Tuesday, May 16, 2017

Only Nixon can go to China

[[This post has been updated. To view the most recent version, click here.]]

What do public disasters and selling real estate have in common? Misfortune creates opportunity. Arising from the ashes of repeal and replace, progressives sense an opportunity to push for a universal healthcare plan: Medicare for all. Even if moderate Republicans and moderate Democrats manage to communicate in a protected bubble outside the rabid screeching of the far right and far left, Medicare and Medicaid have become too stigmatized by the slogans and ten-word sound bites that constitute public debate in this country. We cannot hope to build a system around that stigma. We need not only a new vocabulary but a new willingness to address legitimate concerns of the left and the right without abandoning the rational middle ground.

The good news is we elected a president who is not unduly burdened by adherence to fundamental political principles. He has a transactional morality and a reputation as a deal maker which he now desperately needs to validate. If the moderate middle can put together a deal, this president will sign it in order to take credit for the victory—and we have to be willing to make that sacrifice for the common good. The sad truth is we have not really tried to find a win-win because the two sides have only been interested in a win that would be a loss for the other side. If it is a win-win for all of us, then it will be a win for the president. Those who do not want to see him get a win will have to ask themselves if that desire is more important than a win for us all.

There is an historic opportunity to create a long term solution to this nation’s problem with providing and paying for healthcare. We have been debating this issue as long as we have been a nation and have been doing so in earnest since the end of World War II when President Harry Truman proposed the creation of a national health insurance plan. We really haven’t come up with many better ideas in the last 70 years. The Affordable Care Act is in fact close to being the optimal solution (if all 50 states had expanded Medicaid) that can be created within the existing system, but it leaves significant problems unresolved. It is past time we initiated a comprehensive “reboot” of the system.

Why should anyone listen to my advice? I grew up and still live in a politically conservative area in the middle of this country. I am an attorney. I own and manage a for-profit health system. My focus as a businessman has been on our service mission and job creation. Our health system is known in the industry as a safety-net provider because we focus on providing primary care for an at-risk patient population. As such, I have “roots” in both conservative and liberal camps and causes. I have no political agenda outside of the intersection of politics and healthcare. I know healthcare intimately and expansively. My health system had hospitals in a Medicaid expansion state (Arkansas) and a non-expansion state (Missouri). I have experienced the negative side of bureaucratic regulation—most notably when CMS closed our Missouri hospital because it was doing too good of a job providing primary care to at–risk patients and no longer looked like a typical hospital. I have experienced the positive impact of a government program for rural providers through our critical access hospital and rural health clinics.

I am proposing the creation of a universal health insurance plan that also preserves the existing healthcare payment and delivery system. It would be called Americare because it is similar in some respects to Pete Stark’s Americare proposal to create a public option. Frankly, a robust public option based on Medicare would indeed solve many of the ACA problems—but it would not address legitimate concerns of the moderate right regarding the tendency of any kind of governmental bureaucracy to impose innovation from the top down, or the negative consequences of the Medicaid program—at least as it is perceived by the public.

As a Missourian reared on conservative principles and as a businessman trying to compete on an uneven playing field, I heartily endorse free market principles—but I also insist that people deal with reality and not virtual, political unrealities manufactured from slogans and sound bites. Those on the far right maintain there is no reason to impose a governmental solution on healthcare, because healthcare is a consumer service and solutions would be best left to free market forces. Reality check: there is a fundamental defect in that argument. It ignores the fact that a universal healthcare coverage plan already exists in this country. EMTALA is the law that requires a hospital to treat a person who comes to the hospital with a medical emergency—to the full extent of the hospital’s capabilities and resources—regardless of that person’s ability to pay. If a person comes to a hospital with a medical emergency, the hospital could spend $300,000 or more treating that patient. If the patient cannot pay, then everyone pays because those uncompensated costs are passed on to the people who do pay. As a consequence of EMTALA, everyone in this country is already in a shared risk insurance pool. Unless the Freedom Caucus is willing to repeal EMTALA, the discussion should focus on finding the best way to pay for our existing universal healthcare coverage. I expect people of conviction to be willing to accept the consequences of their convictions. The conversation has to start with EMTALA. Repeal EMTALA and tell hospitals it is okay to deny admission to people who cannot pay and to let them bleed to death in the hospital parking lot. If not, figure out a way to pay for universal healthcare coverage. It is that simple. If a politician will stand up and say hospitals should be allowed to let poor people die in order to have a truly free-market system, I will disagree with the philosophy but I will acknowledge it as a legitimately held conviction. Otherwise, any politician who will not acknowledge the fundamental reality imposed on the provider side while insisting on free-market solutions on the payor side is either ignorant or dishonest.

The second reality—and the one that the Affordable Care Act was primarily designed to address—is that no amount of theoretical access to care is meaningful if that care is not affordable. Absent insurance coverage, healthcare is already unaffordable for ordinary people. Without a comprehensive health insurance system, healthcare in this country becomes a two-tiered system: complete access to care for the wealthy and access through hospital emergency departments guaranteed by EMTALA for everyone else. From a purely economic perspective, the quickest fix to affordable healthcare—which means affordable healthcare insurance—would be to offer a public option paying Medicare prices on the existing exchanges to any provider willing to accept the public option insurance. Sign me up. The only “reality-based” issues one can raise against a public option fix for the ACA arise solely from the fact that it would be a government program. I am not saying there are not legitimate concerns about government programs but I have no patience for people who are opposed on purely political grounds and are unwilling to engage in a true risk-benefit analysis. The “government: bad” versus “free-market: good” simplistic dichotomy is intellectually dishonest when discussing our healthcare system. Some of the solutions to the issues we face will necessarily be governmental. We have to find the right balance between government and free-market. 

Features of my Americare plan:
  • Americare would give everyone something they want and everyone would have to give up something they want. It is an old bromide among attorneys. The best compromise agreement is the one that all parties hate equally.
  • Americare would be a national health insurance program paid for by compulsory premiums collected by the federal government, creating a “single payor” system covering the first 60% of the cost of care. Administration of the Americare program would be built on existing Medicare infrastructure including the use of insurance companies acting as fiscal intermediaries to process and pay claims.
  • The 40% not covered by Americare would be covered by the existing payor system which would be converted to a “secondary payor” program. Secondary payors would also be allowed (encouraged) to offer an expanded benefit package as to which they would be the primary and secondary payor.
  • Americare would NOT be an entitlement program. It would be paid for by the premiums collected by the government. Americare could not borrow from the federal government or loan money to the federal government.
  • Americare would establish a universal benefit package based on the current Medicare benefit package. People would be allowed to obtain additional benefit coverage through the secondary payor system. There would be gold and platinum “club” benefit plans.
  • The Americare universal benefit package would include long term care. Doing so would remove long term care from the Medicaid program but it would necessitate inclusion of long term care as a covered benefit by the entire secondary payor system.
  • Americare would establish the price to be paid for covered care. The Americare program would negotiate price for drugs if the drug company wanted its drugs covered by the program. Drug companies would not be allowed to “carve out” a single drug and offer it only through the secondary market.
  • The Medicaid program would become a secondary payor for those beneficiaries determined by each state to be eligible for Medicaid. The federal government would continue to cover 50% of the cost of care for Medicaid beneficiaries (50% of the 40% not covered by Americare) and the benefit package would be established by Americare; however, each state would be completely free to determine eligibility.
  • Providers would not be forced to enroll in Americare, Medicare and Medicaid programs and patients could elect to pay privately for non-enrolled provider care, but providers enrolled in all three programs would benefit from an additional collection enforcement mechanism. Unpaid claims could be submitted to Americare and the IRS would collect the claim against tax refunds owed to the patient.
  • The relationship between Americare and Medicare would be complicated. In essence, Medicare would be transformed into Americare by both expansion and contraction: Americare would expand Medicare coverage from cradle to grave but would contract coverage to 60% of the cost of care.  
What are the advantages to this Americare plan?
  • Americare is not an entitlement program. It is a pay-as-you insurance program. The premiums will be set at a universal rate for all persons paying the premiums. The moderate middle of congress is not going to be able to sell a new entitlement program. The fact that Americare will use private insurance companies as fiscal intermediaries will appease the insurance industry somewhat and provide cover for those beholden to that lobby.
  • Americare will dramatically reduce federal and state government outlays under Medicaid programs. The Medicaid program has gotten a bad rap and has become a public whipping boy. I have listened to people denigrate Medicaid as welfare for able-bodied adults refusing to work while getting free healthcare who, in the next breath, expect government coverage for long term care on the theory that it is somehow “not fair” to use up all of daddy’s assets paying for a nursing home. They never make the connection that most of the money Medicaid spends goes toward long term care. No amount of re-education is going to repair Medicaid’s image. Medicaid eligibility would be left to individual states to determine.
  • Americare would virtually eliminate the ranks of uninsured. The Americare premium payment would be imposed as a flat rate on all income capped at some ceiling level of income determined by negotiation by the moderate middle lawmakers. There would be no floor income. Everyone would have to pay something.
  • Deductibles and co-insurances would be imposed and collected through the secondary payor system. All of the current quality and payment initiatives in place and being developed would remain in place for the 40% not covered by Americare. Secondary payors would be allowed to impose penalties for patients who fail to show up for scheduled appointments. Care should cost more for patients who are chronically noncompliant. Penalties and incentives would be not only allowed but encouraged in the secondary payor system.
  • Over the next five years, Americare will apply downward pressure on pricing with the ultimate goal to put all provider payments at Medicare rates (as projected forward). Hospitals and physicians will scream that it cannot be done, that it will bankrupt the industry, that hospitals will close and physicians will quit their jobs. It can be done and it should be the goal.
  • People will object that Americare will turn the American system into the Canadian system which allegedly creates long waiting periods for needed care. Americare will contain an “any willing provider” rule that will stimulate competition. Paying one price for the same service to anyone willing to provide the service will level the playing field for competitors who see an area with more demand than supply. I know for a fact that my health system would thrive in a system inviting open competition. The monopolistic forces increasing prices and decreasing competition currently resulting from exclusive managed care networks, huge payor mergers and mega provider systems would dissipate under Americare.
  • Americare will allow “platinum club” benefits for people who do not want to wait in line or who want to fly first class instead of economy class. Although EMTALA will still require hospitals to provide care to anyone who presents in the emergency department with a medical emergency, nonemergency patients who have been screened can pay for a gold card that gets them into the urgent care treatment room in front of others. For better or worse, we have to admit that paying to go first is part of the “American way” and it can be allowed to have a place in the healthcare industry. There is no effective way to legislate against it even if that was the desired result.
The window of opportunity for the moderate middle of congress to broker a deal on healthcare to bring to the president will not stay open for long. It has to be a deal neither side can claim as a loss for the other side. “Only Nixon can go to China.” We are never going to adopt a universal healthcare insurance program while a Democratic is in the White House. It can only happen at a moment in time following a high profile legislative defeat creating a temporary vacuum allowing moderate Republicans and moderate Democrats some free space to craft a law—and with a Republican president in office less interested in rigid political principles and more interested in making a deal for which he will get credit as deal maker. That time is now.

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