My past columns have criticized the conservative Republican approach to health care reform. Its promotion of several proposals thus far displays a disturbing lack of concern for the millions of individuals who would surely lose their insurance.
These proposals would have especially affected older individuals, the poor and those with pre-existing conditions. Remember, there is a human cost of being uninsured. The uninsured are less likely to receive preventative services or have adequate treatment for chronic diseases. Uninsured individuals postpone or forgo needed care, are more likely to experience avoidable hospitalizations and inequitable medical care and are at higher risk for more advanced disease and death. They are also at high risk for medically related debt and bankruptcy.
Further, Republican proposals, at least partially, preserve some of the most popular and expensive elements of Obamacare, yet rescind components critical to assuring the financial viability of the system, thus yielding their proposals untenable.
A recent article in Journal of the American Medical Association looked at paying for the care of costly patients. It reviewed three possible solutions: First, create separate high-risk pools for patients with certain chronic conditions. Removal of identified high-cost patients would reduce the premiums for the larger body of insured. But this would necessitate huge federal or state governmental subsidies to reduce high-risk pool premiums. Republican proposals have not adequately funded these high-risk pools.
A second possibility is to place these patients in Medicare. Considering the projected financial shortfalls for Medicare into the future, placing costly people into the program also is not a realistic option.
The third option is universal enrollment through an individual mandate, a strategy the Republican Congress absolutely loathes and can’t wait to repeal. Universal enrollment spreads the financing of health insurance over the entire population, eliminates adverse selection of older and sicker patients and interrupts the cost-shifting of medical expenses of the uninsured to the insured. A mandate has advantages including ease of implementation and promotion of individual responsibility. Universal enrollment is essential to a functional, affordable and sustainable health care system. Without it, premiums will be costly.
There are a number of well-preforming foreign multi-payer health care systems that offer quality medical care at a fraction of the cost compared to the U.S. system. These systems provide universal coverage, guaranteed issue for pre-existing conditions, choice in choosing coverage, uniform premium ratings regardless of health status and other protections that Obamacare contains.
The individual mandate in these foreign systems is strongly enforced and substantial penalties are instituted to ensure compliance, a shortcoming of Obamacare.
Without universal enrollment, a Republican plan will financially fail. Republican proposals overly rely on insurance company competition and free-market principles to lower health system costs and expand enrollment. Insurance industry competition is important, but can only go so far to reduce the inherent high costs of medical services and the perverse quantity-based incentives promoted by our fee-for-service payment system.
No amount of free-market principles or insurance-company competition will carry the day. Any health care system based on health insurance must assure the participation of low-utilizers to offset the costs of high-utilizers of services.
We need a meaningful individual mandate.