Commentary: Clear direction needed
By Scott Crocker, MD Texas Medicine March 2018

The best course for providing health care lies between entitlements and options

Discussions about health care have become incredibly disoriented.

There are many opinions and agendas, but a coherent plan is missing.

It’s like when 10 people are in a rowboat, it’s dark, and a storm is coming up. They know they’re in trouble if they don’t move and move fast. Everyone is paddling, but they don’t know where they’re going.

Without identifying where the shore is, their energy and good intentions may be wasted or could even worsen their situation.

Solving the health care dilemma poses similar problems. It’s best to know where you’re going before you take off.

So the first issue is to decide where we want to be with the health care system. The next issue becomes, how do we get there?

To address the destination, consider some points of general agreement: Some aspects of health care are looked upon as entitlements for anyone in this country. Examples are immunizations for children, prenatal care to protect newborns and mothers, emergency care to handle trauma victims or unexpected catastrophes, and hospice care for terminal comfort measures.

At the other end of the spectrum, elective cosmetic procedures, excessive medical care, and blank-check, heroic, end-of-life measures should be options for those who wish to pay for them but not entitlements that society is obligated to pay for.

In a similar fashion, it’s generally agreed that our society won’t tolerate people starving to death in the street. Soup kitchens with nutritional food are available for those who need it and choose to take it. However, no one expects to have a fancy five-course meal with steak and lobster at the taxpayer’s expense. If you choose to use the soup kitchen, that’s fine, but you don’t get to order off a fancy menu. You don’t get to sue the kitchen if you don’t like the soup.

You get to say thank you. If you choose to go to a restaurant and order a fancy meal, that’s fine, but you get to pay for it.

Providing basic health care has already been established as a one-payer system. The one payer is the taxpayer. An estimated 60 percent of health care expenses are already paid for by various government agencies, including Medicare, Medicaid, the Children’s Health Insurance Program, and Veterans Affairs, but the implementation has not been efficient. For instance, it’s ridiculous to force veterans to go to designated facilities where they have no choice about location or whom they see. A great advantage of the Medicare system has been that patients can choose to change hospitals or doctors if they are dissatisfied. That has been an essential feature for quality.

For entitlement health care, it is not necessary to add an insurance company to the bureaucracy. Since the government is already making the rules, setting the fees, and writing the checks, insurance companies will only siphon off funds and add roadblocks to care. The federal government can simply decide what portion of the gross domestic product (GDP) it provides for health care.

Local governments must design ways to distribute the entitlement resources. Corruption of decisions is greater when the power is centralized, more difficult when diffuse.

Also, distribution decisions will be more appropriate at the local level as requirements vary from place to place.

Protecting patient choice of providers and transparency of outcomes is the best safeguard for quality.

Improving quality by publicizing outcomes and satisfaction levels is far more effective than trying to micromanage the many steps in the process.

Principles for delivering entitlement care include the level of federal funding indexed to GDP and regional distribution of funds based on population. Factors to be considered for determining entitlement service include age group, medical necessity, acuity, and cost. Entitlement services should be determined and administered by regional and community organizations. 

Tort reform to discourage frivolous, excessive, or extortion lawsuits is extremely important. “Loser pays” is a strong principle that works well in other Western systems.

Medical information systems should allow access by providers and patients so that reports can be retrieved easily. Although we already have a single payer for the majority of health care, more than 200 electronic medical record systems are in use. They don’t communicate with each other and in many cases are forbidden to do so because of overreaching privacy laws.

The obvious remedy is to provide a single format for information storage and retrieval. Privacy could be maintained by familiar methods such as those used by banks or credit card companies.

For non-entitlement health care, the free market approach would work very well. As in other fields, successful providers would be the ones with the best outcomes and service. Insurance companies could structure their business on a risk-adjusted basis just as they do with house insurance or car insurance. The less government interference, the better.

So there it is. The goal is efficiently providing essential, entitlement health care for the general population while allowing a vigorous free market medical system for other options.

This requires a fusion of single-payer entitlement health care for the entire population with openended, free-market health care for those who choose to buy something more. 

Scott Crocker, MD, is a cardiovascular surgeon in Abilene.

Tex Med. 2018;114(3):12

Last Updated On

May 03, 2018

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