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A Bill of Rights for Health Care Reform

Our nation’s Founders created a pretty good system of government by starting from what they wanted to achieve, exemplified by the Bill of Rights, so perhaps we would be wise to base health care reform on a similar footing.  Instead, Congress is doing its usual muddled process to produce legislation that is likely to make no one very happy, but at least tries to minimize the number of people made very unhappy.  As is too often the case, it is easier to create straw men to attack than to address the real problems. Insurance companies seem to be everyone’s favorite target to demonize, but the “evil” health insurance industry is like the various other players in the health care system: responding to the numerous and often perverse incentives in the current system.  There are bad things done to people by insurance companies — as there are done by doctors, hospitals, government, and just about every other player in the health care system.  There are both angels and demons working in health care, but mostly it is just normal people.  Perhaps ninety-nine percent of the people working in the health care system try to do right by the people they serve, but “doing right” may not mean the same thing to different people.

The problem with our health care system is that health care has become something done to patients, something too complicated or too important to let those patients take responsibility for — the way they manage the rest of their lives.  “Patient” may indeed be an appropriate description, since they certainly need plenty of patience with the various ordeals they face navigating the health care system.  We need a better word, and since “consumer” has somehow been tainted by its use in “consumer driven health care,” perhaps we should just talk about people as people. So let’s start from first principles and imagine the things we want to be true in a reformed health care system:

1. Everyone should be able to obtain meaningful health coverage, in a risk pool that spreads risk across a broad spectrum of risks.  Even – and perhaps especially — people with health conditions must be able to get health coverage that doesn’t discriminate against them for having those conditions.

2. Insurance companies have a right to be able to maintain a broad spectrum of health risks. People with health conditions can’t be allowed to get health coverage only when they need it; not even Medicare accepts anyone at any time, at least not without penalty.

3. People have a right to affordable – but not free — health coverage and health care.  There should be public subsidies to help lower-income people pay for health coverage and health expenses not paid by their health coverage, but everyone should have direct incentives to spend money wisely, as if it was their own money…which, in a very real sense, it is.

4. People have a right to use their health care data to manage their health.  Providers need to keep their own records (hopefully electronically), but the information belongs to the patient, and should be collected in a way that is easily available, portable, comprehensive and actionable for each person, across time and health care providers.

5. People have a right to make informed choices. There need to actual choices — of treatments, providers, and health plans – and for each such choice there need to be solid data about costs, quality, and effectiveness that consumers can use.

6. People have a right to be able to understand their health coverage, and fairly compare their choices. Insurance policies are too filled with legalese and confusing exclusions/limitations (the “fine print”) that vary between policies and companies, making them very difficult to understand or reasonably compare.

7. People have a right to have health care professionals who are appropriately trained and monitored. Integrated delivery systems like Kaiser or the Mayo Clinic may not happen everywhere, at least not in the short term, but well designed data reporting and analysis with feedback loops can go a long way towards achieving the same kind of peer collaboration, peer review, and use of best practices.

8. People have a right to expect that payment for health services rewards health care professionals for acting in their best overall health interests.  Fee-for-service payment on a piecework basis is a prescription for disaster, which is a fair assessment of our health care crisis – for both cost and quality.

9. Health care professionals and insurance companies that act within accepted best practices about clinical issues have a right to not be second guessed by the judicial system or other non-clinical entities. Mistakes happen, not every treatment works every time, and experimental treatments belong in clinical trials.  Punishment should be reserved for knowing or willful wrongdoers.

10. We all have a right to expect that people take responsibility for their own health.  The health care and health insurance systems shouldn’t have to artificially prop up people who refuse to try to adapt and to maintain healthy behaviors. Let’s throw in one more as a bonus:  All parties in the system have a right not to be bankrupted by truly catastrophic expenses.  Individuals, families, employers, insurance companies, and even health providers face the specter of financial ruin when a terrible misfortune falls upon some unfortunate person.  These are the kinds of events that should be a shared societal obligation. With rights come corresponding responsibilities.  We all should be more prudent about our health and how we use the health system, given the right information and with the right incentives.  The above rights would go a long way towards allowing that. None of these rights are likely to be easily realized, and reasonable people may disagree about the best way to achieve them.  In truth, there are no perfect solutions, but if we get health care reform that doesn’t address these basic goals, then one has to wonder if we will have squandered a once-in-a-generation opportunity for true health care reform.  As citizens, we can at least try to agree on the goals, and measure how well our elected officials do in meeting those goals.

Kim Bellard is former vice-president of eMarketing & Customer Relation Management for Highmark, Inc. in Pittsburgh.

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14 replies »

  1. to get straight to the point all heath care and insurance providing companies need to be combined into one “monopoly”, if you will. the reason that there are so many problems with insuring the people and having affordable insurance is that the competitive market focuses on making money, the only way they can do that is by raising rates, then another will lower theirs slightly to make it seem that some good is being done. but as with all of them if you can understand all the legal and technical bs you find that its really all the same. if every doctor and every pharmecutical company was 100% regulated and controlled on the same level then insurance would become as availible to the poor as it is to the rich, the sick as the healthy. wal-mart is so affordable because they cut out middlemen and all other senseless and costly providers by being in control at the source. this health care bill is a good idea being done in the entirely wrong way. if there was ever a situation where all you’re eggs should be placed in one basket this is definately it. as long as insurance premiums, medicine costs, and hospital fees are closely monitored and controlled, the people will actually win

  2. The doctors are making to much money!!! Ok education and hard work yes i understand that . But have any of yall paid for medicine lately ? O yall are jus the advil users bottom line this healthcare is gettin out of control . its time to correct this matter Go OBAMA!

  3. Just curious – why do you feel doctors need to be “monitored?” They are already well-educated and well-trained. Why not let them do their jobs? Costs would plummet without the regulatory nonsense.

  4. There are bad things done by the beneficiaries who receive the healthcare benefit. Yes the patient is to blame.
    MEDICARE AND MEDICAID BENEFICIARY ABUSE: IS THE BENEFICIARY TO BLAME?
    The Center for Medicare and Medicaid (“CMS”) lays the ground work for providers and physicians committing fraud and abuse within the Medicare and Medicaid system. Provider and physician fraud accounts for between 60 to 100 billion dollars per year. However, CMS makes no provisions for abuse committed by the beneficiary. Yes, the recipient of emergent or urgent medical care may be guilty of abusing the healthcare system thereby costing the government sponsored and private healthcare plans millions of dollars.
    Please check out my blog for detail of how the beneficiary contributes to the healthcare abuse.
    Visit me at http://www.lawdocblog.com

  5. Kim,
    If by structural you meant the capacity of health insurers to operate at loss ratios of 80%, and the capacity of the profit based health insurance industry to bend the ear of Congress to insure its continued existence, then yes, by all means, the problems of health reform are structural. And as Klepper et all point out cost incentives are perverse. However “rights” are not the way to address that problem. Klepper et al are making that general point themselves when the conclude:
    “Finally, the American people should demand that Congress revisit and revise the conflicted lobbying practices that have so corroded policymaking on virtually every important issue. Doing so would revitalize the American people’s confidence in Congress, and would re-empower it to create thoughtful, innovative solutions to our national problems.”
    In other words, the for profit health insurance industry corrupts our democracy, and Klepper et al know it. The for profit health insurance industry is particularly insidious compared to other for profit industries because it produces nothing of value – it’s a flow through operation that primarily makes money on the stock market. It then invests a good part of those proceeds in Congress and in propagandists to ensure that it can keep going.
    Meanwhile, it has an extremely perverse incentive to expand the percent of GDP spent on medical care so as to increase its cash flow through and available funds for investment. It is a unique form of capitalist dead weight – all of the down side to corporatism without even the upside of enhanced productivity or the creation of value.
    Pushing back and reigning in corporatism (of which the private health insurance industry is just one component) won’t solve the crisis of democracy in which we are now situated, but it might reduce the number of essays arguing that this particularly perverse form of the modern corporation, health insurance companies, have “rights” in a democracy that are somehow on par with the rights of actual human beings.
    I apologize for the need for anonymity, but I purchase insurance on the individual market and necessarily must protect my family’s safety and insured status.
    But, as I say, all in good fun.
    Mike

  6. Mike – at the risk of prolonging a discussion with an anonymous poster about something that appears to be more of an article of uncompromising faith for you instead of something that can rationally be discussed, I honestly have a hard time understanding the animosity towards insurance companies. I don’t expect the federal government to pay for my groceries, my housing, or my/my kids’ education, so I don’t quite follow the arguments about why it should be true for health care. Even Medicare, the model that many single payor advocates would build on, is deeply flawed — antiquated design, only acceptable because most Medicare recipients have private insurance, and funded through deficit financing that is not sustainable.
    The real issues of health reform are more structural than the financing source, as the article by Kibbe, et. alia on today’s THCB so rightly point out. Arguing about if health insurance should exist is not particularly productive.

  7. Kim,
    What the hell is a “bill of rights for health care reform”? Who or what is health care reform that it needs “rights”?
    Last time I checked a Bill of Rights grants someone, you know, “rights”. I’m pretty sure that “health care reform” isn’t a person or entity in need of rights.
    Your scheme makes that quite clear that “health care reform” is some new rearrangement of a health insurance industry based health care delivery system.
    What you have written is more like the slavery accommodating American Constitution. I’m not without understanding for your position, much as I can understand the position of delegates to the Constitutional Convention from the slave states. The possibility that a special institution (then slavery, here, the health insurance industry) would simply be abolished is somehow considered too radical by the bewigged or besuited power brokers of the day. Even if they are able to speak the language of “rights” they somehow carve out a space for existing power structures and manage to avoid addressing the deep contradiction between the language of individual rights and the institutional interests that subvert those rights.
    Such failures of the moral imagination are not uncommon in history. But, as they say, the arc of history is long, and it bends toward justice. We shall see.
    I slept like a babe.
    Mike

  8. The responsibility that each and every one of us has as a consumer of healthcare services is an important piece of the health reform puzzle. We as patients—as consumers of healthcare services—have to behave better and differently if we are to achieve healthcare reform that covers everyone, improves quality, and holds costs and the deficit at bay. This means being more informed about the costs of the healthcare services we are using, engaging in preventive healthy activities, and being proactive about managing our health.

  9. To Dennis: yes, certainly people who are truly incapable of making decisions on their own behalf need different treatment, with someone making decisions on their behalf, and certainly health care often puts even the most intelligent & decisive individuals at a loss as to the “right” decision. But what I don’t think we can afford is a system that treats all patients as incapable and blindly assigns the decisions to the health care professionals. We need to orient towards people being responsible, and look for ways to give them the best information, and to give the various entities the right incentives to act in their best interests.
    As for Mike, well, perhaps you did not gather that this was a bill of rights for health care reform rather than being the patients health care bill of rights — something that would also be useful, but not quite the same. I’m sorry that you can’t get past your dislike of the insurance industry. I do believe in a capitalist system, with appropriate consumer safeguards, and see no reason why health care should be an exception. I don’t think it is realistic to expect health care reform that will not include some sort of role for the private insurance system, and believe it makes more sense to look at ways to ensure that reform is done well assuming that. I at least hope your response allowed you a good night’s sleep. No hard feelings indeed…

  10. I think your bill of rights covers a great deal that we need, but you don’t address one often forgotten issue: there are many people in this country who simply cannot — through no fault of their own — be the “responsible” patients your bill assumes. (I’m mainly address points 4,5,6, and 10.)
    I’m refering to the elderly suffering from dementia, the mentally ill, and, in some cases, the typical person when confronted with an unknown or incomprehensible ailment — that may or may not be serious. And while, viewed from the perspective of the nation as a whole, we may not be talking about a lot of people, but when viewed from the perspective of the entire health care industry, we are talking about a significant amount of resources.
    We can’t always be good consumers of health care like we try to be when we buy a car or groceries. Sometimes decisions are simply out of the individual’s reach and, in that case, someone else has to make it for them. We typically defer to family members, but they are not always available and can spend more time debating than deciding (if they ever do). And sometimes, no matter how smart we are or how hard we try to understand, the best health care approach is simply incomprehensible to us. This is where I think the health care profession has a moral obligation to step in do what’s best for the patient.
    No, I don’t know the answer to what’s best, but I think the health care professionals will do better if they can put away the ledger sheets and tell the insurance company to go to hell when faced with a difficult situation like I described above.

  11. Who can resist a rewrite of the Bill of Rights before dinner? Not me! But this bit of insurance industry hackery misses a basic point about the Bill of Rights, to wit, that it is a bill of largely individual rights. The absurdity of a Bill of Rights that grants some of those rights to the insurance industry should not need stating, but in case it does, here goes.
    Skip to the end if you want to read the summary.
    “1. Everyone should be able to obtain meaningful health coverage, in a risk pool that spreads risk across a broad spectrum of risks. Even – and perhaps especially — people with health conditions must be able to get health coverage that doesn’t discriminate against them for having those conditions.”
    Hard to see how the right to health care should be dependent upon the risk pool. Either you’ve got a right or you don’t: how systems distribute risk is hardly a matter of high principle. And what’s this about “coverage”? Is it a right to health insurance that we want to take a stand on, or a right to care? This sounds like insurance industry hackery. Shouldn’t this just say Everyone should be able to obtain meaningful health care. A right to “coverage” indeed – talk about insurance industry wet dreams!
    “2. Insurance companies have a right to be able to maintain a broad spectrum of health risks. People with health conditions can’t be allowed to get health coverage only when they need it; not even Medicare accepts anyone at any time, at least not without penalty.”
    Why should insurance companies have rights? Who says there will be health insurance companies, much less that their existence should be assumed and implicitly guaranteed in some imaginary Bill of Rights?
    “3. People have a right to affordable – but not free — health coverage and health care. There should be public subsidies to help lower-income people pay for health coverage and health expenses not paid by their health coverage, but everyone should have direct incentives to spend money wisely, as if it was their own money…which, in a very real sense, it is.”
    It is an odd thing to describe a right but insist that it not be taken too seriously or too far. Writers of constitutions should take care with their language. If there is a right to “affordable” care then let’s say that. After all, free is affordable too. Why bother to suggest that free care violates some right?
    “4. People have a right to use their health care data to manage their health. Providers need to keep their own records (hopefully electronically), but the information belongs to the patient, and should be collected in a way that is easily available, portable, comprehensive and actionable for each person, across time and health care providers.”
    At last, a right that we can all agree upon. Providers will of course point to their purported work product ownership rights. This amendment avoids that issue and just says that regardless of provider rights, the patient has a right to the data about his or her body. Finally, a little sense buried in the nonsense.
    “5. People have a right to make informed choices. There need to actual choices — of treatments, providers, and health plans – and for each such choice there need to be solid data about costs, quality, and effectiveness that consumers can use.”
    Really? Do people really have a “right” to choose more than one health plan? Is some human right violated by the British system or the Canadian system?
    “6. People have a right to be able to understand their health coverage, and fairly compare their choices. Insurance policies are too filled with legalese and confusing exclusions/limitations (the “fine print”) that vary between policies and companies, making them very difficult to understand or reasonably compare.”
    This marvelous right presupposes the author’s desired world of multiple health plans. I put it to you that the posited right is more like the enshrinement of a smoke screen, designed to busy consumers with the myopia of obsession with small and meaningless distinctions. The entire idea that you need to choose your health plan, and equating that choice with your choice of treatment or provider, is self serving health insurance industry propaganda. I assume the author takes it seriously, but I hope that you dear reader have more sense. I don’t care what you understand about the details of your health plan so long as you understand the false choice that the entire health plan choice system is presenting you with. Health reform efforts seek to make health plan choice work better… but they don’t address the fact that there is no compelling reason to have separate plans in the first place.
    “7. People have a right to have health care professionals who are appropriately trained and monitored. Integrated delivery systems like Kaiser or the Mayo Clinic may not happen everywhere, at least not in the short term, but well designed data reporting and analysis with feedback loops can go a long way towards achieving the same kind of peer collaboration, peer review, and use of best practices.”
    I think this is reasonable. Together with 3, it is the second point here that makes sense as written. So far we are 2 for 7
    “8. People have a right to expect that payment for health services rewards health care professionals for acting in their best overall health interests. Fee-for-service payment on a piecework basis is a prescription for disaster, which is a fair assessment of our health care crisis – for both cost and quality.”
    Well sort of. Is it that I have a “right” to expect my doctor will be paid for acting in my best interests? Hmm. I think I have a right to expect a physician to exercise his or her fiduciary responsibility as my agent, and to disclose incentives that may function against my best interests. However the right to have a physician act in my best interests seems to extend far beyond the payment system. My right is to a standard of care, not to a payment system. The payment system is only one mechanism that enables my right. Call this half right, and put the score at 2.5 out of 8
    “9. Health care professionals and insurance companies that act within accepted best practices about clinical issues have a right to not be second guessed by the judicial system or other non-clinical entities. Mistakes happen, not every treatment works every time, and experimental treatments belong in clinical trials. Punishment should be reserved for knowing or willful wrongdoers.”
    Whose right is this? I thought we were talking about rights that “people”, you and me, have. OK, so doctors and insurance companies have rights too. Nice to know that insurance companies are right there in importance equal to physicians. And they both have a right to tort reform! Sorry, there may be a different balance to be struck, but the idea that the judicial system or “other non-clinical” entities won’t be there to protect me gives me the chills. Some Bill of Rights. Fail.
    “10. We all have a right to expect that people take responsibility for their own health. The health care and health insurance systems shouldn’t have to artificially prop up people who refuse to try to adapt and to maintain healthy behaviors.”
    As the explanation clarifies, this is not a personal right but a right of insurance companies, and it is a loophole big enough to drive a truck through, and operates in direct contradiction to right number one. Fail.
    “11. All parties in the system have a right not to be bankrupted by truly catastrophic expenses. Individuals, families, employers, insurance companies, and even health providers face the specter of financial ruin when a terrible misfortune falls upon some unfortunate person. These are the kinds of events that should be a shared societal obligation.”
    Here, a bonus right not to be bankrupted is thrown in, and this applies to everyone. Do insurance companies face financial ruin the way individuals do? Don’t they have, you know, re-insurance for that? But never mind we get it. There exists a right not to be bankrupted by catastrophic expenses and it applies to apples, oranges, and tuna fish. Whatever. Here’s another idea. Individuals have a right not to be bankrupted by catastrophic medical expenses. Insurance companies, in contrast, are corporations chartered by governments, which exist at the arbitrary discretion of governments and which can be disbanded, regulated, and put out of business if they fail to serve the public interest.
    —-
    OK, so I’ve been a little harsh here, but hopefully all in good fun. This list of “rights” is just such an annoyingly incoherent set of self serving industry hackery that I wasn’t going to be able to sleep tonight without pointing it out. No hard feelings. Insurance industry people can’t help it. They’ve had nice long careers in the field, put their children through school, and paid their mortgages by the work in the industry, and they can’t help but feel that some how their parasitic little shell game is an important part of reality as it ought to be, just as basic to health care as patients, and doctors and mom and apple pie. I suspect that they are largely sincere in their beliefs. Unfortunately they are deluded and their delusion and the mind share that their delusions capture, pose a terrible cost to the rest of us.
    2.5 parts sense to 8.5 parts nonsense is perhaps a good metaphor for the general value of the health insurance industry to America, although that might be a bit generous.

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