I have been covering the health reform debate regularly over at ZDNet Healthcare and running into the predictable flak.
(The picture of a bookie shop is from Wikipedia.)
When my writing does not meet the ideological approval of the audience, I’m called biased. This is inevitable no matter what I write because the issue is so contentious.
So here I want to briefly tell you where I stand. I stand for peeling the layers.
Health insurance currently covers all three layers of health costs — what we know we need, what we’ll probably need, and what we might need.
The bottom layer includes things even the youngest and healthiest adults need. Regular check-ups, wellness counseling, help with diet and exercise. We routinely pay these costs for little kids, but once you’re 21 you’re on your own. And you become accustomed to not seeing these costs as real or necessary.
Once you turn 40 or (gasp) 50 you start paying these costs as part of your routine. You get the pap smear, the colonoscopy, the prostate exam. You get your cholesterol checked and adjusted, you get serious about your blood sugar, you start going to the gym or at least walking each day.
If these things had become habits at 20 you might not be hustling to catch up. We can save a ton as a society, over time, if everyone is paying these costs and getting these benefits.
This is not “insurance.” Insurers are bookies. They can set rates for the outside chances of cancer or a heart attack, they can estimate the odds you’ll fall and or get in a car wreck. They are good at this. They are not good at paying out on sure things.
That’s what bankers do. So health care should be run by bankers, not bookies.
If everyone has costs (and they do) everyone should pay them into a common pool. You then designate a health system to take that money — you can change if you move or switch jobs — and they use that money for your basic care.
They assign you a wellness coach, who uses data from your regular check-ups and anything else they can learn to keep you as healthy as they can. This should be a doctor, but we don’t have enough primary care doctors so most people will get this through groups that have doctors at the top and a range of people aligned to them.
Health insurance, too, comes in two layers. There are the likely hazards — cavities, eyeglasses, mental problems, maintenance prescriptions — and there are the unlikely ones.
You can insure that second layer or handle those costs yourself through a Health Savings Account (HSA), whose sponsor might win you discounts through buying power. Insurers can and do set up such plans today. It’s a conservative idea that can work.
Then there’s real insurance, the “catastrophic care” plans some Republicans consider a total solution to the problem. This is where the insurance industry started, gradually expanding into wellness because there was money in it and savings were promised.
We should have insurance for catastrophes, just as we have car insurance, fire insurance, and business insurance. The market works well here, and for those who don’t go to the market taxes can pay for care that’s as good (or bad) as the public wants to make it.
That’s a good place for a political debate.
So what do we have?
- A per-capita wellness tax everyone pays, which providers compete to get your piece of.
- A layer of costs we can either cover through forced savings or pay cash for.
- A layer of catastrophic coverage we handle through the market, with taxes paying for minimal standards of care on the uninsured.
The “Dana Plan” has something in it to make everyone angry:
- Conservatives are going to hate the wellness tax. They’re going to hate the nagging it pays for even more.
- Liberals are going to hate the standard of care the uninsured get, when compared to those who buy insurance.
- There are going to be gaps in the middle as people treat necessities as extravagances.
This isn’t a political plan. I am quite tired of politics when it comes to health care.
But this is the honest truth. There are costs everyone must bear to stay well. Avoiding them, and evading their message, is what leads to chronic conditions like diabetes and heart disease. The rich also expect a different level of care from poor people, and in the American system they have a right to that.
I wish I could have written this two years ago, when I first started covering health care for ZDNet. I wish I had this plan 30 years ago when I began covering business for a living.
Better late than never.
