An Immodest Health Care Proposal

The October 9, 2008 perspective articles under the names of Obama and McCain in the New England Journal of Medicine lack new ideas, specificity and detail.

Here are my dozen proposals for readers to consider, react and respond to:

1) provide contractual direct tuition subsidies for qualified students to receive education through accredited institutions, in critically important personnel-short areas of health care (physicians in certain needed fields, Ph.D's in patient-care related areas, nurses, physician assistants, certain radiologic and lab personnel and others).

(2) Subsidies will require a two-years of work for one-year of subsidy payback in an independent-chartered federal health program. While working for the program, pay would be less than the person would earn in "private" practice, but considering the tax benefit and loan interest-savings of the subsidy forgiveness, the person would financially benefit.

(3) Put these people (in addition to those who, without subsidy, choose to work for the program)to work full-time in cities and other areas where they are needed in federally run health facilities open to selection by all Americans.

(4) Couple enabling legislation with the requirement that all Americans be insured through their employers, privately, or through government programs at precisely the same premiums for exactly the same range of benefits available to Congresspeople. For those who cannot pay, federal financial support will be needed.

(5) If private employers or insurers offer "Cadillac" benefits, they can do so as supplemental insurance programs at any price they wish, but such employment benefits and "Cadillac" insurance will not be tax exempt or deductible.

(6) There will be no "networks" of providers: as with Medicare, essentially all licensed health care providers, including hospitals, will serve all Medicare and private plans without payment differentiation from plan to plan.

(7) Continued provider participation will depend on providers' provision of care (and compliance with applicable law) meeting generally accepted professional and institutional standards. Individuals will be able to change programs every two years.

(8) Those coming into the programs after the first year will be assigned to the federal or private programs (to the extent the private programs wish to increase their subscriber base) through random number generation so that insurer "cherry picking" (which tends to exclude individuals with rare diseases and health history problems) ends.

(9) A scientifically appropriate federal formulary will be available for all of the programs; prices of drugs will be negotiated at arms-length federally. Program quality standards and compliance will be federal functions, will be free from political intervention, and will be based on scientific recommendations from non-conflicted scientific panels. Appeals will be heard through an administrative appeal system.

(10) The federal government will collect all premiums and pay insurers (or for those enrolled in the federal program - the program) directly at a set contract price. Providers will receive the same fee for the federal and private insurer programs. Any physician or provider which "opts-out" of the program will receive payment distributed from what is left of the premium pool at the end of each year, if there is any surplus. Providers will not be permitted to balance-bill.

(11) The federal program will develop, test and use electronic medical records. Other systems and providers will have their claims paid electronically after valid electronic claims submission. Providers would be encouraged, but not required, to institute electronic medical records with significant federal financial support.

(12) States will be required to provide care for non-citizens who require emergency health services or health services which are required to protect the public from injury. The Medicaid program will be eliminated.