The Indispensible Dozen: What We Need In a Public Health Care Plan

It seems hard to believe to us, but there is actually a debate going on about whether health care reform should include a public plan option – as opposed to only private insurance plans. (Never mind whether health care reform should simply be one public plan, or a choice of public plans!)

We have discussed why a public plan is necessary. The inevitable conclusion is that any reasonable approach to health care reform must include, at the very least, a public option.

But what would a public plan look like? What elements of a public plan are essential? Here are the indispensible dozen elements:

1. Like the long-standing, public Medicare program, the plan should be available to all, throughout the United States, without exclusions for pre-existing medical conditions, and with community rating (the same base premium for all, regardless of age, medical history or other “category” that the person may fit into).

2. The public plan should resemble the traditional, public Medicare program. (Polls show that 80% of Medicare beneficiaries are either “extremely” or “very” satisfied with Medicare.) In designing health care reform policy makers should learn from the successes of traditional Medicare and the costs of privatization.

3. The public plan, as well as any other plans authorized by Congress, should receive additional payments or “risk adjustments” for sicker or more costly patients. This is necessary so no plan ends up being a default for more costly people with the result that it becomes insolvent.

4. The public plan’s benefits should be at least as broad as traditional Medicare, and should be enhanced by adding coverage for mental health, dental services, long term care, vision care and eyeglasses, hearing aides, and increased coverage for preventive services.

5. A greater emphasis should be placed on primary care, especially for manageable chronic conditions. This emphasis should be financially encouraged with incentives to providers and enrollees. Perhaps most importantly, the plans should have a clear rule that care designed to maintain (as well as to “improve”) function or health status is covered.

6. Out-of-pocket expenses should be limited. Public plan premiums (and those of private plans, if they are to be offered) should be affordable, with no co-insurance or deductibles. Although there is a school of thought that requiring patient co-pays makes them better health care consumers, studies show that when cost sharing required, many people cannot afford it and forego necessary medical care or prescription medication. The result: more serious medical conditions and more costly care down the line. (Rosenthal, What Works in Market-Oriented Health Policy, New England Journal of Medicine, May 21, 2009)

7. Subsidies should be provided for lower income persons, based on a sliding scale, which would assist with premium payments. Premium costs should capture regional costs differences, as should subsidies to lower income people.

8. The public plan should have the authority to negotiate prices with health care providers and pharmaceutical companies.

9. Enrollment procedures and time frames in the public plan should be user-friendly. Eligible persons should be able to move freely between whatever plans are offered, particularly when there has been a change in an employer’s health care coverage or a change in the individual’s circumstances.

10. There should be a simple, easy to use appeals process for (public and private) plan participants based on the Medicare appeals process, and assuring that all current due process and appeal protections guaranteed to Medicare beneficiaries are afforded to participants in plans created through health reform, including the public plan and any private plans.

11. The public plan should include financial payments to providers for offering interpreter services and for translation of materials into the major languages of the enrollees whom they serve. Education and training should be offered to providers to assure that treatment and patient education is culturally relevant, in order to assure positive health outcomes and minimize the need for more expensive care down the line.

12. US citizen-children and the parents of those children, if the parents reside in the United States, should be eligible to purchase insurance through the public plan.

These dozen essential elements of health care reform would ensure that enrollees are able to access comprehensive, affordable health care and achieve positive health outcomes at a reasonable cost to society.

Isn’t that what health care and health care reform should be all about?

Source: CMA Health Policy Consultants