My Freedom Based Vision for Health Care Reform

My Freedom Based Vision of Health Care
I would like to offer my vision for American health care for the 21st century. This vision statement is not a specific policy recommendation. It is a vision of what the world could be like after a series of incremental changes. I present my vision first because it is essential, in the current health care debate, that we have a common vision before we argue about specifics. I occasionally make mention of specific policy changes in order to persuade you that the vision is realistic. But keep your eyes on the big picture and see if you don't agree that this is a world that you'd want to live in.

My vision of health care is guided by some core principles: I believe in charity and sacrifice by those blessed with more, but I also think people should lie in the bed they make for themselves. I believe in free choice. I believe that the United States has been the beacon of freedom to the world, and that it needs to remain so.


My Vision
I envision a health care system where people choose their doctor and pay their doctor much in the same way that we choose our barber or our mechanic. People would save for health care the same way they save for home or car repairs. They would budget for it and it would be their choice where to go and how much to spend. Prices would be just as transparent as they are at the local department store. And the less fortunate would have no need of insurance because society would provide free care the same way we provide Section 8 or food stamps (no mansion, and no fillet mignon but you do get what you need)

Health care would be often be delivered at home. I'd have phone and email access to my doctor. Nurses would be allowed to do more. The licensing system for medical professionals would allow for much greater latitude in the use of physicians assistants (PA). These PA's would roam the cities to deliver in-home care at hours that are convenient for their customers. People would rarely visit the hospital. Broken leg? A PA would drop by (much like a plumber drops by for emergencies). They would be licensed to perform all manner of outpatient care. Self-blood draws and self-measurement would be the commonplace. Nobody would trudge into the doctor's office just to have their throat cultured. Everyone would have health appliances that can send vitals electronically to their doctor. An additional tier of prescription drugs would be created that would allow some drugs to be prescribed by a pharmacist (Electronic medical records would be an enabler for this.) More drugs would be available over-the-counter.

My medical records would be available instantly from a medical record provider of my choice. Standards bodies (much like the ones that govern the Internet) would ensure portability of records to any service provider. Privacy laws would be enforced to ensure my data remains private.

An aside on a new personal health paradigm: The CEO of Intel, Paul Otellini recently wrote of an entirely new paradigm in health care. Please read his views on a paradigm of personal health at Politico. You see, instead of copying France or Canada, the United States should lead.

Employers
Just as people are free to choose their doctors, they would be free to choose the funding model. No longer would employers be selecting insurance providers. In fact, the tax incentives that force employers to provide insurance would have been abolished. In lieu of health insurance, employers would have increased the salaries of the employees and gotten out of the health business. If the health of employees was important, they could require yearly physicals much like they do in the Armed Services. But they wouldn't be choosing how health care is delivered to their employees. No more worrying about losing health care because you lost or changed your job! (To get there, we need to tax employer health benefits and move the tax relief directly to individuals).

My Vision on Insurance
People would carry only catastrophic health insurance. This is much like how we use home insurance to cover unforeseen events. Home insurance premiums would sky rocket if we expected insurance companies to clean our bathrooms and replace our worn carpets.

The health of society would be measured by whether people receive care or not (the number of insured wouldn't matter). Most people would buy insurance. Some people would choose not to have insurance. In my vision of health care, these people would still receive the health care they desire and can afford. Most health care will be so affordable, it will be paid for out-of-pocket (and with tax credits) If they really can't afford it, they can receive charitable care, which I talk about below.

A word about genetics. In my vision, genetic information would be strictly guarded as a private information. Insurance companies would be prohibited from requiring genetic tests. But, as now, they would be able to ask about lifestyles, habits, and past health history.

A word about pre-existing conditions. If someone waits until their house burns down to get home insurance, it is too late. It would be down right nonsense to require an insurance company to take on a customer that will be a guaranteed liability from day one. Insurance wasn't invented to take care of people. It was invented to enable people to have peace of mind while they buy homes and have children during their prime working years. If you didn't buy this peace of mind, you will need to rely on charity, as I describe below.

My Vision of Charity:
Local and state governments would provide free access to student hospitals and clinics. The care in these hospitals would be rationed the same way it is in Canada. The difference being that, had they chosen to insure themselves, they would not be receiving rationed care. (In Canada you have no choice but to receive rationed care). And unlike Canada, the indigent care would be funded to a high degree by philanthropists, organizations like the United Way, and by state and local taxes. It is a fallacy that only the federal government is rich enough to help the poor. Several states refused New Deal handouts during the Great Depression and took care of their poor quite well. The funding of these clinics, in principle, would not come from the federal government. However, because the Supreme Court has already broadened the General Welfare clause, I would be swimming against the current to deny any role for the federal government. We would continue to provide Medicare-like services for the elderly. The federal government would be allowed to fund student and research hospitals which provide free care as long as it can be shown that the expenditures fell evenly across the states in proportion to their populations. Such federal expenditures would be modest in comparison to the size of the health care economy. In my ideal world, a constitutional amendment would have restricted all "General Welfare" expenditures of the federal government to be 10% of GDP or less.

Under my vision, every American would receive basic health care. Those who choose to provide for themselves will receive the best and most timely health care. We cannot turn our backs on the principle of the harvest. People must reap what they sow. If you didn't plan ahead, you will be cared for, but it will be Canadian style, and prompt delivery cannot be guaranteed. And your doctor will probably be less experienced. But look at it this way, those who receive free care are providing a service to society by helping doctors gain experience.

Cheap Health Care
In my vision of health care, we would honor contract law. Contracts that cap liability would be enforced. People would be free to undergo experimental treatments. The FDA would provide an experimental tier of drug availability. Doctors would guarantee their work, much like a roof contractor guarantees a new roof. Now, obviously, they can't insure every procedure will be successful. But they can guarantee specific treatments by providing free follow-ups and/or money-back if the customer is not satisfied. And because everyone is paying for their care in much the same way they pay their mechanic, costs will be driven way down for any treatments that enjoy economy of scale. (Think Brakes Plus, Midas Muffler, or Pep Boys.) And don't under estimate how cheap care would be if we allowed more in-home care as I mentioned above.

My Vision of Honoring the Constitution
In my ideal world, all law would have to be accompanied by a statement of constitutionality. People would honor the spirit, not just the letter of the the Constitution. The distribution of government from federal, to state, to county, to city would look more like a uniform rectangle rather than an inverted triangle.

The Constitution does not enumerate the power to manage health care. (Please read the 10th amendment in the Bill or Rights.) It does allow taxation and court precedent does allow spending on the "General Welfare". But the spirit of the law is that the federal government does not micromanage the affairs of the people.

Health care services arise from the fruits of someone's labor. Health care is no more a right than dental care, automotive service, or housing. That the government might decide to bestow services to the needy does not make it a fundamental right. Constitution guarantees equal rights, not equal things. Rights have to do with free agency, not with the receipt of goods and services.

A word about Social Security:
In my opinion, Social Security violates the spirit of the Constitution. However, it was found to be constitutional by the 1937 Supreme Court. The old-age portion of SS won assent by 7/2 vote and the unemployment portion squeaked through on a 5/4 vote. Some historians speculate that Justice Owens, the swing voter, was influenced by FDR's court packing scheme. So we now have a legacy in which the "General Welfare" clause of the Constitution can allow the federal government to justify almost any spending. But this does not nullify the spirit of the law.

And what if it can be shown that spending detracts from the General Welfare? If so, it is unconstitutional by any standard. Today, we have unfunded liabilities that if not fixed will eventually bankrupt social security. The 1937 supreme court approved a system that was self-funded. Today it is pay-as-you-go and is producing a huge generational transfer of wealth. The program has led to an unquenchable appetite for pork barrel spending. With 70 years of hindsight, we can definitely see that the program has exceeded James Madison's worst nightmares. What they needed in 1937 was a stimulus program with a sunset. That would have promoted the general welfare in a time of need and then returned the country back to the normal balance of power.

In my vision, two amendments to the Constitution would be enacted. The first, (as mentioned above) would keep "general welfare" spending to less than 10% of GDP unless temporarily overridden by a 3/4 vote. The second would be a balanced budget amendment (again with a 3/4 vote override provision).

Summary
In short, in my vision, freedom of choice is preserved while still guaranteeing help to those in need. I have no illusions about my vision being a panacea. It is just a vision. If only 80% of it were realized, we'd be the envy of the world. It would take a lot of work. As affluent as we are, we'd probably still pay 16% of GDP on health care but it would be by choice. And the rewards would be spread evenly across all people in a way that balances choice, accountability, and charity. Above all, this vision honors the spirit of the Constitution and preserves the principles of freedom which have blessed all of humanity.

Our Best Hope
The best legislation that I have seen to-date is The Patient's Choice Act. I don't understand why this Act isn't being discussed more actively. I know the President would be reluctant to give credit to two Republicans, but this bill addresses the insurance problem while providing a universal solution! He could claim victory at getting everyone covered and receive the bipartisan support which he claimed he would strive for.