senate 4 Yes, Medicare is expensive and clinicians and hospitals may be concerned by reimbursement rates. But what if the insurance pool also included younger,
Some economists5 think that just by moving to governmental instead of private insurance would save billions of dollars. The administrative costs of Medicare are about 2 percent of total expenditures. For commercial insurers it can be 15 percent The ACA attempted to cap the latter. We are paying for advertising, for the administrative infrastructure that negotiates rates, determines fee schedules and approves and denies claims, shareholders.
If you are worried about the impact of Medicare for All on the businesses and jobs within the health insurance industry, you might not need to. Just as today, private insurers act as the claims intermediaries for Medicare and as they sell actuarial, care All could maintain some of these services with the bargaining power of the Federal government helping to keep things in check.
The next choice on the list, Single Payer, should be easy to understand at this time. As with Medicare for All and the Individual Mandate, the underlying assumption is that everyone is in the insurance pool. Similarly, the answers to the earlier questions of how the system is paid for (by employers and/or taxes, and
how much of the contribution is from consumers) apply to Single Payer. Single Payer in practicality is really Medicare for All. But, maybe you can imagine an approach based upon states or regions of the country that use commercial payers or physician-hospital networks, such as Accountable Care Organizations, as the single payer. Maybe that region has different health care needs, or wants able to take on risk (e.g. Kaiser Permanente in California).
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