| 摘要 | The Obama administration has signaled that it may be willing to forgo creation of a federal government insurance plan (the so-called “public option”) as part of its healthcare “reform.” This is far less of a concession than it appears.
Even if the public option is excised, the healthcare bill under consideration by Congress would still impose a heavy blanket of federal regulation on every aspect of insurance and healthcare itself.
The government would determine what interventions “work” and are included in plans’ coverage. This would include a judgment on what is cost effective—does a treatment justify its cost? The government would put a monetary value on the number of years a patient’s life is extended or improved. Would everyone’s life be valued the same?
The government would mandate enrollment practices; regulate how premiums are determined; specify what co-payments can be collected; and dictate how much of the premium would have to be paid out for claims. The government would switch money back and forth among plans (“risk adjustment”) to compensate plans that cover a larger share of sick people.
It would impose “uniform marketing standards” on insurance plans and regulate how plan documents are written to ensure that they use “plain language.” Although the evolving legislation manifestly fails this test itself, it requires insurers to use language that is “clean, concise, well-organized, and follows other best practices of plain language writing.” To help the hapless insurers in this task, the newly created health choices commissioner would “develop and issue guidance on best practices of plain language writing.”
The newly created health choices commissioner would take bids from plans, negotiate with them, and enter into contracts with selected plans. This opens the way for undefined and unchecked informal regulation of plans, including, for instance, the number, type, and location of providers included in a plan, and how they are paid. The government would be able to use the contract mechanism to introduce any requirement it wanted, including social policies in favor at any particular time.
The government’s determination of covered benefits and cost effectiveness would determine what care patients receive. The financial impact of the regulation of insurers would determine the number of people who go into medicine and nursing and thus whether there are manpower shortages, the speed with which patients can see a doctor they want, their access to hospitals, how modern the hospital is, and the distribution of doctors and hospitals.
This extensive federal regulation would politicize and bureaucratize healthcare more than it already is. The healthcare system would be governed by Congress and the administration, with their attendant commissions, panels, boards, and collaborating experts. Instead of focusing on meeting consumer needs, insurers and providers would hire more lobbyists.
Effective healthcare reform would deal with the specific problems that need fixing. We should assist those who want private insurance to obtain it, including those at the highest risk. We should examine what regulation is needed to ensure insurers do not fail to uphold their obligations, and how the federal and state roles should be defined. We should change our tax and subsidy structure to encourage families to own their insurance. This would let them keep their coverage if they change jobs or move. Longer-term relationships between insurers and families would enhance Americans’ security, improve the incentives in healthcare, and enhance prevention. The current medical malpractice litigation system raises the cost of healthcare and is not fair to patients; we should reform it.
The approach now being pushed by the president and his allies in Congress completely ignores the problems of our litigation system; uses the uninsured as a pretext for imposing extensive and counterproductive new federal regulation on the healthcare system; and would give control of healthcare to Congress and the administration rather than to American families.
When the president belittles and dismisses those who warn that his proposals would result in federal control of healthcare, he is being either cynically misleading or naively delusional. Either alternative is troublesome. Even if the congressional leadership agrees to drop the scheme of government-run insurance, the bill still would give the federal government control of the healthcare system. A new direction is needed.
John S. Hoff, a trustee of the Galen Institute, was a deputy assistant secretary in the Department of Health and Human Services from 2001 to 2005.
Image by Darren Wamboldt/Bergman Group.
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