PREMISE: The current health care market is financially unsustainable long term and morally insufficient for an advanced society. Rather than continuing to react to the proposals, statements and propaganda of the major players, I elect to list the major features of any health care reform program that might improve the situation.

1. COVERAGE: Virtually all legal residents of the United States must be covered, including the currently uninsured. We end up paying for their care after the fact anyway, but with poorer outcomes because of the episodic and chaotic nature of their care, and many of them end up bankrupt despite our (society’s) financial outlays.

2. SUBSIDIZE PREMIUMS for the poor on a sliding scale based on income.

3. WE CAN HAVE A SEPARATE POLITICAL DEBATE ABOUT HOW TO PAY FOR THIS (through general revenues, hence a “progressive tax” method, or through taxation of a percentage of the value of all other health insurance programs, ( not advisable, see # 5 below), or taxation on a percentage of high-end insurance premiums above a set amount, subject to political adjustments by the Congress periodically, etc). President Obama’s pledge not to raise taxes on those earning less than $250,000 annually must be abrogated. The cost of this coverage is too much to be born by 1 or 2 percent of the population without causing those people to seek to avoid taxation, with consequent primarily negative unforeseen consequences in terms of business formation, job creation and general tax revenues.

4. INCENTIVE FOR PURCHASE: The U.S. government cannot order citizens to purchase health insurance without taking a very large step down the road to tyranny. However, it can control or limit protections it already has in place in the marketplace. Specifically, prohibit bankruptcy protection to those individuals who become insolvent primarily because of medical expenses if they have refused to purchase health insurance. We can help those who need help without babying those who refuse to act with personal responsibility

5. INDIVIDUAL HEALTH INSURANCE PREMIUMS SHOULD BE FULLY TAX DEDUCTIBLE, up to a certain limit set by Congress, whether paid by employer or employee. This would allow small businesses to compete more effectively with large businesses, since their workers could still have insurance without the business being saddled with the cost directly -- rather, workers would figure it in during salary negotiations with prospective employers. Likewise, an excise tax on all private health insurance plans would be counterproductive, as it would disproportionately impact small businesses, which have been and likely will continue to be the long term driving force behind economic growth.

6. PROTECT WORKERS WITH A VESTED INTEREST: MEDICARE. Those who have paid in to Medicare over the years and received no benefit from it while working should have a recognized, vested stake in whatever comes next. If Medicare is continued, there must be no reduction in coverage or increase in co-payments. If not, those who become 65 years of age should have coverage without further premiums reflecting their contributions over their working lives, plus whatever additional coverage and premium costs the new part of the system entails.

7. PROHIBIT EXCLUSIONS FOR PRE-EXISTING CONDITIONS. But recognize that this will increase insurer’s costs and hence will be reflected in premiums.

8. PROHIBIT SELF REFERRAL in all programs that receive any federal subsidies – essentially all programs – with no exceptions for procedures with fees above a certain small amount, to be determined. Cardiologists should be able to perform echocardiograms in their offices, general internists should be able to perform very basic lab work and EKGs, but no physician should be allowed to refer patients to high-tech, high-expense testing on equipment in which they or a family member own any interest (other than stock in a publicly traded corporation listed on one of the major exchanges). Start by repealing the “in office” exemption under the Stark Act. This alone could save more than a billion dollars annually just under Medicare, and if extended to all age ranges, many times more. It is a sorry fact that human nature and the financial strains under which physicians’ offices operate do in fact influence medical decision making regarding the necessity and frequency of such procedures.

9. ADDRESS THE FINANCIAL INSECURITY OF PHYSICIANS. As noted above, financial strain influences medical decision making regarding high-tech imaging and testing. The flattening income curve and rising new graduate debt curve, particularly for primary care physicians, is influencing new graduates to specialize in procedure-oriented specialties rather than in less-well-compensated activities such as primary care. This is creating an increasing lack of access to primary care in intercity urban settings and rural settings, while artificially increasing the number of specialists, particularly those who perform high-price procedures! Capping pay for specialists is not consistent with the ideals of a free society, and would unfairly penalize those already working in a specialty by eliminating some of the “deferred gratification” they considered when deciding to delay their income-generating years (often by as much as a decade) by undergoing additional years of residency and fellowship training. Attempting to increase the pay of primary care physicians relative to specialists could be attempted but would be a patchwork effort between hundreds of different insurance plans. Lowering the debt burden of new physicians through increased tax-supported funding of medical education would affect all new physicians equally and could be uniform throughout the country as it would not involve the insurers.

10. THERE SHOULD BE A FREE MARKET within which all suppliers, including pharmaceutical companies, and all insurers, private, government, or Medicare, would negotiate costs. Medicare should not be prohibited from negotiating drug pricing.

11. DRUG MAKERS should be protected from the financial drain of the necessary long lead time for developing, testing, and gaining FDA approval for truly new drugs by an extension of the duration of patent protection, perhaps by five years.

12. CMS OR A NEW AGENCY SHOULD COMPARE PHYSICIAN AND HOSPITAL OUTCOMES for select high-volume, high-risk procedures and conditions such as coronary revascularization, peripheral vascular disease, and select major cancer operations, and develop data to identify whether certain providers have unusually poor outcomes compared with the norm. When the data is available, we could have a new discussion (if indeed there is a significant number of such outliers) regarding the possibility of excluding such providers from all federally assisted insurance programs.

— Leland D. Cropper Jr., M.D., Orangeburg

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