I was working in the ER this weekend when one of the nurses asked me a simple question: “How would you fix the health care system?” Obviously, this is a complex problem requiring complex solutions, but in an environment where at any minute a heart attack or a stroke could disrupt a conversation I prepared a sound bite for an answer.
“Do you want the short answer? Or the long one?” I replied. With a smile, she requested the short one. “Be like Switzerland.”
This simple answer, , emphasized some of the features of that I like. The Swiss base their system on the private delivery of insurance, with privately practicing physicians, with the distinction that basic insurance products must be sold on a not-for-profit basis. This not-for-profit national ethic is something that seems inherently un-American but aligns itself with the goals of health care; I for one think this is .
The Swiss system also codifies something which every other European system embodies and the United States appears to abhor, social solidarity. A term I learned from one of my professors in public health school, social solidarity is sorely lacking in America. The Swiss, and the Affordable Care Act (Obamacare), get it right – every individual needs insurance but also shares the responsibility to obtain it. The individual mandate is the keystone buttressing the Swiss system (and Obamacare) from collapse. It ensures for the Swiss a universal risk pool. “Everybody in, nobody out,” a mantra from socially liberal health advocates, can be accomplished with an adequately designed and incentivized individual mandate. What we need in America, at least at the state level, is a universal risk pool.
We already have agreed to supply life-saving health care to our entire society through EMTALA. No matter who you are, no matter how much money you have, if you have a life-threatening condition, every hospital in this country* is required to assess you and stabilize your condition. Where we fail as a nation, is that there is no guarantee of care after that. So we wait until that person’s health starts to spiral out of control again requiring another hospitalization.
Why not ensure that all Americans can actually get the care their need when they need it, not just when they are deathly ill?
With EMTALA, even though that individual does not necessarily pay for that care they receive, our current society finds hidden ways to cross subsidize the costs: taxpayers cover the elderly, disabled, and the poor with Medicaid and Medicare; insured people pay more to cover the uninsured (at a cost of $1,017 per family); and health care providers write off the rest as charity care. The uninsured pay for only about 37 percent of the care they consume out-of-pocket.
Why not have a more rational system? Why not allow the people that know how to administer health insurance and manage provider networks best (insurance companies) do so? Why not allow government (with its infinitely better mechanisms for collecting and redistributing money) to handle the financing? Why not place the responsibility on the patient to pick a plan that works best for him or her? Why have Medicaid when clinicians can easily distinguish and discriminate between it and private insurance, when low-income Americans could have assistance to purchase “mainstream” health insurance instead? As the Swiss currently do, subsidies would be provided based on income, to ensure affordability.
I think we need to fully embrace two opposing philosophies, the Affordable Care Act’s insurance exchanges and the private (not-for-profit) insurance sector, to heal our broken health care system. We need to consolidate all these different state and federal health programs and streamline them into one financing system while allowing patients to choose their actual insurer. And we must have every one covered with monetary contributions from everyone who can afford it.
That’s how I would start with fixing the health care system.
Cedric Dark, MD, MPH
*EMTALA applies to nearly all hospitals in the U.S. as the statute defines participating hospitals as those that accept payment from Medicare