If anyone cares

There are three issues that need to be solved for effective health care reform. These three issues are Cost, Access, and Quality.

Access

This is where the current reform proposals really focus. The tools are guarantee issue (no pre-existing exclusions, no loss of coverage with loss of job), individual and employer mandates (pay or play), and an insurance exchange with a public option to keep those bad boys honest (I am an ex bad boy large group underwriter, so I KNOW). With these tools, reform starts to address the three key goals, sometimes referred to as The Triple Aim:

Improve the health of the population;
Enhance the individual's experience of receiving health care; and
Reduce, or at least control, per capita cost.

Speaking of Cost:

We got a ways to go here.

Did you know the Medicare Trust Fund was underfunded by almost 13 trillion dollars in February of this year - 2009? To put that in perspective:

a million seconds ago is sometime last week
a billion seconds ago is sometime in the 70s
a trillion seconds ago is 30,000 BC

(courtesy of a presenter at a recent legislative update seminar I attended)

The root cause of this horrifying statistic is that the current health care system operates under misaligned incentives. The more Doc does, the more Doc is paid under the current economic model. Pay is not tied to patient outcome - in fact the opposite is true. Extraordinary efforts with a lousy result are paid at a 1000 times the rate of preventing that health event from happening in the first place.

Coordinated care for patients with complex conditions, a registry to make sure they are getting all their immunizations and preventive care, is not paid for now. The Health Care Home initiative in the reform proposals would change that.

There are a few Medicare demonstration pilots funded in the reform proposals (they look at bundling services, paying differently) but nothing near what we need. However, once everyone is covered, then I guarantee you providers and insurers will find a way to lower their costs now that they can no longer just deny the claim or refuse the coverage.

Those who say they don't want to subsidize others' coverage are missing a pretty giant point. Right now, private commercial plans (employer coverage, small group market, individual insurance) subsidize short payments on Medicare and emergency care for the uninsured to the tune of 10% of commercial premiums.

The most egregious subsidies are state to state - the best subsidize the worst. The worst states are NY, FL, TX, and LA (Interesting fact - Louisiana ranks 51st in quality! Either Washington DC or Guam or someone like that beat them out). The highest Medicare rate is paid to FL, which ranks 41st in quality. LA gets paid the second highest rate for the WORST quality care.

Here's the rub - the high quality/low cost states of MN, both Dakotas, IA, NE, MT, ID, UT, NM, VA, ME and WI, have a lot less legislative representation in the House. And the delegate-rich, population-rich states that are REALLY killing Grandma with lousy quality care every danged day will never vote to fix this per-capita cost/quality/pay rate imbalance.

Back to access. MN loses here too - health care reform is not gonna help us, since we, along with Hawaii and Massachusetts, already have the lowest number of uninsured (although our governor sure seems to be working hard to change that), and offer the highest quality care at lower costs. We will end up subsidizing TX and LA (again) in MEDICAID based on the percent uninsured in each state.

Our share of federal funds to cover our uninsured (8.7% of 5 million and change) will be $3.9 billion. Nothing to sneeze at, right? Our costs though, are estimated to be $13.7 billion. So we will LOSE $9.8 billion on the deal.

Meanwhile, TX (percent uninsured - twenty-freakin' five percent of 24.2 million state population) will get a federal share of $132.2 billion. Estimated cost for covering their Medicaid patients is half that($64.7 billion). So they will be raking it in, all the while decrying the socialist feds who are taxing them to high heaven.

(Ah well, our Nordic heritage makes us happy to help others. And keeps us a bit calmer. Maybe that is part of our lower health costs - less self-induced histrionics?)

Anyway. Are the current proposals on the table the be all and end all? Of course not. No thinking person even pretends it to be so. However, knocking off the frankly immoral problem of access, forcing everyone to pay or play, and the widespread dissemination of cost/quality data is a darned good place to start. Once everyone is IN the pool, everyone suddenly cares about the quality of the water.