BLUE DOG CARE - REASON OR CAPITULATION?
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BLUE DOG CARE – REASON OR CAPITULATION?
THE HEALTH CARE DARE: BETTER, NOT PERFECT
By Jay B. Gaskill
THE PRESIDENTIAL CHALLENGE
On June 10, the president challenged, “To those who criticize our efforts, I ask them, ‘What's the alternative?’”
A SANE RESPONSE
Health care partisans are disturbed by that irritating, in-house truth teller, the Congressional Budget Office, whose cost numbers are chillingly honest. There is no realistic scenario in which the pending utopian plans, however the costs are disguised, do not come with a huge tax burden.
Top-down, bureaucratic cost containment has a clear history: It always fails. The repeated attempts of government bureaucracies to imitate market-driven efficiencies are like drunken Cossacks plodding their way through a ballet. Subsidies prop up prices. Bureaucrats are clueless when asked to produce real efficiencies, but they do know how to reduce performance. The inevitable budget cutbacks are always felt in delayed diagnosis and treatment. The current, crisis-driven hard sell is like pushing bypass surgery on someone who just needs cholesterol reducing meds and daily aspirin. Worse still, the bypass that is proposed will actually starve the heart, eventually requiring a new one. By that time, the only option will be a crude mechanical pump, one size-fits-all. The country is on the precipice of a legislatively enabled led health care catastrophe, one that risks permanent damage to the system.
A massive new set of entitlements would be foolish to undertake in the best of times. During a recession it is flat out insanity. Fortunately, a growing number of my fellow Blue Dog Democrats are beginning to balk. Almost any alternative would be better than the poison-pill entitlement scheme currently at the prow of the “reform” juggernaut. If moderates and conservatives take up the president’s challenge, we might be able to make some progress without killing the patient.
REFORM GUIDELINES:
1. Incremental reform. We are living through an economic crisis, not a heath care crisis. Global, top down “reform” proposals have failed in better times, and they deserve even more to fail now when the consequences of making bad policy are amplified tenfold.
2. Better portability and access. The proposal is for “better” not perfect.
3. No new unfunded (or under-funded) entitlements.
4. Incremental, testable progress. By addressing the real problems realistically and gradually, there will be an opportunity for a progress metric, allowing for self correction and adjustment.REALISTIC PROPOSALS:
1. Price Transparency. Hospitals, physicians and clinics will be required to post actual costs and prices and given incentives for discounts, including a tiny subsidy for accepting credit card payments (offsetting the bank-lender fees).
2. Expanded, Shared Risk Pools. In cooperation with state governments and private insurers, the government will insure shared risk pools that contain a sufficiently large mix of patients to offset the high-cost patients. The resulting per-patient cost then is shared by all private insurers who buy into the pool, subject to the federal guarantee. Note: The scope of the guarantee is carefully limited, though it can be augmented by state, municipal and charitable supplements. The risk pools should be assembled incrementally, but available nationally as they come on line. An illustrative example: $4,500 deductible per condition or per year for serial conditions, with a $1 million cap. Private individuals could buy-in directly; private insurers, from HMO’s & 80% coverage models to self insured small businesses could contract to fold the group in to a package that includes other coverage. Each fiscal year, costs and risks would be reevaluated by industry and government actuaries and guarantees adjusted accordingly.
3. Indigent Clinics, Not ER Crowding. The requirement that no one can be turned away from an emergency room would be relaxed whenever a hospital, otherwise subject to that mandate, facilitates the establishment of a qualifying clinic nearby to which the hospital contributes at least one physician on call and a nurse practitioner. The financial arrangements are to be kept flexible, with an expectation that private donations could be commingled with public resources, including volunteer medical staff. These would be structured as not-for-profit entities, loosely affiliated with the parent hospitals that would establish operating standards but would be fully insulated by law from all liability. Fees for service would be scaled, a nominal fee for all (to be waived in extreme cases) up to the full fee. Credit cards and prepaid medical cash cards accepted.
4. Fast Track Medical Bankruptcies. A separate, streamlined bankruptcy procedure would be established for medical expenses only. Under rules established by the court, for good cause, additional bankruptcy filings can be entertained before the current waiting period.
AVOID THESE HEATH CARE TRAPS AT ALL COSTS
- DO NOT, UNDER ANY CIRCUMSTANCES OR GUISE, FORBID OR DIFFERENTIALLY BURDEN THE RIGHT OF AN INDIVIDUAL PATIENT TO PRIVATELY CONTRACT WITH A WILLING PHYSICIAN. THIS IS NO IDLE CONCERN. THE ORIGINAL BILL WOULD HAVE SET IN MOTION A BUREAUCRATIC JUGGERNAUT THAT WOULD HAVE ACCOMPLISHED JUST THAT. DO NOT APPROVE ANY BILL THAT HAS NOT BEEN CAREFULLY VETTED TO PROTECT THE PATIENT’S ACCESS TO PRIVATELY RETAINED MEDICAL SERVICES.
- BEWARE THE “FUTILITY” DOCTRINE. BUREAUCRATIC CONTROL OF HEATH CARE RESOURCE ALLOCATIONS NECESSARILY MEANS TOP-DOWN COST CONTROLS IN THE FORM OF DOCTRINES GOVERNING ‘APPROVED AND ‘NOT-APPROVED’ MEDICAL PRACTICES.’ ONE OF THESE DOCTRINES IS THE ‘FUTILITY’ DETERMINATION. THIS IS A DRAMATIC STEP THAT CAN BE INVOKED RIGHT IN THE ER, WHERE TREATMENT SUDDENLY STOPS. THE DOCTRINE ALLOWS A PHYSICIAN (OR COMPELS THE DOCTOR SUBJECT TO A BUREAUCRACY THAT CONTROLS PHYSICIANS) TO DENY ANY TREATMENT IF IT IS ‘FUTILE’ GIVEN THE PATIENT’S AGE OR OTHER CONDITION. THIS IS A SLIPPERY SLOPE. IT STARTS WITH THE DENIAL OF GRANDMA’S HIP OPERATION, BUT QUICKLY LEADS TO THE DENIAL OF YOUR HEART OPERATION BECAUSE YOU ARE OVER SIXTY FIVE, THEN FIFTY FIVE.
- DO NOT ALLOW AN UNELECTED COMMITTEE OR AGENCY TO CONTROL YOUR ACCESS TO MEDICAL CARE, ITS QUALITY OR SOPHISTICATION.
SOME my fellow Blue Dog Democrats are getting the message: The federal ‘In-box’ is already jammed with spending far beyond the national means. Don’t screw this up for our children.
Will the forces of common sense and fiscal restraint acquire the necessary backbone in time?
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Jay Gaskill, a California Attorney, was the former Alameda County Public Defender
