To the editor:
We need to improve our huge health care system, which is responsible for 200 million people with private insurance, 45 million on Medicare, 40 million on Medicaid and 45 million without insurance.
But reform does not require revolutionary change full of unintended consequences. The following modifications would, in the aggregate, control costs, while preserving and improving quality, access and choice.
Change federal tax law to allow individuals and small businesses to use pre-tax dollars to purchase health insurance, lowering cost and increasing coverage. Enable small business groups to purchase health insurance for their employees at a savings, just as large businesses do. Allow health insurance to be sold across state lines (Shadegg bill), bypassing expensive, disease specific mandates and community rating. Avoid guaranteed insurability, which, in Massachusetts, results in short term insurance policy holders spending 600 percent more than average during the same time period.
Eliminate Explanation of Benefits (EOB) for routine, low cost outpatient services in all insurance plans, including Health Savings Accounts (HSAs). 85 percent of claims are for $100 or less, at an administrative cost of $55 per claim. Provide transparency so the patient knows, in advance, the fee and the payment for services, the balance being negotiated by the patient and the provider, by previous agreement.
HSAs save money, and, along with other high deductible plans, now cover 20 percent of the privately insured patients. Reduce administrative costs further by allowing payment at the time of service, higher deductibles and higher HSA contributions.
Provide better insurance options for that important group with pre-existing conditions by allowing higher deductibles or secondary insurance for those patients, possibly with some means-tested tax refund, and reform, standardize and expand high risk programs available in many states today.
Poor Medicare payment often makes access to primary care difficult. Eliminate EOBs for low cost, routine expenses. The newly created Medicare Savings Accounts should be encouraged and monitored closely. The father of HSAs, John Goodman, calculates that allowing contributions to a Health Retirement Savings Account during one's working years would permit a gradual increase in Medicare eligibility age to 67 by the year 2019 and maintain the current percentage of revenues necessary to fund Medicare.
Continue testing innovative Medicaid programs for the medically indigent with combined government and private efforts to assure availability of cost-effective, quality care. Create tax refunds for the uninsured, medically indigent.
Egregious graft by criminals and malpractice litigation abuse are two huge sources of needless waste. Criminals set up phony Medicare and Medicaid clinics, receive millions of dollars from bogus government payments, and dismantle their entire operation before being apprehended. A cap on non-economic awards will control malpractice litigation abuse.
Avoid over correcting the health care system with an imposed top-down, bureaucracy that, once established, will be extremely difficult to alter or reverse. We will make correctible mistakes, but reform with the capacity to innovate and modify, based on needs, successes and failures, must evolve through a combination of market and supportive governmental activity.
Robert F. Hamilton, M.D.