The institutions that provide education and health care in our country are vastly different. But the services they seek to provide – learning and health – share many characteristics.
Both involve interaction between consumers with some set of hopes and needs (students and patients) and providers with some set of skills and resources designed to meet those needs (teachers and health care providers). Despite the best intentions of all involved, the outcome of these interactions can never be guaranteed.
The interaction between student and teacher, between patient and provider, is, in the end, more art than science, more individually specific than collectively generalized. The process of acquiring both learning and health is essentially relational. The outcome of the relationship depends upon what each participant brings into it. And that fact introduces the element of risk.
No matter how standardized the curriculum, the procedure, the test, neither a school nor a hospital is a factory. Outcomes cannot be guaranteed. Neither students nor patients are widgets designed and produced for some predetermined outcome.
Yet in both arenas, public pressure today is on precisely that – focus on, measure, test for, pay by, outcomes. Returning to my theme of designing social programs on principles rather than political parties, here are some suggestions for ways to think about the ongoing debate over health care in this country – first with respect to the constitutional, democratic (small d) principles involved and, second, with respect to programs that would flow from those principles.
In my opinion, any public health program established in the United States should:
• Be based on and enhance the centrality of the patient-provider relationship.
• Include incentives for all parties in the health care relationship to continuously seek ways to improve health outcomes.
• Make a clear and simple distinction between health care programs and services and health insurance.
• Guarantee a basic level of care to all those in need regardless of age, income, current health status, ethnic or any other identity distinction.
What would such a program look like?
First, it would do away with the anachronism of employer-provided health insurance by abolishing the tax deductibility of such insurance.
This simple change would immediately remove the current craziness of employers negotiating with insurance companies for benefits, and providers negotiating with them for payments, while employees and providers (the real partners in the relationship) meet only after the fact and with no incentive or often even ability to establish long-term, health-focused relationships.
Such a program would simultaneously increase the international competitiveness of all U.S. companies, remove the second-class status of all small employers and the self-employed and non-employed who currently struggle to find insurance coverage in the artificially limited market for individual health insurance. And it would release the pent-up demand for individual exploration, career advancement and entrepreneurship now stifled by the fear of leaving a job with “good” health benefits.
It would immediately create an enormous national market for individual and family health insurance.
Such a market would be reinforced by mandates for universal coverage enforced as car insurance is now mandated for acquisition of a driver’s license.
Such a mandate could additionally be enforced by requirement of proof of insurance at other significant social gateways such as entrance into a public school, and receipt of government assistance programs, including government-financed mortgages or government-insured bank accounts.
And it would enable a straightforward calculation of a national “universal care” budget through an actuarial analysis of the costs of providing premium subsidies for those whose combination of income and demand for health services pushes their premium costs above some established maximum personal contribution (along the lines of the “minimum local commitment now used in financing public education in Maine and many other states).
This nationally “shared” portion of the health care budget would be financed by a premium surcharge added to all individual policies.
We would all be able to see exactly what we are paying to provide universal coverage. Proportions of these surcharges would be deductible from federal income taxes, diminishing with higher incomes.
Clearly any program such as I have described here would generate heated debate. It would not, however, immediately descend into the arcane, inside-baseball complexities we are sure to hear in the coming debates about repealing or keeping Obamacare.
Instead of trying to hide complexity in sugar-coated euphemisms, this proposal continues at every turn to return to fundamental principles. And that, I believe, is the only way to garner broad public support for any health care reform.
Consulting economist Charles Lawton, Ph.D., can be contacted at:
cttlaw3@gmail.com
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