Introduction

Concerns over our healthcare delivery system are certainly not new. The FDR Administration looked at “universal health insurance” during the Depression. The Truman and Johnson Administrations also visited the topic. Ancient President Bill Clinton won election in 1992 with the pledge to solve our national economic crisis by solving the healthcare problem. ¹ Hilary Clinton brought national attention to the issue as First Lady, valiantly attempting to offer solutions but getting defeated by special interests and “the Bureaucracy.” Now, with the looming Presidential election, concern has become even more heightened. Over these past 15+ years, we are no closer to a solution while healthcare spending is expected to advance 20% of GDP by 2016. ²

The first problem with healthcare is that there are too many problems. No matter what “solution” is offered, there is always someone to disagree and point to something else. “The problem is Federal and State mandates.” “No, the plight is the third-party payor system.” “No, the problem is the lack of consumerism.” “No, the problem is uncapped jury awards and malpractice insurance costs.” “No, the problem is the 40 million+ uninsureds.” So you see, the first thing that needs to happen is that everyone must agree that “all of the above” is the correct answer! I also understand that many people are “positioning and posturing,” while others are legitimately concerned about their future. We need to agree to acquire the compromise solution and achieve aside our individual agendas.

There is little doubt that the current system is unsustainable. Premium costs continue to increase while benefits and services seem to decline. Just over the past five years, premiums have increased 57% to $5,646 per employee, ³ which now represents almost 32% of employers’ total payroll. Healthcare costs have outpaced inflation for some time now (see supporting chart), and a recent Hasten Poll identified these increases as the number one financial concern among American families. ⁴ It is also important to note that this increasing cost has a direct impact on the increasing number of uninsureds. ⁵
At the same time, medical spending as a percent of Gross Domestic Product continues to increase. When Congress created Medicare in 1965, the estimated cost for 1990 was $9 Billion! The Heritage Institute recently projected Medicare/Medicaid entitlements to reach 11.1% of GDP in 2006 and rise to $2 Trillion by 2030! ⁶

To further complicate the announce, consumers are unaware of the accurate costs of care, expect only the best in treatments, and complain about any increase in their shared cost. Recent news headlines decried the reduction or elimination of retiree health benefits for major corporations. The major unions fight an ongoing battle over increased cost-sharing for their members, and Wal-Mart recently fought a public relations battle over the availability of healthcare for its many seasonal, part-time, and transient workers. Every day brings new issues and debate.

The second scrape hindering real reform is that everyone has an “agenda.” Since healthcare affects everyone, everyone needs to agree to some compromise. Doctors need to accept some reduction in pay in return for jury-award caps. Insurance brokers and agents need to accept a shift in revenue sources for medical coverage (fees vs. commission). Insurance and Pharmaceutical companies need to agree to compete in a new environment. Consumers need to agree to more cost-sharing and become more active in care decisions.

I understand that many will feel that it is naïve to think that such a consensus could ever be achieved. But I say to those people that we are reaching a point where there will be no alternative. Thomas Edison was fond of saying that “Nothing is impossible. – The impossible objective takes longer.” As long as we respect each other’s interests in this debate, and enter the fray with a sincere desire to achieve a long-term solution, what I am proposing herein is truly achievable.

First, let’s understand the cost-drivers.

What Drives Healthcare Cost Increases?

Utilization & Consumer Demand

American employers have offered medical coverage to their workers for quite some time now. In the past, Conventional Health Plans had a low deductible, e.g. $100 or $250, and 100% coverage thereafter. As costs began to rise in the late 1960’s and early 1970s, employers were forced to start introducing “cost-sharing” through HMOs, PPOs, and other similar plan models. However, by then consumers had become accustomed to great care with minimal out-of-pocket expense, and we are still paying for that precedent.

As a result, utilization has increased significantly, and consumers, particularly unions, continue to demand the best care with the least cost-sharing. The biggest problem with this reach is that consumers fail to develop an understanding of the true cost of their care. They go to the doctor, pay a $10 co-pay, and walk out thinking that their visit’s cost was $10!

A second pickle is that, because consumers do not know or care about the true cost, they do not “shop” for the best values. This results in high utilization costs and in many cases unnecessary spending. Over the past 15 years, this problem has been increasingly addressed, most recently by the introduction of the “Consumer-Directed” healthcare models. Conventional Plans have fallen to 3% of the total plans offered in 2006, simply because they are no longer affordable. ⁷ This move toward greater cost-sharing and consumerism, which will be addressed in more detail later, is a recede in the honest direction but has failed to solve the broader problems.

Technology & Medical Advances

In order to deliver the best possible care, providers need to keep up with technological advancements. Over the past 20-25 years, these advancements have come very rapidly and at an increasingly higher cost. This is not expected to change and is generally considered as share of the “cost of doing business.” However, we need to also recognize that other industries also face rising technology costs and do not experience the higher-than-inflation cost increases seen in the healthcare market. Thus, this is clearly only a contributing factor.

Aging Population

As the general population ages, with Baby Boomers now facing retirement, utilization increases. This is also generally accepted. Some studies have posited that 80% of our total healthcare costs are driven by 15% of our population. ⁸ This too has become a generally accepted fact, i.e., that our aging population will continue to require more care.

Federal and State Mandates

As a former Benefits Consultant, I straddle both sides of this fence. Many mandates are necessary and do indeed provide care where none would otherwise exist. However, over the past 20 years, many mandates have been introduced at the urging of various groups which have added to the cost of care. This problem has been further complicated by the many State mandates that exist. As of the destroy of 2005, there were 1,824 state mandates nationwide! In many ways, this accounts for part of the reason coverage might cost under $2,500 in Iowa or Wyoming and over $6,000 in New Jersey.

Inflation (CPI)

Another driver of cost is inflation. Little can be done to change this. As the costs of materials and labor increase, providers must also increase fees. So inflation will remain a part of the cost.

Litigation & Malpractice

Medical providers walk into situations every day that involve split-second decisions affecting their patient’s very survival. Sometimes, mistakes happen. The recent case involving a celebrity’s infant children receiving the wrong medication is a perfect example. The manufacturer of the medication in question used blue labeling for both the 10mg and 10,000mg bottles, with petite difference in font size. The only dissimilarity between the two bottles was that the 10mg bottle used a lighter shade of blue.

Is this actionable? Against whom? The manufacturer, or the pharmaceutical administrator at the hospital that dispensed the wrong medication? Perhaps the nurse that administered the medication without noticing the dosage level? Or the hospital itself? The reality in today’s litigious society is that everyone will get sued. Perhaps, some deserve to be. But the “rush to sue” is the root problem here. Not all mistakes are, or should be, actionable.

That said, calls by various lobbies for laws restricting one’s “right to sue” are misguided. There needs to be an injection of “reasonableness;” however, everyone should have the right to peep redress if warranted by the details.

What if I now told you that this same mistake was made before, at another hospital in Indiana? Following that mistake, which seriously threatened three infants and cost the lives of three others, the manufacturer failed to retract the existing stock of drugs. Nor did they issue a request to existing known buyers of these drugs to post warnings near the bottles or to segregate existing stock. All they did was add a red warning label to new stock. Does action against the manufacturer now seem more actionable???

My point here is that in every instance there will be a point at which, when crossed, the “mistake” becomes actionable “negligence.” What is needed in our healthcare system is a law mandating a process to flesh this out before cases can move to the courts.

Pharmaceutical R&D

This leads to a major cost driver – the high costs of medication. No one can argue that the use of medication should be controlled by anyone other than the doctor. And the availability of medication choice is one reason why America enjoys some of the best care on the planet.

So what is the problem? Why must Americans pay $115 per pill for a drug available from Canada for $40?

I salvage as fact that pharmaceutical companies need to invest significant sums into R&D in order to bring a drug to market. I also accept as fact that these companies deserve to be reimbursed for this expense through the sale of the drug. The problem, as I see it, is in the lack of oversight in establishing this R&D cost and/or the fair market price for the drug. When a pharmaceutical company claims that it had to spend $2 billion dollars in R&D, who is there to verify this? Who is there to ask for the financial records to prove the claim? This may yell out for increased funding and support for the FDA, perhaps increasing the bureaucracy that will assist our new system. But it is imperative to success that we remove the restrictions to fair competition that currently exist in regard to pharmaceuticals and stop allowing these companies to charge “whatever the market will bear.”

It should be recognized here that the FDA does perform an important function. Recent contamination discovered in the drug Heparin, manufactured in China for Baxter International in a move to increase profits (they didn’t lower their price!) illustrates the need for greater oversight. However, this contamination occurred because the FDA did not have sufficient funding to inspect the plant in China or the drugs that it imported. If we are to allow for open competition and the importation of drugs, we must also allow for the FDA to grow sufficiently in manpower and funding to protect the American public as they have done in the past.

Federal & State Regulation

The sad fact is that, without some regulation, many providers would simply grasp advantage of consumers. Greed exists, and it is silly to pretend that it does not. Without regulation, scam artists and disreputable practitioners would be free to “take whatever they could get.”

However, after over 50 years of regulation, there are many regulations that should now be removed or relaxed. This includes many of the filing, licensing, and manufacturing regulations that permeate all aspects of the current system. When multiple participants must increase costs in order to offset these regulations, healthcare costs increase exponentially. A simplified regulatory environment would go far to removing this problem.

National licensing of insurance companies, brokers, and agents would allow centralized and standardized regulation while opening competition across position lines. Simplifying FDA regulations in bringing a drug to market would help ease R&D costs. Removing restrictions on buying drugs from non-domestic sources would help competition and drive down drug costs. I am determined that the FDA can salvage some way to guarantee quality and still allow such imports with proper funding.

These are just a few examples of how Federal and State regulation can be addressed. The debate that I hope will come from this article can certainly flesh out more.

Fraud & Abuse

This is an negate that applies to many levels of the current system. Consumers “abuse” the current system if they have access to, and can afford, healthcare but go without, brilliant that hospitals won’t turn them away if they need care. As stated earlier, greed also drives many providers to “milk the system” in regard to false treatments, inflated claims to insurers and Medicare, and other well-documented scams. Furthermore, some insurance companies are only in the business of making money and not “paying claims.” This is also a type of fraud that needs to be stopped.

There will always be people looking to “get over” other people. It is a sad indictment of society over the past 30 years that this is just how some people are raised. No proposed system will be able to eliminate this cost driver completely. However, if everyone had access to care, the reasons to “scam the system” would be greatly diminished.

What In The Current System Works?

When this article was first written in 2004, health care wasn’t even on the national radar; now, there are many “solutions” being proposed. Most proposals try to keep what is excellent in the fresh system, and rightly so. There is worthy qualified.

First, we have the freedom of choice, not only between carriers and providers but also in regard to plans and coverage levels. Any solution that proposes removing this freedom is, I feel, doomed from the launch. Thus, proposed “solutions” that include mandated plan designs are, I feel, misguided.

While most people would express dissatisfaction over the cost of healthcare, the fact is that the current system does consume Market-Driven Pricing. Individuals and employers have the freedom to decline coverage that they consider too expensive. Carriers understand this and must price their plans competitively; otherwise, they will erode market part and eventually face reduced profit.

Finally, the current system includes Market Competition. While this market is dominated by a handful of national providers, the current system also allows small regional providers to offer competitively-priced alternatives. This in turn forces the big nationals to be more careful in pricing themselves where this competition exists.

The successful solution needs to retain these elements.

Can We Achieve A Long-Term Solution?

So, you might well ask if we can ever glean control over our healthcare costs while level-headed delivering acceptable levels of care. The respond is an unequivocal “YES!” The solution however must include sacrifices from all participants: (1) the providers of care; (2) the carriers; (3) the insureds; (4) belief and network administrators, (5) employers, and (6) the brokers/agents. Most attempts at serious change have failed to find a solution palatable to all parties, thus leading to lobbying and political in-fighting and eventual failure. I believe that the following proposal, while still requiring some sacrifices from all parties, can achieve the necessary balance to allow for success.

The Basic Structure

I propose that we run our national health system just like the major corporations of the world run their plans. Think of it like a huge self-insured opinion covering 281 billion people. Yes, — it sounds “daunting.” But it is possible.

As in any large, Fortune 100 health conception, there exists the following participants: (1) the providers of care (doctors, nurses, surgeons, labs, etc.); (2) the carriers; (3) the insureds; (4) the plan administrator, and (6) the broker/agent. The broker/agent initiates a Request For Proposal (RFP) and sends it to all vendors that might be able to supply the required services. Responses are analyzed and the top bidders are presented to the client. A selection is made, and implementation begins.

There is no reason why a similar process cannot take place for our National Healthcare System. With the structure shown in Figure 1 below, nine (9) carriers can be contracted with 3-year terms to provide three (3) plans each. Plan 1 can be a PPO, plan 2 can be an HMO, and the carrier can be free to offer any Plan 3 it wishes. This will promote freedom of choice in coverage levels.

After the initial 3-year Phase-In, three carriers would come up for vow each year. This will promote competition and allow new players to access the market in the future. In order to assure broad National coverage, carriers will be forced to make their networks competitive or negotiate with regional networks. During the transition, all existing plans, both public and private, would continue to operate in order to minimize disruption. This would also allow current players the time to adjust to the new market environment.

Now let’s look more closely at the components:

The National Healthcare Commission

A “National Healthcare Commission” [NHC] should be formed to conduct the selection process and run the program. It can be made up of industry leaders representing the many interest groups, such as pharmaceutical manufacturers, hospitals, the AMA, the American Bar Association, insurance carriers, Pharmaceutical Benefit Managers, labor groups, AARP, etc. Congress can also create a new Cabinet Level post for the National Health Director, who could be non-partisan and appointed in much the same way as the head of the Federal Reserve or a Supreme Court Justice. Seats on the NHC should also be non-partisan. At the end of the three-year transition, we would have nine carriers interested, with three coming up for re-bid each year thereafter. This would ensure ongoing competition and heed efficiency. Plan designs would be at the discretion of the carrier subject to a minimum standard set by the NHC and including those mandates that are determined to be of value.

Such a system would allow people to select networks and exercise doctors of their beget choosing. Claims would continue to be processed by the participating vendors. Pricing would still be driven by administrative efficiency and network discounts. It would also allow vendors such as Multiplan, Beechstreet, and other national network administrators to compete. I am distinct that enterprising and intellectual people “out there” would find ways to achieve additional pricing efficiencies that would allow them to compete under this new system. I also envision that such a change would lead to mergers and acquisitions within the industry among networks and carriers, which would also lead to additional efficiency as well as market growth.

Furthermore, as we know with any self-insured plan, the administrative National Healthcare Committee and the Healthcare Director would also have all the tools they would need to track and manage utilization, implement early intervention, consume Disease Management or Work/Life programs, and implement any of the many cost controls currently available in the industry. What they would NOT be empowered to do is dictate coverage beyond the basic mandates or establish reimbursement levels.

So, we would have a national healthcare system in which: (a) Doctors continue to operate much as they do now, (b) Carriers continue to operate much as they do now (with forced efficiency), (c) Insureds select providers and plans like they do now, and (d) The levels of care and benefits are smooth dictated by the market, not the government. What we would get rid of is extinguish and inefficiency. The only government involvement would be in the annual RFP process of selecting carriers, the collection and disbursement of funds (like any Fortune 100 employer), and the data analysis that would lead to contracting initiatives and future cost savings. Because of the size of the plan, there would be immediate “credibility” in negotiating premiums. The NHC could also negotiate bulk pharmaceutical discounts. This proposed system would provide the greatest efficiency and the best use of existing technology in controlling costs.

Employers

The largest beneficiaries of this proposal would be employers. Yes, they would still need to participate in some funding mechanism. However, they would be freed from the administrative and HR burdens associated with the current system. Furthermore, for many it would mean a net savings from fresh healthcare costs. This should result in pay increases as well as increased profits, which in turn should generate additional discretionary consumer spending and market expansion.

Enrollment

Although carriers would no longer be paying a “commission,” there would still be a need for them to pay service fees per participant to the broker who enrolls and services that participant. With employment remaining the indispensable access for most eligible citizens, it is also reasonable to suggest a 6-week “open enrollment” every year beginning in mid-October during which all employers would be required to allow their brokers to enroll their employees into the National Health Plan. Those brokers with existing books of group health plans would therefore have each and every employee on these plans as a possible client and receive an “enroller” and “service” fee for each.

Providers and Hospitals

Since claims processing and payments would still come from the carrier rather than the government, providers and hospitals would continue to function very much like they do under the current system. In many ways, at the end of the transition when existing plans like Medicare, Medicaid, and the Federal Employees Health Notion would be folded into the recent National Health Care Plan, hospitals and providers would be freed from the administrative burdens imposed by these existing plans and may even derive additional revenue from higher payouts.

Carriers and Conception Administrators

This proposed plan would require carriers, plan administrators, and network administrators to change their business models slightly. However, the end result would be greater efficiencies and the opportunity to bid on a National Contract. Regional network administrators would negotiate with carriers to succor improve the carrier’s efficiency. Inefficient vendors unable to make this transition would have to look to different markets. Mergers and acquisitions would probably be the long-term result, but this too would lead to greater market efficiency.

Brokers and Agents

It is true that this proposal calls for a phased end to the current system over three years from its inception. I expect that it would pick two years from the decision to implement this system for all of the parties to work out the details and get the National Director and NHC in place. Thus, we are looking at about a five-year time horizon here. Many brokers and agents who rely on medical coverage will need to seek new revenue. That said, these same brokers and agents would be in a residence to receive enrollment fees from carriers for their existing books. With nine competing carriers, the carrier’s profits would improve with higher participation; thus each carrier would be incented to offer “enrollment fees” to brokers and agents would could deliver them enrollees. Brokers and agents would also continue to act as consultants to their clients for all other attend matters. The money employers and employees would save from no longer paying medical premiums could be re-allocated toward Voluntary Worksite Benefits, non-qualified fringe benefits, and pensions.

So, yes, there would be a valuable adjustment. But it wouldn’t be the “destroy of the world” many in the insurance industry predict.

The Uninsured

Since anyone with a Social Security Number would be eligible for coverage, there would be a significant reduction in the number of uninsured. Those who remain uninsured would probably do so because they distrust the system, they are in the U.S. illegally, or they fill they can scam the system. In any of these cases, these people would eventually risk needing care, at which time they would need to establish their financial ability to pay. This new system may also drive those here illegally to become legal citizens. One critical aspect of any new system, however, is the end to “free care” for all but the most needy.

Consumerism

“Consumerism” comes the closest to addressing a root cause of the problem: the lack of involvement on the part of the healthcare user. It must therefore have a part in any long-term solution.

The opinion finds its roots in the legislative authorization for Medical Savings Accounts [MSA], an idea that never gained widespread acceptance in immense part because of the restrictive contribution limits. EBRI began researching the issue at its 49^th Policy Forum in May of 2001. In 2002, at a National Symposium in Baltimore on healthcare, Johan Hjertqvist of The Timbro Health Unit in Stockholm addressed consumerism in the pharmaceutical industry as a way to simultaneously: (1) deliver improved outcomes in medical care, (2) meet social and moral obligations, and (3) improve Quality-of-Life.

The 2004 Economic Report that was commissioned by President Bush then took the view that those without insurance are, in fact, “efficient buyers of healthcare services” since they only incur expenses when they are truly needed. The recount asserted that the insured population is actually over-insured and their behavior is wasteful. It is this philosophical stance that now drives us toward Consumerism, in an attempt to make the insured more like the uninsured. The point is to provide incentives to the insured to make more carefully-reasoned buying decisions – in the process making them pay for more services out-of-pocket like the uninsured.

Essentially, all Consumer-Driven Health Care [CDHC] models involve the same components: (1) a high-deductible health plan [HDHP], (2) a reimbursement account, and (3) consumer tools.

Consumer Tools are the critical component. They will determine the level of consumer involvement and the success of the outcomes. Common offerings include: (1) Employee Assistance Programs [EAP], (2) Discount Programs for vision, dental, convenience items, and prescriptions, (3) Disease Management and early intervention programs, (4) online provider performance measures, and (5) personal “MyHealth” web pages where consumers can manage their own medical histories, download documents, track claims, and manage their reimbursement accounts.

Incorporating these characteristics into the new system will also be critical to its success.

Now the Funding

As for the collection and administration of the funds, I would suggest that computer systems exist that are fully capable (with some unique programming and a very large storage capacity) to administer such a plan. As for where the money would advance from, I am not an economist or an actuary, and I am obvious there are many people better qualified than I to “flesh out” the funding details if this proposal sparks some interest. However, I will offer some general observations.

In a recent article in Life, Health & Disability, distributed by the Society of Financial Service Professionals, Malcolm Gladwell of The New Yorker stated that the uninsured “spend, on average, $934 a year on medical care. . . . Those of us with private insurance, by contrast, steal $2,347 worth of health care a year.” ⁹: He also points out that “The United States spends more than $1,000 per capita per year – or cessation to $400 billion – on healthcare-related paperwork and administration, whereas Canada, for example, spends only about $300 per capita per year;” This leads one to think that significant savings can be achieved through increased efficiencies.

Americans spend $6,700 per capita on health care every year ¹⁰, over three times the industrialized world’s median of $2,193; Many of the “naysayers” in the debate on national healthcare point to the $2 trillion plus per year that we currently spend on healthcare, saying that funding such expenditures is insurmountable. I suggest that the funding needs are indeed attainable and the actuarial analysis that I expect to occur must allow for new inefficiencies.

Since per-capita spending is expected to reach $12,300 by 2015, ¹¹ I would suggest starting out funding for about $7,500 per capita. The latest population number identifies a total United States population of 299,199,906. The Department of Labor lists total healthcare spending at around $2.1 trillion in 2006. Using these numbers, all the actuaries have to do is figure out how we can collect $7,019 per citizen per year.

Of course, I am over-simplifying to make a point. Naturally, you cannot expect a family of five to pay over $35,000 for their coverage. Under the current system, funding is provided through the following: (a) Employer premiums to insurance carriers, (b) Employee payroll deductions to their employers, (c) Insured copayments to providers, (d) Medicare/Medicaid premium deductions from SSI, (e) Individual premiums to insurance carriers, (f) Federal subsidies to carriers and providers, or (g) Federal subsidies to States.

Under a National self-funded Health Plan, we would be paying for actual claims plus administration only. Claims would be paid by the carriers and reimbursed through standard, self-insured claims reports. I ask that some combination of collection methods will be necessary, since payroll deductions cannot work for the unemployed. Some collection methods that I believe can work include: (a) Employer’s Quarterly 940 or 941, (b) Corporate 1120s, (c) Employee Payroll Deduction, (d) Tax Assessments on Individual 1040s, and (e) A separate billing mechanism similar to Property Tax collection.

I would also expect that a dual-pricing strategy would be significant to maintain the pricing for new Medicare participants and those covered under the recent Federal Employees Health Benefit Plan. The proposed “phase-in” would allow for a collected transition for the participants of these and other existing programs.

Co-payments and coinsurance would also provide a portion of the funding. This of course would be driven by plan do and participation, but these are issues faced every day by those running spacious self-insured medical plans.

The point is that the size of the task should not deter us from trying. Furthermore, funding for $7,500 would allow for a possible surplus, which hopefully would also be grown through cost savings and efficiencies. All I suggest is that there are brilliant actuarial minds in this country who I am certain can arrive at a workable funding solution. The first step, however, is in believing it is possible.

Conclusion

By now you are wondering why an insurance broker who specializes in Employee Benefits would be proposing an approach that will effectively end this market as we now know it? The answer in part goes back to my opening statement about “sacrifice.” Yes, there will be some adjustment. I believe this opinion reaches the needed compromise to satisfy all participants. Carriers would be forced into efficiency but essentially continue to operate as they do now. Hospitals would be freed from much of the bureaucracy that currently hinders profit levels. Consumers would access health care from carriers and process claims much as they do now. Brokers and agents would give up “commission” income but pick up consulting fees. The National 6-week enrollment period would provide brokers and agents with additional enrollment fee income. Doctors and other providers would join networks and function the same as they currently do. Malpractice insurance premiums would come down following reforms in the system.

There has been a saying that I am sure many readers have heard before: “There is always a reason not to do this.” I now say to you that there are far more reasons to put our differences aside and get this done. So the next step is to allow that this could actually work and . . . begin the dialogue that could lead us to a real and long-lasting solution to the healthcare problem!

Endnotes

¹ Gallup Organization, “What Do You Reflect Is the Most Critical Scrape facing this Country Today? ” Gallup Poll Most Important Problem Series, Oct. 11-14, 1990, through Sept. 14-16, 2007.

² John A. Poisal et al., “Health Spending Projections through 2016: Modest Changes Obscure Part D’s Impact,” Health Affairs, 26, no. 2 (2007).

³ Mercer Human Resource Consulting, “2005 Survey on Employee Benefits.” Please note that there is a methodological discrepancy between the Mercer numbers and the trend as reported by the Hay Benefit Group, which I believe is based in the weighting methodology worn by Hay.

⁴ Gallup Organization, “What Is the Most Important Financial Problem Facing Your Family Today? ” Gallup Poll Social Series, July 12-15, 2007. http://www.galluppoll.com/content/? ci=28384.

⁵ Todd Gilmer and Richard Kronick, “It’s the Premiums, Stupid: Projections of the Uninsured through 2013,” Health Affairs, 25, no. 6 (2006).

⁶ James G. Lakely, “Spending Escalates Under GOP Watch,” The Washington Times (November, 2003).

⁷ Kaiser Health Research & Education Trust, “Employer Health Benefits 2006″ Kaiser Family Foundation, 2006.

⁸ William Copeland, Jr., Ed. “The Catalyst For Health Care Reform,” Deloitte Consulting LLP, 2006, Pg. 12.

⁹ Malcolm Gladwell, “The Moral-Hazard Myth: The Bad Idea Behind Our Failed Health Care System,” reprinted with permission from The New Yorker, Life, Health & Disability (December, 2005).

¹⁰ William Copeland, Jr., Ed. “The Catalyst For Health Care Reform,” Deloitte Consulting LLP, 2006, Pg. 3.

¹¹ Ibid.

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Why can’t a rational discussion of healthcare reform occur without being called a communists, socialists, or Nazis. Even the Heritage Foundation has called on Congress to create a system similar to the Federal Employees Health Benefits Program (FEHBP) for Americans which all members of Congress enjoy. However, the health insurance industry is and willing to do anything to derail any option that will be a benefit to the consumer and effect their bottom line.

Most minute business would love to provide health insurance to their employees, but simply can’t or the ones who do have very expensive plans with limited coverages. I know this first hand because I am a small business owner. The U.S. health care system is the most expensive in the world on both a per-capita basis and as a percentage of GDP, yet fails to provide Universal coverage. A study published in 2008 in Annals of Internal Medicine, a leading medical journal, showed 59 percent of physicians “support government legislation to achieve national health insurance,” while 32 percent oppose it and 9 percent are neutral.

I have a personal experience with a government public option in health care call the Veterans Administration Health Care System. Being a disabled traditional, I have the opportunity to participate in a health care system in which all trustworthy veterans have the opportunity to be taken care of without the fear of cost, deductibles, or copays. Is this system perfect no, but even Conservative commentator and publisher, Bill Kristol, admitted on The Daily Show with Jon Stewart, the VA system was one of the best health care systems for our veterans in the world.

Another experience I have involves my 4 year old autistic daughter. Without the SCHIP Program, Region Children’s Health Insurance Program, a government health care option that expands health care coverage to over 5 million of the nation’s uninsured children, my daughter would not be receiving the in home intensive therapy for her autism and would still be on a waiting list for care. Children began receiving insurance through SCHIP in 1997 and the program helped states expand health care coverage to over 5 million of the nation’s uninsured children in February 4, 2009, when President Obama the Reauthorization Act of 2009 into law.

Private health insurance carriers like Humana, would not cover my daughter’s in home intensive therapy and basically covered very little of anything else that had to do with her autism. Humana’s insurance policies contain specific exclusions for autism and this created a hardship for our family, because we were forced to cope with delayed, inadequate, and fragmented care through the Medicaid system until SCHIP was funded and Hannah came off the Autism Waiver List. We paid for the costly treatments in the beginning out-of pocket and accumulated a substatial debt in the process. This should have never occurred in a land with a supposed “good” health care system.

So what are the pieces of misinformation that are being propagated in the debate of health care reform.

No public option/Single Payer!-Well I would imagine then since Members of Congress and the Conservative Right believe America should not have a public option or single payer, then they will be submitting legislation to demolish Medicare, Medicaid, V.A. system, military hospitals (especially seeing even Republican members of Congress enjoy use of Walter Reed and Betheseda Naval Hospitals), and any State sponsored plans, ie Wisconsin Badger Care, SCHIP, and others. America needs to wake up, we already have a public option that is utilized by millions in Medicare, Medicaid, VA, and Military hospitals. If it is good enough for our disabled, seniors, Children, and military why isn’t that option good enough for all Americans?

Death Panels-This one is beyond belief that Members of Congress and the Conservative Right would say this and Americans would believe this, but then seeing Republicans including Senator Demint compare the Democrats and President Obama to Nazis, what would we expect. The provision in the bill, which ironically a Republican Congressman had introduced originally, would allow Medicare for the first time to hide patient-doctor consultations about end-of-life planning, including discussions about drawing up a living will or planning hospice treatment. Patients would, of course, seek out such advice on their own but they would not be required to. The provision would limit Medicare coverage to one consultation every five years. This isn’t a “death panel”, but something many people need to do rather than not have a plan when an end of life relate arises.

Medicare Will be Cut-Another valiant face lie by the Members of Congress and the Conservative Right . What the President is going to do is cut the 10-year cost of $177 billion in subsidies paid to insurance companies to allow them to participate in Medicare Advantage. This is wasteful spending that can be eliminated to attend Medicare.

Americans Don’t Want a Government Ran Healthcare Plan-This is another lie. In a poll conducted by New York Times and CBS, 66% of Americans polled would like to see a government ran option similar to Medicare.

Rationing of Health Care-Another lie plus if you assume our health care is not already rationed think again. Every day insurance companies recount coverage for a myriad of reasons. So how could it be any worse, maybe the pre-existing condition removal alone would help us all, and considering a public plan would not be able to shroud all procedures, private insurance plans do not either.

Single Payer System Would Give Us Worse Healthcare-If the single payer system is so bad then why do we give to our military veterans and yet members of Congress call the VA system the best care for our veterans. A U.S. newspaper wrote that under the British system Steven Hawking would be allowed to die due to his deteriorating condition, but Hawking said, “I wouldn’t be here today if it were not for the NHS.”

Why don’t we have a honest debate with all options on the table. By doing this we would truly consider the needs of the American people without the monetary influence of the health care industry and nay saying by Members of Congress and the Conservative Correct.

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Whether you are making a choice between the health insurance plans offered by your employer, or buying an individual policy for yourself, here are 10 tips to recall into consideration.

1 Know thy needs
Before you earn down to comparing different plans, it is important to determine your insurance needs. You may not find a policy that will cover every contingency, but you should try to accept a plan that at least covers the essentials, and meets your medical needs.
Does a family member have special needs? Do you opinion on having a baby in the next couple years? Does a dependant need prescription drugs? Do you travel abroad? Thinking this through will enable you to match your next policy with your novel and future medical needs, and get the kind of coverage that is right for you.

2 Shop around
All health insurance policies are not created equal. You or your insurance agent should gather quotes from different insurance companies for comparison. You will find that there are broad differences in the cost, benefits and exclusions offered by various policies. By shopping around, you may not only set aside money on your insurance premium, you may also find a policy with benefits that are better suited to your needs. While shopping, be sure to do an apples-to-apples comparison of the standard benefits that each company has to offer.
One of the most convenient ways to get quotes from a number of health insurance companies, is at an insurance comparison website. You will acquire out a single questionnaire and get several different quotes. Here are three comparison sites:
www.ehealthinsurance.com
www.netquote.com/
www.LowerRateQuotes.com/health-insurance.html

3 Review the Benefits
Before you commit to buying a policy, it is essential that you understand exactly what it will pay for and – just as important – what it will not pay for. Be definite to read the exclusions section of the policy very carefully, as many health benefits are strictly optional, and will vary from one plan to the next.
*Does the policy cover preventive care?
*Does it offer vision and dental care?
*Will the plan cover pre-existing conditions?
*Is ambulance service included?
*Are prescription drugs covered?

It can be financially disastrous if you fall ill only to find out that your policy does not mask your particular condition and you are left on the hook for the bill.

4 Out of pocket expenses
Your monthly premium is not the only expense you will incur as far as your healthcare goes. Whichever insurance plan you go with, there will usually be some out-of-pocket expenses that you will have to pay. Before you buy your policy you should find out upfront what these expenses are going to be. What is the co-pay on the policy? If there is a deductible or co-insurance, what are the amounts? What is the maximum amount you will have to pay out of pocket?

5 Choice, Cost and Coverage
There are several types of health insurance plans out there: the HMO (Health Maintenance Organization), PPO (Preferred Provider Organization), POS (Point of Service), HSA (Health Savings Account) and traditional indemnity insurance idea.
The insurance conception you choose will determine:
*The flexibility you have in choosing your health care provider
*The cost in insurance premiums and out-of-pocket expenses
*The level of coverage offered and the benefits excluded

Make sure you compare and deem the pros and cons of each option when choosing your health insurance. If you are looking to save money, for example, an HMO has the lowest out-of-pocket expenses, but it has the most restrictions. Indemnity and PPO plans offer greater flexibility, but have higher out-of-pocket expenses such as a deductible.

6 The Price you pay
Price should not always be the determining factor in choosing a health insurance plan. Ensure that the plan you determine offers all or most of the health benefits you may need, particularly coverage for major medical conditions. Having to pay for a necessary medical service out of your maintain pocket may cost you far, far more than what you could possibly save in premiums. It may also be financially devastating.
In the long run, the plan with the lowest premium may not work out to be the cheapest idea. The least expensive plan is the one that offers the best price for the particular coverages that you need.

7 The “free look” Clause
Be sure your policy has a “free look” Clause. Most insurance providers allow you a 10-day period during which you can cancel your policy and have your premium refunded with no penalty. This allows you time to carefully review the policies documents, and make a final decision as to whether or not you like the terms and the coverage offered. Bewitch advantage of this provision to read and really understand your policy and the policy terms, and even get a second belief.

8 Guaranteed renewable coverage
Some health insurance companies will cancel your insurance policy or hike your rates if you drop sick – considerable like an auto insurer may execute your coverage if you have one too many accidents. This is actually legal in certain states.
Look for a policy that offers non-cancelable coverage, guaranteed to renew each year. If this is not available, a “conditionally renewable” policy is another option. Under this policy, the company will reserve the right to cancel all its policies that are similar to yours, but you cannot be singled out for cancellation.

9 Maximum Life Benefit
Another important consideration is the maximum lifetime benefit. This is the total dollar amount your insurance plan will pay out as long as you own it. that your insurance company will pay over the lifetime of the policy. Ideally, this limit should be at least $1 million

10 Questions are the Answer
Choosing your health insurance belief is a crucial financial decision. Before you put any money down, be distinct that you understand your new insurance contract. Ask your insurance agent or company to fully explain anything on the policy that you do not understand. Ask questions and be sure that you understand the answers. If not, ask again.

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• Family Health Insurance

Everyone knows about Social Security and the choice you make between receiving it at age 62 or waiting until you are 65 to get more per month. If you count the income received the three years between 62 (smaller amount) and 65 (the larger amount), the total amount of money you receive is about the same. It really doesn’t matter worthy when you begin receiving Social Security.�

What most people don’t realize is that when you reach 65 you begin to pay mandatory Medicare payments. The government deducts the payments (about $68 per month) from your Social Security check whether you want the Medicare insurance or not. Some people have a good health insurance program but Social Security charges for Medicare whether you use it or not. Most regular health insurance programs do not discount for the Medicare coverage, so inquire an increase in your overall health insurance program.�

Social Security has another program that is not advertised very much. It is the Supplemental Security Income (SSI) program, but unlike Medicare, everyone who wants it, must apply for it. It is not automatic and there are several qualifying rules that must be met. Some people believe SSI is just for the indigent, but the program covers many more people than that. SSI can be used to supplement regular Social Security if the applicant is aged, blind or disabled.�

For people receiving Social Security, SSI is generally available if they are 65 years of age and have limited income. If you have no income, the basic monthly payment is $552 per month for an individual and $829 for a couple. If you have some income, the amount is reduced to compensate for your income.�

However, not all income is counted against SSI payments. Generally, one-half of your income plus $65 is not counted. Payments received for certain energy, support, maintenance, food stamps, most federally funded housing assistance, and region assistance are not counted.�

You can qualify for SSI payments and calm have property. For instance, you can keep up to $2,000 in cash ($3,000 for a couple), your home, most household goods and your car.�

In addition to the federal SSI program, many states have optional assistance programs. For instance, Alaska offers a monthly payment of $352 for an individual and $528 for a couple, but Wyoming only pays $9.70 and $24.60. You will need to inquire about your state. All states have different payouts.�

Receiving SSI means you will also get full health care, food stamps and other benefits. Learn about the program online by visiting www.ssa.gov/d&s1.htm/supplemental-security-income. To get all the details on both the federal and your local plot programs, call 1-800-772-1213 for an appointment with a local Social Security representative. Request publication 05-11000 for complete description and qualifications for SSI. You may have government money available; you just need to request it.

I hated to admit it but after years of dodging the issue of some other kind of supplement to counteract the costs that Medicare parts A and B don’t camouflage, I decided to observe into it. For at least three years I stuck my head in the sand saying I couldn’t afford a third premium.

In May of this year, the billing department at my doctor’s office made me pay two years of unpaid visits totaling $96.36, which I paid in corpulent. I called in October of 2007 looking for the first charge. The lady on the phone said Medicare would handle it and that I was fine. They called me into the billing department in 2008 and told me of the $49.30 I owed from 2007. After explaining to her that I never got the bill, she made me pay a $49 co-pay before proceeding to the triage area. I never received the bill from ‘07 or the unique charges incurred from ‘08. I asked the recent people in that office to find out why I wasn’t getting my bill. All they would say was that Medicare had to refile in ‘08, and that we send out bills once a month. Something wasn’t right because I never got a bill.

Now, for the reason I need a Medicare Supplement Plan, my doctor bill for May of 2009 was $139.82. That covered the May 12 visit and the follow up visit May 26 after the blood work. Medicare only covered $68 of this bill because on the bottom of the Medicare Summary peruse, it said I have used $68 of the annual $135 deductible. The reason why I had a big charge was, the second visit ran 5 minutes over the traditional 10-minute limit. It cost me $8 per minute, which made my bill $40 higher. Medicare only paid $10 for the lab work and $20 for the first visit, there were probably a few other charges not marked on my bill but they are marked on the summary perceive.

While a lot of people don’t think a $140 doctor bill isn’t all that awful, another bill like this in the same year would hurt someone on a fixed income. They seem to forget I paid a chunk in addition to this bill too of help charges. I want a supplement to cover what Medicare parts A and B don’t, If I find a little coverage for Medicare Part D,

I won’t complain. Because of all the procedures done on my lower extremities in 2005, I now know how it hurts to pay for meds out of my pocket. The blood thinner I took cost $91.40 for a 30-day supply. I split it into two payments of $45.70, putting it on a credit card. This happened two months before Medicare Part D Prescription Drug Coverage opened to the public.

Mom suggested I try to get Medicaid to pick up my expenses. In the state of Texas, under a program called QMB or Apt Medicare Benificiary, one can do that, but they have income requirements. One can make up to but no more than $903. I acquire more than then that amount. Once they see my bank statement, it will show I can make my premiums. Pudgy medical coverage wouldn’t be possible. My friend at church, Ms. Charli Tulk who is on this program, discovered this when we discussed this issue two months ago on the phone.

I don’t know how many online medical forms I filled out on Tuesday, August 25, 2009, but I was bombarded with calls starting at 11:25 a. m. with Medigap360. This man asked me the necessary questions to determine whether I was eligible for coverage. After 10 minutes of third degree, the agent informed me the only company in Texas that would insure me was AARP. Since he already knew my birth date, we both knew I was too young for that program. His advice was to sit tight, wait till I turned fifty, and sign up then. After what I went through in 2005 and a few months ago, that wasn’t the smartest option. I had been rejected two times for supplement coverage before 2 p.m. because the agents that contacted me didn’t do that. However, the agent from IMAC said he could residence me in contact with agents that covered Medicare Supplement Plans in his company. By this time, I had decided to go with Blue Cross Blue Shield of Texas. Blue Medicare Rx covers me on Medicare Part D. Maybe they had Medicare Supplement Plans. As luck would have it, they did.

I filled out the form on line, but it wouldn’t go through, so I copied the 1-800 number down and dialed it. That was a mistake, because it was the wrong department. I went through two more toll free numbers and a host of automated menus before getting to the right department, I begged the third operator to transfer me because my head throbbed so badly. She connected me to a lady named Sara. After answering Sara’s inquiries on my health and whether I had Medicare A and B and what type of Social Security I received, she achieve me on own, but not before taking my address and phone number. I also mentioned that her company covered my Medicare Part D Plan. After putting me on hold, she told me to seek information from a packet in the mail of Medicare Supplement Plans and premiums, with her card in it.

Suitable now, it doesn’t hurt to study into the issue of Medicare Supplement Plans. I was warned that it wasn’t cheap to do this, especially through Blue Cross Blue Shield of Texas. Hopefully, by the time I need the above, there will be an act of congress forcing medical companies to crude their rates so that everyone will be able to afford coverage. I forgot to factor in my $135 Medicare A and B Deductible. Prices get lower when it gets broken-down up. Hopefully, by the time I need the above, there will be an act of congress forcing medical companies to low their rates so that everyone will be able to afford coverage. While it doesn’t look like that will happen this year, there is a design to make your voice heard. I would read the Myths vs Facts page at the end of this article first and watch the video. I saw the video on television this weekend. Go to Healthactionnow at the end of this article. Click on your state of residence. It will give you the list of House and Senate Representatives. Use the earn letter on the right to place those names in the form before sending.

Yes, this decision was very hard to make, but I’d rather do it before another medical catastrophe hits me that I’m unprepared for than afterwards. Now is not the time to stick my head in the sand or talk myself out of getting coverage by saying I couldn’t afford it.