Can health care reform be simpler?

Obama has admitted that a health care reform bill probably won't be on his desk by the August recess. Kind of like I admitted that I probably won't be back to my rugby playing weight by the end of the summer. But neither of us are admitting defeat.

Due to the attention and media coverage, it feels like the average citizen is getting very well versed in previously arcane health care terminology. I no longer get blank looks when I mention terms like "bundled payments" or "DSH payments" and receive knowing nods when I mention McAllen, TX (click on the link to see what a former McAllen physician thinks of all this attention). However, the mechanics behind the debate are still complex and require actuaries to understand them. Bills hit 1,000 pages and senators like Chris Dodd give up trying to make concise points with comments like, "I'm just going to start talking and when 10 minutes pass, someone just stop me from talking."

The pursuit of health care reform is missing a clear simple goal. Rather than have a end goal of putting a man on the moon, the end goal is prevent adverse risk selection or cost shifting or something equally wonkish. Does every policy piece require a committee of experts and an actuarial demonstration? And what is an actuarial demonstration? An attractive coworker asked our Office Space-esque actuary that question and was told, "I can show you when I get off work at 5." However, digress.

These ideas below will not solve everything and some are not easy to implement. But they provide direction and are close to meeting 80/20 rule as they accomplish 80% of the goal with 20% of the effort. They give reformers a destination rather than a myriad of direction that include public transport routes, routes that don't use highways, bike routes, old pony express trails, etc.

1. We go back to one of the health insurance industry's earlier ideas.
Simple Explanation: Everyone in the US has to buy insurance and insurance companies will accept everyone. Everyone get the same price based on their age. Insurance is defined as anything that meets the basic state definition so there is no requirement on how comprehensive the policy must be.

Rationale: By accepting all, you remove some insurance administrative costs and share the risk. With no requirements on a certain level of insurance you give everyone the choice on how much insurance they want. Employers can choose to not offer insurance (and perhaps pay employees more) since their employees can get insurance on their own.

While this was initially criticized as a grab for new business by the insurance companies, this can solve more problems than it creates.

The only cost containment levers are likely through individuals having leaner plans (especially for those who choose to purchase catastrophic plans) and using less services. Employers who choose to offer health insurance will likely be larger and have purchasing power or those who feel like they can control costs (like General Mills).

2. Oregon Health Plan for the nation
Simple Explanation: We as a nation (aka a committee of a very prestegiously colored ribbon) decide how much we will spend on health care and rank what we want to cover. When we run out of money, we stop covering services. In Oregon, we call those "below the line services".

Rationale: This is a dramatic overhaul and the committee who decides what is covered will control 20% of the United States economy. However, it controls cost, coverage and can result in a very simple health care system. Medical providers have one entity to convince and they are done with all of their sales and marketing work. Their is one payer, one insurance plan, and one set of benefits.

3. Insurance companies become data centers

Simple Explanation: Insurance companies main function becomes sharing data on how much procedures cost with their set of benefits and provider contracts. That is the vehicle on how people choose their insurance plans.

Rationale: I have been trying to figure out a way to make insurance companies less evil by highlighting their strengths which is a comprehensive set of data. Insurance companies are in the best position to show how much everything costs. With this approach, rather than saying, "No, you can't have it" insurance companies would say, "Sure, you can have it but this is how much it costs."

This information would help both providers and patients understand what a procedure costs. Patients can ask their providers why they charge more than other providers.

4. We make primary care dead sexy
Simple Explanation: We have a lot of specialists, subspecialists, and sub-subspecialists who are expensive and well, specialized. Let's get more primary care physicians and put them in charge of the whole patient rather than just their ascending sigmoid colon.

Rationale: Only 30% of providers are primary care physicians because we have made this specialty unappealing by paying half as much as specialist get paid for half the appointment time. The residency system would be overhauled and primary care physicians would be placed in charge of the health care dollar in the form of capitation. Just like mustaches, capitation would make a comeback and become cool and retro.

While all of these ideas require some substantial institutional change and lifting, they are much simpler to articulate and help a reformer know their goal. For example, reducing geographic cost variation is a great idea but there's nothing in the idea that provides a guide towards an ideal future state. During these hot summer months, health care reform needs ideas that someone can visualize while meditating, not ideas that need a calculator to explain.