Buckeye RINO

Hillary Clinton has a health care plan. Barack Obama has a health care plan. John McCain will be visiting Cuyahoga County tomorrow to tout his health care plan. AND DJW, THE BUCKEYE RINO, HAS A HEALTH CARE PLAN! Can we vote Daniel Jack Williamson as a write-in for U.S. President?

Actually, this was my take on health care when I was running for state rep back in 2004, so reprising this demonstrates my commitment to recycling.

The basic premise of the DJW health care plan is that the health care insurers do not operate within a competitive marketplace. They enjoy captive markets, so consumers get screwed. Campaign contributions from PAC’s helped get legislation passed over the past generations to shield health care insurers from fierce competition. So, the DJW health care plan calls for drastic marketplace reforms.

Let’s first assess some of the common problems we, the consumers, face.

The rising costs of providing health benefits has private employers asking employees to contribute more. Government budgets are also being thrown out of whack because health care coverage for public sector employees has also become more expensive. The state’s Medicaid costs are increasing dramatically, too.

However, HMO’s seem to be doing quite well. They have lavish headquarters offices and pay for lots of advertising. Who are they advertising to? Our HMO choices are limited by our employers. It seems they have a lot of extra cash to dispose of. Why can’t they reduce our premiums with all that cash they have?

They keep their expenses to a minimum, which you can tell by trying to get in contact with a real person when you call, but you have to weave your way through complicated phone menus first. If you’ve seen the help wanted ads, these HMO’s don’t pay their customer service representatives very much money. They have a whole bunch of rules you must follow in order to guarantee that they will pay your medical bills. If you must appeal because they denied a claim, you will have to jump through lots of hoops and cut a lot of red tape. Physicians often get reimbursed much later than service is rendered. I can’t count the times that the physicians have tried to bill me directly because they didn’t see the money coming through the pipeline from the HMO, forcing me to call the HMO, weave through phone menus, and wait on hold a long time before I can talk with someone to find out what happened (or didn’t) on their end. This long wait for payment, along with very stingy reimbursement rates has caused a lot of physicians to drop out of many HMO networks. I have talked to many who have said that they are having trouble finding doctors in their HMO network anymore.

The behavior of the HMO’s reminds me of SBC and its predecessor, Ameritech. This phone utility has had fines levied against it by PUCO for poor service, most notably late repairs and especially late installations. One time I bought a new house in the Columbus area and I had to wait for over a month for installation by Ameritech. Calling them constantly from pay phones to try to reach them was annoying, and I wasn’t getting anywhere with them when I did manage to get a real person on the line. At the time I was moving in, I had started working for Ameritech selling cable television subscriptions for them because they had just received permission to compete with Time Warner. My boss was so annoyed that she could not reach me at my home phone. I told her it was the fault of the company we both worked for! Luckily, after training, we were provided with cell phones so that she had a way to contact me. We were not well paid. I eventually left Ameritech. Ameritech had a huge advertising budget pushing local phone service. Why? Why, when there was no other local phone company to compete with them, did they spend so much on advertising? Ameritech had a huge regional headquarters in Columbus, comprising two neighboring skyscrapers joined by skywalk over the alley that ran in between them. Much of the office space was vacant. When you consider that much of the customer service representative work was done at another regional headquarters in Indianapolis, or out of the corporate headquarters in Naperville, Illinois, it seemed likely that the landscape of the Midwest was dotted with these white elephant Ameritech facilities. Our installation service in cable TV was just about as bad as telephone installation. I didn’t get paid my commissions until the new customers were installed, and I lost a lot of commissions because Ameritech was having to cancel and reschedule installations to the point that the potential customers no longer wanted to hook up with us. When the company vice president over cable operations paid us a visit, and I spoke up to complain, I soon realized that the company wasn’t going to add any more installers to their staff. On the phone side, their lousy service was one of the factors that started the trend toward abandoning land lines in favor of cellular phones. Then there was the bill. They would automatically add new features to your phone service so they could jack up your local bill. Sometimes you could save by having some features removed, but sometimes they didn’t give you that option.

The problem with utilities? If they don’t enjoy an outright monopoly, they have very few competitors. The problem with HMO’s? Same thing. They treat you that way and make millions because they can get away with it. We are a captive market. If your employer offers more than one plan, they keep you captive by only having enrollment periods once per year. If you switch jobs to get better health benefits, you will usually encounter a waiting period before you qualify for coverage, and even then there are exclusions for pre-existing conditions.

The solution? Marketplace reforms that allow for more fluid movement of customers from one HMO to another. It should be like shopping for auto insurance: Find the service you want at the best price. They will have to work harder to attract and keep customers. The actuaries will have to factor in smaller profit margins when determining rates in order to compete with rivals. HMO’s would have to be more timely in reimbursing physicians because pleasing physicians will allow the HMO’s to enjoy a larger provider network, which would be a key selling point in enrolling patients. Government would not have to bombard HMO’s with mandates on what conditions must be covered because HMO’s would want to have a more full array of plans to aid them in enticing more people to enroll. Best of all, when patients call their HMO’s, they will likely reach a real person instead of a menu, there won’t be so much red tape to get claims paid, and it will become more rare to have to file an appeal due to a medical procedure being denied coverage, because HMO’s will want to establish reputations for providing great customer service.

The considerations that we must take into account in order to make shopping for health insurance like shopping for car insurance are primarily: 1) adverse selection, where the people most likely to enroll in an insurance plan are those who are most likely to need medical treatment right away; 2) the law of large numbers that helps mitigate against adverse selection by averaging in healthier populations with those not as healthy; 3) a mechanism that makes enrollment in all health-insuring corporations available to all workers regardless of employer; 4) a mechanism that allows consumers to transfer from one insurer to another as easily as transferring money from one bank account to another, or at least as easily as selling shares of a stock on Wall Street to buy shares of another stock on Wall Street; and 5) the administrative costs to insurers that accompany customer turnover.

Just as car insurers charge higher premiums for high-risk drivers, adverse selection can be dealt with in much the same way, that is, those with certain health claim histories would have to shop around among higher-risk policies. However, the more successful an insurer can become at attracting a large market share, the more the law of large numbers will help keep the premiums low. The law of large numbers is what makes group coverage premiums so much more attractive than individual coverage premiums. Each insurer would treat all enrollees in the same plan as a large group instead of a bunch of individuals. If all employers set aside the health benefit dollars into a special account (instead of contracting with an insurer of the employer’s choice) that can only pay out to insurers (and thus remain tax-free dollars), the premium can be automatically debited from the account on a pro-rated daily basis, allowing for the change to a different insurer on any day the employee desires. The employee can also deposit funds from out-of-pocket into this special account in order to make up the difference for insurance costs beyond what the employer provides. These deposits would also be tax-free. If an employee’s health coverage costs less than the benefit dollars in the account, the account could earn tax-free interest as a hedge against inflation and could be stockpiled for future years when the employee is more likely to need higher-risk insurance that costs more due to an increase in age and other risk factors. If an employee’s chosen coverage costs more than the benefit dollars that the employer provides, that will determine the amount of the employee contribution to the health plan. To avoid churn and cover administrative costs, set transaction fees will be debited from the special account by the discontinued policy insurer and the new policy insurer, much like a stock brokerage fee (but more affordable). If there is not enough in the account to cover the transaction fees and the first day’s premium under the new policy, the employee would not be able to change coverage at that time. If the payment of the health insurance premium goes unpaid for 30 days or lags behind schedule for 90 days without ever being brought up to current in the 90-day period, coverage would lapse, and the employee risks being subject to exclusions for pre-existing conditions, and a physical examination that could result in being placed into a higher-risk category before being permitted to enroll in a health plan again. Benefit dollars flowing into the special account after the lapse in coverage could continue to be debited by the discontinued policy insurer until the premium for the time up to the date of the lapsed coverage is paid in full along with the discontinuation transaction fee. If the employee has not yet enrolled in a new plan, but the discontinued policy insurer is paid in full, then benefit dollars flowing into the special account will accumulate until enrollment with a new insurer starts the debiting process again. Because of modern technology that allows for very cheap electronic transfers, it is not anticipated that daily depositing by employers or daily debiting by insurers will be the cause of prohibitive administrative costs, but if employees and employers agree to quarterly or monthly or weekly deposits, that would be an option that could be set up when the special account is created for that employee. Likewise, if insurers want to add incentives to consumers to enroll in a plan that debits weekly, monthly, or quarterly, that would be permitted. Pro-rated adjustments would have to be made, however, if there is a change in employer or insurer. Those with two jobs could have benefit dollars deposited in the same special account. Families could have benefit dollars from all earners deposited in the same special account. Some members of a family may be enrolled in a different plan than others in the family, and more than one insurer would be able to debit the special account. If there is no survivorship provisions, however, the special account would not constitute an inheritable estate, since benefit dollars are tax-free and are only withdrawn by insurers. Those who are self-employed or financially independent can create special accounts as well, to make tax-free deposits for health coverage at group plan rates rather than individual plan rates.

Insurers will still be able to take advantage of re-insurance for stop-loss coverage to keep costs down, as they always have before.

I am leary of government-sponsored, single-payer, universal health care proposals. What would be the mechanism for holding down costs? We would likely need a flood of new taxes to pay for it. Universal coverage would be a nice goal to achieve, and I am open to public debate on how we can best achieve it, but I do not believe the solutions lie within the public sector.

Medicaid is a government sponsored, single-payer health program. There is no mechanism that holds down those costs. Nursing home operators appear to be well connected to their state legislators and are able to negotiate ever increasing Medicaid reimbursement rates for nursing home costs. Many Medicaid recipients in nursing homes do not even require nursing home care. Nursing homes are expensive because of the costs of medical attention and nursing care. However, many are healthy enough not to need nursing care, but because of advancing age, are too feeble to bathe or dress themselves. All they really need is a personal care attendant to fill this role, not a nurse. This kind of help is available with in-home assisted care and assisted living facilities. These are cheaper than nursing homes. However, Medicaid is not designed to help with in-home care or assisted living. Medicaid is for medical and nurse services for the indigent. The state-sponsored PASSPORT program to assist with in-home care is a small program that is constantly operating at full capacity. There are few slots to accomodate more persons at the present time. So, since many cannot participate in PASSPORT because they have already reached capacity, a huge number of seniors are liquidating their assets in order to qualify for Medicaid, which is only paid to nursing homes. So, into the nursing home they go at high expense to the taxpayer whether the patient is in need of nursing care or not. The private sector, however, offers long-term care insurance that does provide benefits for in-home care, assisted living, or nursing home care, depending on the physical condition of the insured. If many many more people had long-term care insurance, they could possibly enjoy life a little more by living outside of a nursing home while holding on to their estate with all its assets. Perhaps if the state spurred the insurance industry to promote long-term care insurance through public service announcements, we could prompt more Ohioans to obtain this coverage and help save the state oodles and oodles of money. Plus, with a competitive marketplace to help hold down health costs, the state may be in a stronger position when negotiating costs for Medicaid.

Health care reform measures that my platform calls for would also need action from Congress to implement, because we would need to change the medical expense insurance marketplace on the national level. However, states are often the incubating laboratories of national programs, as we saw with welfare reform. Ohio can probably get the green light to pilot a few of these proposals so that Congress can assess the feasibility of implementing the whole plan. Just because this is a huge undertaking doesn’t mean we shouldn’t press forward. I think Clinton, Obama, McCain, and especially DJW, all realize that the time has arrived when we need to totally revamp our health care system.