I have a hard time getting my arms around the public plan option debate.  As other have said far better than me, it is not central to health reform, although it clearly central in the debate around health care reform.  Instead it is a proxy for a lot of other issues.

UHCAN Rally June 25

Just about everyone in the health care debate/discussions has their lynch pin issue.  It’s what I call the “just fix this” syndrome. They range from, “If everyone would just exercise more,” to “if the government would just pay for everything.”  In between is a whole range of touchstone issues, including numerous proposals for delivery system reform, payment reform, tax reform, the list goes on.

My three key issues

First is  “universal affordable coverage.”  Everyone tosses those words around, but few people grasp their own words.  How do you make sure that the guy who lost his job and his health care coverage (in today’s world) yesterday, can “afford” health care tomorrow?

How does a tax rebate, for example, help someone who can’t make his next mortgage payment.  He or she lived paycheck to paycheck before the job loss.

Or the guy my daughter met recently selling picnic tables he made who also had two part time jobs.  He had no health insurance.

We do have a model in this country that addresses that – the Taft-Hartley multi-employer health funds.  Employers pay a fixed amount per hour worked and the fund pays for coverage for the families and during periods of unemployment.

We also have many models of companies who charge employees for health care coverage a percentage of income, some on a graduated scale.

These examples demonstrate that payments based on income rather than “the cost of insurance” is not Un-American.

Payment Reform

The second key issue is payment reform.  For me that means that physicians and hospitals get paid the same regardless of who they treat.  No insurance company should gain market power by leveraging reimbursement.  The current system that pays providers less for treating poor people compounds already existing health care disparities.  The only thing differentiating provider payment should be provider performance.

The third key issue is to deprive providers, primarily doctors, of any incentive to perform unnecessary services.  As long as there is fee for service compensation, cutting service fee rates only provides an incentive to perform more unnecessary procedures.  That could perversely increase total costs.  There needs to be payment reform that puts doctors at risk for managing care within a budget.

It can be capitation, or episode of care reimbursement, or some other form of global reimbursement.

Many years ago, I was at a seminar at Dartmouth.  A panel of three medical directors addressed this new phenomenon called “managed care”.  They dared to suggest that we were entering a “new paradigm”.  This new paradigm would demand that physicians not treat each patient as if unlimited resources were available, but instead that resources for this patient might deprive the next patient of needed care.  We never got there.

The current paradigm is “Stand at the gate until you can pay the freight.”

I recent article in the New Yorker by Dr. Gawande that has attracted a lot of attention describes the perverse incentives of fee for service medicine without calling it out.

The debate around the public plan option addresses very few of these key issues.  Instead it is a debate of form over content.  It is a debate that is frustrating only because it is long overdue

The debate around the public plan option is more about “public” and less around “plan.”  It is clear that the public wants public.  Poll after poll supports that idea.  They don’t trust the private insurance companies.  And private doesn’t want “public”.  Campaign coffers and lobbying contracts offer ample evidence of that.

The argument is ultimately about our values as a society and about the public trust.