When Massachusetts’ health reform plan was enacted in 2006, one of the principal features was the concept of the individual mandate to purchase or have health insurance, on the basis of CommonwealthCare, essentially a system of low-cost health plans with insurance premiums subsidized by the Commonwealth. The system also includes a form of “play or pay,” whereby most employers must contribute to their employees’ health insurance. Fueled by the individual mandate, the number of uninsured in Massachusetts has fallen dramatically. That’s a real accomplishment, although it’s important to examine how that was done.
Health reform was trumpeted as the chief accomplishment of Romney’s one term as Governor. Yet some critics argue that a mandate has dangers as well: among other things, what incentive would there be to reduce the costs of premiums? The Commonwealth has an interest in that issue, too, not only to reduce the overall cost of healthcare but in fact to reduce its own costs, given the subsidies.
Yesterday’s Washington Post had a lead article, “In Retooled Health-Care System, Who Will Say No?,” which discussed limiting access to health care treatments after health care reform – in a word that no one in politics wants to use, rationing.
Here’s what the Post reported on Massachusetts (emphasis added), with a bit of federal policy at the end:
Massachusetts, which has achieved near-universal health coverage but is struggling with high costs, is considering major changes in this direction. A legislative commission is about to release a report recommending that the state goad providers into joining networks that would receive payments for each enrollee, rather than for each procedure delivered.
Proponents say it would differ from the “capitation” approach — fixed payments for each member — used by the HMOs in the past because there would be more focus on performance and long-term value than on simply keeping costs down.
Skeptics say such a system would force the state’s many solo practitioners or small groups of physicians into big networks and would renew complaints from the HMO era about limiting patients’ choice. In Massachusetts, for instance, most parents with a sick child would demand access to Children’s Hospital; and most cancer patients would want to go to the Dana-Farber Cancer Institute, no matter what network those were in.
The plans being considered in Washington do not go nearly as far in seeking to change providers’ spending habits. They contemplate changing some Medicare payments from fee for service to a “bundling” system in which providers would be paid for an entire episode of care, giving them an incentive to reduce repeat hospital admissions. Another idea is to empower the Medicare advisory panel whose recommendations now tend to be ignored by Congress, or to create a separate, Federal Reserve-like entity to make tough decisions about federal health-care spending.
So Massachusetts, through its Payment Reform Commission, is contemplating going further than the current federal proposals, with the concept of “global payments” to insurers. Call it “Capitation Light.” This leads to a number of questions:
- As Massachusetts goes, will any new federal system inevitably follow? Congressional Republicans have a duty to ask this question now, when the plans are being debated, not later when it’s too late. This directly impacts the current debate. Capitation was not popular; will Republicans be seen as the opponents of Capitation Light?
- Does the very concept of a mandate lead inexorably to rationing? The burden should now be on mandate proponents to show that it does not. (Remember, Obama opposed an individual mandate in the primaries last year. Here’s a Democratic take on why that was smart politics for them.)
- We’ve heard a lot in the recent healthcare debate about how most employed Americans are happy with their healthcare. Would a switch to capitation-like payments as an obvious next step change that?
- More specifically to Massachusetts, what promises were made at the time CommonwealthCare was enacted? Have the cost estimates proven accurate? If so, why, and if not, why not? (Granted, personal incomes have been squeezed, making the cost of the mandate higher for many people, but it can’t all be blamed on the recession.)
- The bit in the quote above about Children’s Hospital and Dana-Farber is a bit of a red herring. Those are wonderful hospitals, but Massachusetts full of wonderful hospitals and doctors. Here’s the real question: does Capitation Light mean that patients will be sharply restricted from specialist care? Under what circumstances and standards? And who makes those decisions: doctors, patients, or insurers?
For an analysis of the payment reform proposals from a physician perspective, see here. For an insurer perspective, see here.
Perhaps the proposed Massachusetts reforms will lead to a Mayo Clinic-like nirvana of coordinated care. Perhaps this time there really will be a focus on “prevention” (but if so, why criticize all the spending on MRIs?). But I’m skeptical of arguments that “it’s different this time” when the financial incentives are so clear. That applies to health insurers as much as to mortgage brokers or anyone else when financial incentives are geared a certain way. Human nature is human nature. And in a crowded and busy healthcare system, in which reform will likely lead to more paperwork, not less, the Mayo Clinic vision seems difficult to implement in practice – one reason why it would be easier, as well as cheaper, for the Commonwealth simply to delegate the task to a person’s insurance carrier.
Meantime, the Massachusetts Republican Party has a Martha’s Vineyard-sized whale of a problem in coming up with its own proposals for healthcare. Here’s what the party’s principles say about healthcare:
Healthcare
Every citizen should have access to affordable healthcare without excessive government intrusion or control. Massachusetts Republicans support applying market-based solutions to achieve greater healthcare access, lower patient costs, and improve quality of care.
Unsurprisingly, that’s effectively the Romney vision, as he was the last GOP Governor. Republicans may oppose the Payment Reform Commission’s ideas, but the Democrats would respond that they’re just applying the same principles of “market-based solutions” that Republicans support. If patients – who must now have insurance – oppose “global payments” as they did capitation in the 1990s, the Democrats will blame Republicans for the design of the system that led to this result. So unless the Republicans come up with something different, they could be in the situation of taking the blame for de facto capitation and eventual rationing, even though the Democrats actually introduced the second step.
Unless, of course, Romney can run and win for his old office next year on a platform of fixing CommonwealthCare from the changes the Democrats have made. After all, he wrote in 2006 that “A great deal will depend on the people who implement the program.”
Success there – limiting costs while avoiding rationing – really would be an accomplishment of national importance.
11 responses so far
1 sinz54 // Jul 9, 2009 at 8:34 am
Any health care system must include rationing of some sort. Because no one wants to die because their health care costs too much. Thus a sick patient will always demand whatever health care is necessary to make him well, cost be damned.
Currently, we ration health care by income: If you’re poor, you get less care or even no care save Emergency Room urgent care.
The dirty little secret no one wants to talk about, is that to offer decent health care to those who currently don’t have it, may require increasing the out-of-pocket costs (through higher premiums and co-pays) of those who currently enjoy decent health care. It’s precisely this kind of socialist sacrifice that has always been a tough sell to individualistic Americans.
My answer is: There but for the grace of God go thee: You may be enjoying decent health care from your employer today. But if you get sick and then get laid off, you may be one of those poor uninsured that currently gets poor care.
2 balconesfault // Jul 9, 2009 at 10:25 am
“The dirty little secret no one wants to talk about, is that to offer decent health care to those who currently don’t have it, may require increasing the out-of-pocket costs (through higher premiums and co-pays) of those who currently enjoy decent health care. ”
As you note many “who currently don’t have” insurance are those who are uninsurable due to pre-existing conditions, dropped from a previous plan due to condition or to loss of job. This is an example of insurance companies keeping premiums and co-pays lower for their customer pool by simply sluffing off the higher cost/higher risk policies.
As a society, it seems to me we have 4 options:
a) lassiez-faire – let the marketplace work. If people are denied or can’t afford coverage, they shouldn’t have coverage. If they can’t read their policy terms closely enough to realize their exposure in the case of a serious illness or injury, that’s too bad if they end up needing greater coverage. Perhaps some charities will pick up the slack (or emergency rooms, which end up acting as de-facto charities).
b) government intervention to force private companies to expand their coverage levels and limit their control to reduce their risk pool
c) a public option to enable the currently uninsurable to buy into a government run program
d) universal single-payer health care
******************
I do have one issue with an individual mandate. Is it constitutional?
I can see why the state of Mass. can require it. It seems to me that the federal government can not.
3 barker13 // Jul 9, 2009 at 11:19 am
A few comments…
“…a system of low-cost health plans…”
Sounds good. The problem is, “low cost” can only be balanced by… er… low or lower usage – paying $1.00 for something that necessarily costs $1.01 (let alone $2 or $3) simply isn’t sustainable.
“…a system of low-cost health plans with insurance premiums subsidized by the Commonwealth.”
Ahh! So that’s how we get around the problem of the math not working – we have the state “subsidize” the shortfall. The problem with that of course is that the state gets its money from… er… us.
So… we’re not really talking “low cost;” what we’re talking is cost shifting – we’re talking income redistribution.
“Fueled by the individual mandate, the number of uninsured in Massachusetts has fallen dramatically. That’s a real accomplishment…”
Actually… it’s not. It’s not because it’s not the “insurance” that’s absolutely necessary – it’s the CARE.
Now you may say the two are inseparable. But they’re not. Every single person without insurance who is healthy, who doesn’t require insurance payouts for CARE is “winning” big time. You need to understand that.
For a time when my wife and I were young we made the conscious decision NOT to pay hundreds and hundreds and hundreds of dollars a month – thousands and thousands of dollars a year – for health insurance. We bet that we wouldn’t get sick. We “won.” We didn’t get sick. We saved thousands and thousands of dollars. We didn’t get hurt by not having insurance; to the contrary, we greatly benefited by saving those thousands and thousands of dollars and applying them to various other needs, wants, and desires.
Now you can come back at me with “what ifs,” but my point remains; in the real world, accounting for the real history, not having insurance for a few years was a boon to me and my family.
Anyway, my point is simply that there’s a huge difference between the effects of not having INSURANCE and not having CARE. Just a point to ponder.
“A legislative commission is about to release a report recommending that the state goad providers into joining networks that would receive payments for each enrollee, rather than for each procedure delivered.”
Hmm. Wouldn’t that provide an incentive for doctors to accept far more patients than they could possibly provide high quality care for…???
I mean a doctor’s time isn’t unlimited. Therefore, you can’t delink the amount of TIME required to care for patients from the doctor-patient ratio – can you…???
“Does the very concept of a mandate lead inexorably to rationing?”
Umm… YES?! (Jeez, that was simple!) I mean, unless you have an unlimited SUPPLY of doctors, nurses, equipment, drugs, etc., of course a mandate must lead to rationing.
“More specifically to Massachusetts, what promises were made at the time CommonwealthCare was enacted? Have the cost estimates proven accurate?”
(Anyone else curious about why Mr. Gardner didn’t answer his own question here…???) (So… what is the answer…?!?!)
“Every citizen should have access to affordable healthcare…”
(*SNORT*) What’s “affordable?”
Hey… can I have guaranteed “affordable” car repairs? Instead of paying between $70-$140 an hour based on “book” estimates can government simply mandate that my mechanic charge me no more than $35/hr. (not bad money, actually – tens of millions of Americans would give their eye teeth to make $35.hr.) to work on my car? How long should it take for a professional mechanic with all the proper tools in his shop to change 8 frigg’n spark plugs and throw a new air filter and cabin air filter in? An hour? An hour and a half? Two frigg’n hours! Hey… anyone wanna guess the cost of a tune-up of my Charger if I were to take it to the dealer?!?!
Hey… my point is… what’s a “fair” price on a doctor’s time? Assuming charging in 10 minute or 15 minute increments… what’s a fair reimbursement for a GP’s time? How’bout a specialist’s time? How’bout fair reimbursement for overhead – including paying the nurse(s), the receptionist(s), the rest of the staff?
Hey… just as I threw out $35/hr. for a mechanic… pick a number for a doctor.
NOW… make the math work. Figure out how the mechanic keeps his shop running, affords “capital” equipment, pays his overhead… does $34/hr. work? Hell… I know $140/hr. is a rip-off… but what is the “proper” number?
Now transfer this question, this concept, to the doctor’s office… to the hospital. (*SHRUG*)
We already screw doctors and hospitals with medicare/medicaid. They “recoup” their “losses” from “overcharging” other segments of their patient population – those with insurance and the truly wealthy who may pay out of pocket. (Think airline economics… think 1st class vs. super-saver.)
Anyway… (*SIGH*)… just some thoughts.
BILL
4 sinz54 // Jul 9, 2009 at 12:18 pm
barker13: I gambled too.
But I wasn’t as lucky as you.
I had bought one of those high-deductible insurance policies, to save money on premiums.
And then, years later, my kidneys failed.
Then I discovered that those high-deductible policies paid so little in claims, that I was going to be stuck with a mountain of health care bills.
Fortunately, I live in Massachusetts, whose state law forbids an insurer from denying coverage due to a pre-existing condition, so I was able to switch to a lower-deductible policy.
The reason why the insurers agreed to take folks with pre-existing conditions like me, is that the Massachusetts mandate for universal coverage forced many more healthy folks like you into the insurance pool. That way, the private insurer can pay for my surgeries out of YOUR premiums.
That’s the Grand Bargain that Massachusetts had to strike: Not denying coverage for pre-existing conditions in return for a much larger pool thru universal coverage.
If we don’t have near-universal coverage, and you force insurers to take folks with serious pre-existing conditions, THAT will drive the insurers into bankruptcy eventually.
Because what folks like YOU will do is wait until AFTER you’re diagnosed with some serious illness, and only THEN purchase a policy.
5 balconesfault // Jul 9, 2009 at 12:55 pm
“Hey… can I have guaranteed “affordable” car repairs?”
No.
6 barker13 // Jul 9, 2009 at 2:10 pm
Re: Sinz54 // Jul 9, 2009 at 12:18 pm –
“Then I discovered that those high-deductible policies paid so little in claims, that I was going to be stuck with a mountain of health care bills.”
You… er… “discovered…???” What? You didn’t READ the contract…? Sinz. You’re an engineer, right? A college graduate – right? If you were too lazy to read the contract you could have paid a lawyer a few hundred bucks to read it for you… right?
(*PAUSING*)
Anyway… let’s change tack here. Let’s stipulate that we need legal reforms in this country so that folks like us can reasonably be expected to understand the contracts we sign. (Don’t know if there’s much chance of that, though, when our lawmakers are quite content with passing bills they don’t read.) (*SHRUG*)
As to this specific topic of catastrophic coverage… let’s stipulate that when I call for catastrophic coverage I’m calling for the real deal – policies that actually do provide the catastrophic care they’re meant to. No loopholes. No weaseling out. Cool…???
“Fortunately, I live in Massachusetts, whose state law forbids an insurer from denying coverage due to a pre-existing condition…”
So you’re a welfare case. Great. Super. You’re welcome, Sinz. (*SMIRK*) (*SCOWL*)
“The reason why the insurers agreed to take folks with pre-existing conditions like me, is that the Massachusetts mandate for universal coverage forced many more healthy folks like you into the insurance pool.”
Sinz. We’re not talking “insurance.” We’re talking income redistribution. Furthermore, as you started out by admitting, you effectively “gamed” the system, saving YOURSELF premiums while costing all the rest of us money to make up for YOUR deficit in payments.
Here’s my solution:
I (the state) take ALL your money. I take your savings. I take your house. I take your car. I force you to liquidate all your worldly possessions and I take the proceeds and add them to the state insurance pool.
Next. I provide you with necessary medical care. I provide you with a bed in a hospital ward that resembles something out of the 19th century or an episode of MASH. You get cafeteria type food as if you were an elementary school student or a prisoner in a prison. When you’re well enough to work you get sent out to work. You’re allowed to keep only a portion of your wages, enough so that maybe in a few months, maybe six months or a year you’ll be able to transition out of “ward” housing and get yourself a studio apartment or room with someone. The goal is to allow you to rebuild your life… but rebuild it from basically scratch.
Sinz. You’re not my frigg’n kid. I don’t wanna support you and if you force me to I’m gonna make the experience as unpleasant for you as it is for me.
BILL
7 barker13 // Jul 9, 2009 at 4:22 pm
Re: Balconesfault // Jul 9, 2009 at 12:55 pm –
Damn!
(*AMUSED AND APPRECIATIVE SNORT*)
BILL
8 sinz54 // Jul 10, 2009 at 9:44 am
barker13: I didn’t mean I suddenly discovered that the plan had high deductibles. I meant that I suddenly discovered how expensive caring for kidney failure was going to turn out to be.
Prior to my being diagnosed, I didn’t know that it would cost around $100,000 for my first year of treatment (dialysis + five surgeries).
And I’ll bet you’re the same way. Yes, you knew you were taking some kind of risk by not having health insurance. But I wonder if you actually calculated the odds of you getting at least one of the following: Cancer; kidney failure; liver failure; heart disease; life-threatening injury from accident; etc. The odds are higher than most people think.
Very few of us have all the data to compute the mathematical expectation of our health care needs.
And when we’re relatively young, we tend to think we’re indestructible, and we don’t give much thought to what life would be like as disabled or as an invalid.
9 barker13 // Jul 10, 2009 at 11:12 am
Re: Sinz54 // Jul 10, 2009 at 9:44 am –
Sinz. Are you trying to tell us that you purchased an insurance plan that put you on the hook – out of pocket – for $100,000 in medical expenses in one year…???
“Very few of us have all the data to compute the mathematical expectation of our health care needs.”
What are you BABBLING about…?!?!
Sinz… one doesn’t need to be a math wiz to figure out that an insurance plan that leaves one open to having to pay $100,000 in a single year out of pocket for medical expenses isn’t much of an insurance policy.
(*HEADACHE*)
(*SIGH*) Otto plagiarizes. You got caught lying about your gender. Frum spends most of his time bashing conservatives. What the hell kind of site is this…?!?!
(*RUEFUL LAUGH*) (*SNORT*) (*SMIRK*)
BILL
10 sinz54 // Jul 11, 2009 at 2:56 pm
barker13: My total health care expenses for this year were over $100,000. Let me explain which parts of it were paid by the high-deductible plan I had purchased.
That plan had a $7,500 deductible for surgeries. I never expected to have 5 surgeries in a nine-month period. But I have.
It also had a 20% copay for doctor visits and treatments. With my dialysis and doctor visits costing me some $80,000, that put me on the hook for another $16,000 or so. Total: over $20,000 in out-of-pocket expenses.
And since kidney failure is incurable, I would be looking forward to comparable out-of-pocket expenses every year for the rest of my life.
Kidney failure is usually caused by obesity, high blood pressure, or diabetes. I didn’t have any of those, I lived a healthy lifestyle just like the doctors tell you to. I’m one of the rare cases of kidney failure where the cause is unknown. It just happened.
I never expected a life-threatening illness to just happen at my age. But it did.
The only reason why I’m not going bankrupt, is that Massachusetts has mandated that no insurer can reject an applicant for a pre-existing condition. So I was able to switch from this high-deductible plan to a low-deductible plan offered by Blue Cross.
Tell me: What you or your wife have done, if some life-threatening illness had struck? Could you have afforded to pay for treatment without medical insurance?
11 barker13 // Jul 11, 2009 at 4:24 pm
Re: Sinz54 // Jul 11, 2009 at 2:56 pm –
“That plan had a $7,500 deductible for surgeries.”
(*SIGH*)
Sinz. One more frigg’n time…
I favor a system where there’s catastrophic insurance coverage – coverage that kicks in 100% beyond a certain threshold. The “proper” threshold might might be 10%-20%-30% of one’s yearly income. I’m not gonna get hung up on the details because I’m trying to give you a simple outline of my thinking.
DO…
YOU…
COMPREHEND…???
“With my dialysis and doctor visits costing me some $80,000…”
Sinz. Again. Beyond the question of whether your doctor visits and dialysis SHOULD or should not “cost” $80,000 to begin with…
(See – another aspect of this whole discussion is how much care should reasonably cost – cost period, regardless of who’s bearing the cost – but for purposes of this discussion that’s neither here nor there.)
…what I’m calling for is a plan where, just as an example, just to demonstrate the concept, your income is $100,000 you’re gonna be on the hook personally for medical bills of $10K… 20K… maybe even $30K.
For illnesses that don’t go away, that require constant ongoing treatment… well, then another “tier” would kick in, perhaps something like you’d have to pay a max of $50,000 for five years worth of treatments – which would be 10% of your five year income at $100K/yr.
Next… what if your illness effects your ability to work, to earn? Well then another “safety net” would pick up the slack.
Sinz. I swear to God I don’t know what’s so frigg’n confusing to you. What I’m saying is that I don’t find it anymore unreasonable to expect Americans to pay for their own “general” medical care out of pocket than I do that we pay our shelter (housing) out of pocket or our food out of pocket or our TAXES out of pocket or our car payments out of pocket or our gas out of pocket… etc., etc., etc.!
AND… just as with my auto insurance… just as with home owners insurance… I want the insurance to kick in when it’s truly a catastrophe.
“The only reason why I’m not going bankrupt, is that Massachusetts has mandated that no insurer can reject an applicant for a pre-existing condition.”
(*SIGH*)
You just not getting it, are you…???
OK. Imagine. I cancel my collision insurance. Three years later I crash my car. I go to my insurance company and demand they pay me off for my loss – write me a check of the book value of my vehicle I’ve just totaled. They say, “but, Mr. Barker, you canceled your collision three years ago.” I reply, “well here’s a check for coverage starting today… but I insist you write me a check for the accident that happened yesterday.”
Sinz… you’re not stupid. Certainly you see how there’s a disconnect here.
It’s no longer INSURANCE if what you’re insuring against (but haven’t been paying premiums for) occurs and only THEN do you expect to start paying X amount of money a month for XXX amount of monthly reimbursements.
(*SIGH*)
BILL
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