Saturday, October 13, 2012

Ryan's Voucher system could work, so do it now

Paul Ryan in 2009:

...and 2010:

Which is fine, make it a voucher system and control federal costs for these programs from the bottom up.  Ugly as it may be it could work. I ask this: if this is such a promising solution then why wait 10 years to do it?   Do it now.

Instead Paul Ryan's solution to the rising costs of Medicare, the biggest driver of federal health care costs and deficit spending, is to do NOTHING for TEN years. Nothing. He will allow the system to grow annually at 8%, which means that Medicare will more than double in cost, and perhaps triple when you account for the growing population, and then in one fell swoop cut expenditures to $8,000 per person by handing out vouchers.

To use a tortured cliche, this is the ultimate scenario of kicking the can down the road...and it's political pandering.

As seemingly unpopular as Obamacare may be, it is the only rational way to reform health care. Nobody else has broached a plan even remotely more feasible since Hillarycare in 1993, which was summarily executed at conception. Does Obama's Affordable care Act contain a lot of regulation? Yes. Will it dramatically cut health care expenditures? No, but the cost curve can be bent downward.  Will it work? I don't know, but I do know that doing nothing for ten years is insane.

Both Ryan and Romney have a fundamental problem with mandating individuals to purchase health insurance. So do I. But I have an equally strong aversion to mandating health care providers to see patients without ability or willingness to pay. So let's allow everyone freedom. Nobody has to buy insurance, nobody has to pay for health care, and nobody is required to provide it either.  Win-win-win.  The problem with this approach, of course, is that the Republicans are too squeamish to repeal EMTALA-- the law that mandates emergency care regardless of payment-- and too squeamish to control Medicare costs.

They have to do the heavy lifting or get out of the weight room.

Here's how it'll work: Frank and Zelda are healthy when they turn 65 and get their $8,000 per year voucher and buy health insurance. Frank has chest pain diagnosed as unstable angina and a mild heart attack when he's 66. His premiums go up and they dig into their savings to make up the difference.

The following year, Zelda is diagnosed with breast cancer, undergoes a mastectomy, radiation therapy and chemotherapy. Their premiums double but they have enough savings to cover it for a while. The years go on and Frank develops vascular dementia and has some cognitive difficulties. Zelda has never managed their finances and has always deferred to Frank for those decisions.

At age 72 Frank decides that they cannot afford health insurance anymore and stops paying the premiums. Their kids are not involved and Frank does not include them in the decision. Six months later Zelda has a recurrence of the breast cancer and the doctor recommends placement of a port-a-cath and six cycles of chemotherapy.

Upon reviewing Zelda's insurance coverage, the oncologist's and surgeon's offices notice that there is no active policy and Frank has stated that they do not have enough savings to pay the several thousands of dollars in initial costs. Both physicians are willing to donate their services, but costs will be staggering for the operating room, the chemotherapy, nursing care, laboratory studies, xrays, and CT scans.

Social service is consulted and paperwork is started to see if Zelda qualifies for Medicaid. She does qualify, but her assets-- their house and IRA account-- must be spent down by a certain percentage to cover some of the medical costs. During this application, Zelda's care is delayed for two weeks and the surgeon will not get paid for another 90 days.

Frank has become distraught that his wife has a terminal illness, their assets are being spent, and he has guilt that his poor decision-making has worsened this calamity. His chest pain recurs. Frank neglects to seek medical attention because of his lack of insurance, the lack of available funds and his shame for his part in the situation.

Two weeks later, Frank has had a massive myocardial infarction and is admitted to the ICU. While Zelda keeps vigil in the ICU she neglects two cycles of her chemotherapy. Three weeks later she is diagnosed with lung metastases. 

If you think this scenario is far-fetched, then you know nothing about delivering health care.

MY COMMENT: Vouchers seem like a good idea, but in practice I cannot fathom how seniors would be able to navigate the health insurance morass with any skill. Evening news shows would be chock full of commercials for Vouchercare with former Congressmen and Paul Ryan's mother touting these private insurance products. 

The final cost to taxpayers will be increased when you factor in all the "free" care and the need for Medicaid to mop up after all the uninsured seniors floating around. And the stress put on families would be immense. No modern industrialized nation treats seniors in this manner, and my hunch is that neither Romney nor Ryan would be in favor of this plan when it came to it's implementation. If it were a panacea, they would want it now.

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