First, Obama is not addressing a core issue--the limited availability, high utilization, and high cost of health care personnel. The growth in supply of new primary care physicians is anemic, at a time when the existing patient load is strained. Already patients face waiting times, sometimes up to hours, for scheduled appointments, and it can be difficult finding a doctor willing to accept new patients. We have issues in terms of limited capacity training programs, which applies to nursing programs as well. I have one niece whom recently received her RN in Texas and other niece who had to leave her home state of Colorado to find an opening in a nursing program. Even if we look at the aggregate numbers, it doesn't necessarily notice more acute staffing issues in less desirable areas, e.g., urban or rural settings.
There are a number of issues we need to address: How do we address the problem of additional millions of insured Americans in the health care system? I've mentioned a couple of relevant issues involving retention and productivity of doctors we already have: the need for comprehensive malpractice reform and the overwhelming amount of paperwork that doctors need to go through that distracts them from their core competency of treating patients. We have to do something constructive about the high cost of defensive medicine. We also need to bring Medicare costs more in line with actual costs essentially subsidized by the private sector. (This issue affects the supply of physicians available to older Americans.)
We need to address how existing staff can be better leveraged, e.g., empowering lower-level medical personnel for more routine issues, resource utilization across hospitals and clinics, improved remote diagnostics, etc.
In addition, we should look at how to improve domestic training throughput, foreign training alternatives, and expanding immigration quotas for trained, experienced medical personnel.
Second, I would argue that Obama's crisis in health care is more alarmist in nature than factual in substance. I agree that there are long-term issues, particularly given demographic trends (i.e., older Americans needing more health services). Most people are overwhelmingly happy with their own private sector insurance plans and their own doctors. We have to think long and hard before we made radical changes that result in unexpected ways, e.g., a "public option" that allow the private sector insurance companies to dump expensive risks on the government or that allow businesses to dump more expensive insurance costs in favor of the public option.
I argue that we need to look at ways of addressing problems that I think are clear and more focused:
- catastrophic health insurance: we need to address the fact that catastrophic medical debt is a key factor in personal bankruptcies
- a mechanism to provide pricing power for individuals and small companies. I've seen, for example, huge pricing differences in COBRA rates between large and small employers for comparable coverages, and I've seen prices charged to insurance companies (e.g., for a blood test) to be a fraction of which I would have been or actually have been charged. I would like to see more reasonable markups over costs (i.e., flatter pricing schedules, such as we've seen among some major airlines).
- deregulation of the health care insurance market across states.
- improved transparency and accessibility of pricing information for health services and prescription/ generic drugs
- national malpractice insurance reform, including limits on punitive damages, a higher burden of proof for filing lawsuits, and caps on legal fees
- reforms to assigned risk pools across states to ensure availability
- vested interest for consumers and providers to spend dollars wisely. For example, provide bonuses for patients and their physicians whom control serious medical conditions with relevant diet, exercise, and prescriptions, for physicians to prescribe generic medicines when available. Higher co-pays for not using nursing screens or clinics vs. emergency rooms when the former are available.
- uniform tax-advantaged standards (employer or individual policies)
Third, I am opposed to any Trojan horse public plan. The argument, that a public option needs to be available "to keep the private sector honest", is totally disingenuous. Private sector insurers cannot fairly compete against a government with deep pockets, whom becomes the de facto market leader from the get-go. Since any public plan, by its very concept, must take all comers, it will become the immediate default for all poor health risks, whom have every incentive to subscribe to the public plan below market cost, where the public plan is in the red from day one. If the public plan truly "keeps the private sector honest", it will require massive subsidies by taxpayers, whom will be saddled with all the risk. Existing risk pools, where open and available, spread the poor risks across the insurers. We must not forget what happened when Fannie Mae and Freddie Mac make the secondary mortgage market essentially a government-subsidized duopoly, putting the taxpayer on the hook. There are a couple of things which we should keep in mind: (1) government itself is impeding insurance competition by idiosyncratic state-based regulations and mandates; (2) costs are being driven by a number of factors: demographics (aging population), the escalating costs of malpractice insurance, and passed-along costs from hospitals and doctors (including unrecovered costs from patients, below-cost treatment of Medicare/Medicaid patients, etc.)
I'm particularly concerned about speculations of de facto tax hikes for employers currently not offering health insurance to its employees, which tend to be smaller competitors. Recall the original basis for tax-advantaged health insurance by employers started as a workaround for wage controls during World War II. It is not in the interest of government to micromanage the nature of compensation in the private sector. Insurance is a business cost, just like wages. A unilateral increase in costs (like an employer tax for companies not offering health benefits) could adversely affect business and hiring at affected companies. Finally, we should always be suspicious when larger companies, like Wal-Mart, endorse the administration's legislation. When a dominant competitor starts pushing government legislation, it's likely due to some competitive advantage. For example, smaller chains may have less headcount on employee health insurance than Wal-Mart, which probably can also exploit their size advantage for insurance price concessions. The net effect is to push their competition's costs higher, which is a way of strengthening Wal-Mart's position in the retailing sector. (The same also holds for other government reporting and regulations which place a disproportionate cost on smaller companies.)
Finally, I want to see the government resolve its existing funding issues with Medicaid and Medicare first, before it seeks to extend any government mandate.This should include things like qualification of physicians and full, rigorous anti-fraud measures. At the same time, we need to see pricing competitive with market rates for services and repayment schedules that reflect the private sector. Finally we need to minimize the paperwork requirements, compliance with various regulations, etc., which distract providers from their core functionality of treating patients. I recommend any related standards for medical records, software applications and the like to be made available to private insurers (and in fact, I would recommend their input be actively recruited).
