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.