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Government should define, not run, basic health insurance offerings

By Rudi Keller

Business Today

Every year, the number of Americans without health insurace goes up. In late August, the U.S. Census Bureau released the latest figures, showing that 47 million U.S. residents lacked health insurance coverage in 2006.

That's up 5 percent. And for Missouri, the growth was even more dramatic, up 16 percent for the year to 772,000 people.

And like Dr. Morton notes, being without health insurance doesn't mean those people have no access to health care. Emergency rooms are required to treat people who show up with real emergencies. And clinics like the Cross Trails Medical Center, on Broadview in Cape Girardeau, accept all patients and charge a sliding scale based on the ability to pay.

The trouble with the current system is that it separates people into classes and makes essential care much more difficult to obtain for people without health insurance. People without health insurance rarely get the screenings needed to identify problems at an early stage when they are most treatable. And they certainly don't get the kind of care that most people consider essential, like good dental care, but which is astronomically expensive without an insurance plan.

And for small employers who feel compelled to provide insurance benefits, the costs can be daunting. One instance in recent memory was when the Cape Girardeau Special Road District, with 11 employees, signed on to be included in the Cape Girardeau County employee health plan. Allowing those workers to sign up added $23,700 to the county's insurance bill. The road district made up the difference -- $180 per road district employee each month on top of the regular premium -- but still saved $20,000 over being in the market alone.

Dr. Morton explains that doctors don't get paid when the uninsured show up at a hospital, obtain treatment and don't pay their bill. The people in that position generally aren't the poorest of the poor, who qualify for Medicaid.

And they aren't the elderly, who have Medicare.

The people who are likely to have the most trouble paying their bills are the people who work hard, in low-paying jobs that don't provide health insurance. And while the hospitals must provide the care, they also aggressively pursue payment. So far this year, Saint Francis Medical Center has filed 92 lawsuits against people with overdue bills. And Southeast Missouri Hospital has filed 332 such suits.

And that's just in the three-county 32nd Judicial Circuit.

Well, I've defined the prolem and I bet you are waiting for a solution. Like Dr. Morton writes, there is no simple solution. It is too enormous for simple ideas.

Several states are trying to work it out. Some are using punitive measures, such as a massive payroll tax aimed at politically unpopular companies such as Wal Mart. The irony is, Wal Mart does provide health insurance. It is just that in places like Maryland, where the tax idea was first floated, the politicians who proposed the tax didn't think Wal Mart was generous enough with its health insurance plan.

Vast numbers of people in the U.S. are covered by government-run health insurance programs. More than 40 milion senior citizens and disabled people are enrolled in Medicare; another 47 million people are on Medicaid, the health insurance program for the poor, according to government figures.

Recognizing the amounts they are spending on health care already, some states are seeking to spread those dollars farther by setting up a safety net that covers everyone. Massachusetts, for example, enacted a program that requires every citizen to be insured.

And while a detached, philosophical discussion may conclude that government's role is to stay out of the market, the reality is that government already dictates the health insurance market.

So the question becomes what is the best way to extend the coverage to the most people while retaining maximum freedom to decide what you are willing to pay. And after careful thought, I'd like to see some version of the Massachusetts plan.

I see it as akin to unemployment insurance or autombobile insurance. Every employer pays a tax, based in part on the needs of the unemployment system and in part on the history shown by the employer, to provide a safety net for workers. Automobile insurance is mandated by law; it is crime to drive without it. There are mandatory minimums for coverage. You must buy the minimum. If you want more, you are free to purchase it.

The mandatory minimum health plan I envision is something like the county government's plan I mentioned earlier. A worker would be required to pay everything, out of pocket, up to a set amount, say $2,000 or $4,000 a year. After that, the insurance plan would kick in, paying for medically necessary services.

Employers could provide more. They can split the costs with employees however they like. Failure to provide the coverage, with a minimum employer contribution, would subject them to a tax that would make their employees eligible for a government-sponsored plan. Payments for an employer sponsored plan would count as a tax credit against the minimum payroll contribution.

After defining what should be offered, government would set the insurance companies loose to design their plans around the minimum requirements, market the product and enroll as many people as they could. And hospitals would get paid every time a patient walks in the door and doctors would get something from every patient.

The result, I believe, would be a much more rational health care market. And we would avoid socialized medicine.

Rudi Keller is the editor of Business Today.

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Tax incentives, not mandates, is the best policy to promote insurance coverage

By Dr. Eric Morton

Special to Business Today

I do not claim to be an expert on health care policy. But discussions of access to health care should make a distinction between whether someone can obtain treatment regardless of their ability to pay and whether they have access to health insurance.

In Cape Girardeau County, is there universal health care? Yes there is. What I mean by universal health care is, if you are a woman and you have no insurance. You come in the emergency room because you have massive amounts of bleeding from the vagina and you don't have health insurance, are you going to be treated? Yes, you are.

And are you going to be treated at no cost to you? Most likely yes. The physician, like myself, who is on call that day, is going to be responsible to take care of you even if I know I am not going to be reimbursed for your health care.

The federal Centers for Medicare & Medicaid Services mandate that any hospital that has Medicare funding has to take everybody who walks through the door if they are a not-for-profit hospital. So, even though there are 45 million uninsured or underinsured people in the United States, do those people have access to health care even if they need it? Yes.

So, the answer is not as simple as what can you do to expand health care, because health care is available to everybody.

Is that the best system, to just have somebody walk in off the street and get health care? Absolutely not. It is the worst system in the world. Because that is a reactive kind of medicine. It is not a proactive kind of medicine.

Gov. Matt Blunt is trying to make Medicaid more proactive by putting more money into health screenings and preventive health. That is the best thing that could happen. I haven't studied his system to see how it will actually work. But that is the best thing that could happen. Preventive services are proactive rather than reactive.

One myth of health care is that we pass on the costs of unreimbursed care to patients. That is a widely rumored myth but it is just that. We sign contracts with insurers, those contracts are negotiated and we negotiate fees. Those contracts are not changed by what we bill. I can't bill $175 to make up for the person who is not going to pay us anything. We can bill you anything we want. Unless we make you pay cash, we only can take what our insured contract pays. We can't pass on the unreimbursed cost.

In terms of what is the best approach to health care, there is no best single approach. The problem is too enormous to have a simple solution.

Should government be involved in health care? Absolutely not. Government can't do anything efficiently. They do everything horribly inefficient. If you just look at Medicare, you are talking about 100's of billions of dollars every single year. And is Medicare a viable system? Absolutely not. It is a mess.

In Medicare Part D, they tried to make medical benefits good for the Medicare recipients. But it is so confusing trying to figure out how to use those benefits, that only a small number of senior citizens even signed up for it. And it is still confusing.

It is the first $2,500 so much, then between $2,500 and about $7,500, nothing.

Who thought of that system? Someone who had to finish last in accounting class. Government has never been shown to be efficient at running anything. In terms of health care, they are pathetic.

Should it be socialized medicine? Should government be running medicine? Absolutely not.

Should the market control medicine? I don't think that answer is very good either. The market is going to be based on ability to pay. Physicians aren't stupid, and we are businessmen as well as we are physicians.

If we know our services are going to be marketable to patient X and not patient Y, we are going to focus on patient X. We have to pay our overhead, pay our expenses and pay our health insurance costs for our employees. We run small businesses. We are small business owners. If patient X will get us what we need to run our businesses and patient Y will not, then patient Y will eventually become neglected and it is going to make the problem worse.

So, just going totally free market I don't think is the answer.

Having a combination of tax incentives and market forces is the best. Government should provide tax credits for people to employ and offer insurance to their employees.

Our insurance cost for our employees is unbelievably expensive. The larger the business, the more negotiation there is going to be for the fees.

What would be beneficial to us, and to most small businesses, is if there were a tax break, a plan that gave $100 a month per employee to fund insurance costs. That would beneficial to us and we will manage to make it work.

Dr. Eric Morton, D.O., is an obstetrician who has practiced in Cape Girardeau since July 2000. He is a past president of the Cape Girardeau County Medical Society and currently serves on the society's Board of Directors.