10. January 2017 · Comments Off on #EANF# · Categories: Health Insurance

The health care and health insurance dilemma in the United States penetrates and corrodes the very core of the quality of the American life. Our politicians and legislators are falling all over each other to produce both State and Federally mandated solutions for one of the most expensive problem facing our nation today. Documentaries such as “Sicko” with Michael Moore, and countless television stories and newspaper articles scream the need for change. As the never-ending inflation of medical services and prescription drugs rises, the bureaucracy of the insurance providers keeps pace by increasing premiums, and lowering quality of coverage for most Americans in their health plans. Drug companies are under constant scrutiny to offer more competitive pricing, but face little regulation compared to the foreign countries who have elected to impose cost controls endemic to their individual society’s perceived needs.

So in the face of such a negative equation, how does a capital-driven society like the United States of America re-vamp its health care system, and still maintain the theology of “choice” and “capital market competition”? And how do we do it without killing more Americans?

To answer these questions it is necessary to take in to account what works and what doesn’t in both American society and other societies where socialized medicine is the norm. The problem that Uncle Sam and many self-made American business folks have with socialized programs is the ability of such programs to denigrate a societies progress, and step away from our independent roots, both financially and health-wise. In order to continue to allow health insurance providers to shore up their billions of investment dollars ( a key pillar in our financial framework) and still take care of every American who is sick requires us to radically change the way the risk of such health problems is transferred, but to still collect regular premiums from taxpayers to fund the collective system. My proposed solution will be spelled out in this article in relatively simple terms forming a base architecture which will allow independent insurance providers to remain, independent hospitals and doctors to remain independent, and drug companies to remain competitively profitable while still insuring every American.

Proposal Architecture

I would propose a three-tiered system for Health Insurance, Prescription Drugs, and Medical Providers of all types:

I. Insurance Method

In order to keep insurance companies profitable and provide 100% base health coverage to all Americans at the same time, you need a combination of the net effect of socialized medicine and American free trade. A fund must be created by the federal government which closely mimics a Re-Insurance Company. Most insurance companies whether in the health field or commercial insurers have large re-insurance agreements and policies with major funds. A classic example is Berkshire Hathaway’s “General RE” which underwrites some of the largest global policies in the world in their niche. For description purposes, the federal government needs to take the opposite approach of a non-profit, heavily taxed medicare and insurance system by creating the world’s largest re-insurance vehicle. The re-insurance department is funded by A) a percentage of all health care premiums from all health insurance companies, and B) a 1.5% federal income tax increase across the board for all Americans. From this point forward, all health insurance providers are required to have a BASE INSURANCE LEVEL on all policies which will include a) full prescription coverage included, b) all doctor visits covered, and c) full major medical coverage with no deductible.

From an actuarial standpoint, what you are doing is not eliminating health insurance premiums for Americans. All working Americans who earn more than $16,000.00 per year must pay a scale-adjusted premium of the same category and type for the “base policy”. The scale for premium is driven by total income per individual or household based on their current employment. However, you have just turned the entire insurance industry in to one big “group plan” where the risk is spread out over the entire country. Using the proportion of healthy Americans to those requiring services at any given point, this simplistic approach lowers the premium for the base policy to affordable levels for all wage earners, and gives the base policy for free to low income individuals and families. Those people who meet the low income standards get the same base insurance as everybody else, and are required to file with a private insurance company of their choice for insurance. The federal RE fund pays all insurers a minimum base amount equivalent to what they would get from a paying client. The “Federal RE” model receives 30 to 35% of the private insurance company’s base premiums for all policies. The base premiums and the amount each individual must pay is determined by an actuarial committee of the new federal RE fund, but should be adjusted very rarely. Once the percentage is set, it becomes law, and the 1.5% tax increase across the board is primarily a cushion for the low income and poor.

Insurance companies then endeavor to differentiate themselves by adding features to the base policy for their clients for their marketing and packaging. They do NOT differentiate themselves by providing sub-standard insurance, as it is not optional. The base policy for all is a major medical insurance policy based on California Standards, and covers all co-pays and deductibles 100%. In order to make additional insured dollars, the health insurer must provide more elite services to guarantee a client who is willing to pay for additional features an even better position than the base position. This enables the following to occur in logical order:

* The federal government actually makes money on investing insurance premiums the way insurance companies do by their re-insurance department. Risk is spread out over each American that can afford to pay premiums. Premiums are minimal because of the inflated group size and reduced insurance company risk. The combination of a small federal tax increase to hedge dollar volume and beef up the account combines with receiving the RE premiums and investing them makes this federal program slightly profitable, and with the ability to adjust policy when needed.

* Insurance companies lower their risk, and are able to simplify and streamline their base coverage for major medical. Since all rules apply to all insurers (new or old) they can compete based on important but “ancillary” products to improve the insurance quality of those that can afford extra benefits. Major payouts will be largely reduced due to automatic RE participation on the policy’s base components.

II. Prescription Drug Costs

By making Federal RE the “co-payer” in most medical transactions for both medicine and medical services, you have also created a need for a private-style approach to controlling the cost of drugs and other prescriptions. This is a sticky area, because development costs for drugs are hyped as being out of control if they cannot be later recouped with high prices.

Since the federal government in the form of Federal RE is now a payer/customer of the pharmaceutical companies, prices for medications must find a happy medium to allow for development and free trade, but with sane maximums for purchase. It is the job of the federal government to prevent monopolies. A monopoly is not defined as a single producer of a product (or drug) being the only source for a given product. A monopoly is defined as that single-source-producer charging an amount which hurts our society, and potentially prevents competition. (generic drugs) Standards must be developed for the maximum payment amount allowed for each category of medicine and medical supply. This will be an ever-changing exhaustive piece of work, done on a very ongoing basis by employees of Federal RE. The purpose is never to set prices, but to determine the maximum the fund will allow an insurance company or itself to collectively spend on a medication, taking into consideration all aspects of the newness of a product by using fluctuating actuarial and monetary scales. If a Pharmaceutical supplier will not meet these maximums, then unfortunately, the medicine will not be available until they are willing to bend. This is a flaw in the ointment than cannot be fixed any other way due to the way drugs are really developed in the United States. Americans who add to their “base policy’ with supplemental insurance that covers expensive cutting-edge medicine could receive the medicine, but not the base-only policy holders. Drug companies will therefore be forced by demand to reduce their charges at least to the point of scale, in most normal scenarios. This portion of the plan cannot be altered to appease any particular party, because if you do the entire buying system falls apart. However, groups currently involved in assisting low-income victims could shift their focus to those precious few who are not able to get the most cutting edge product in time. The money simply cannot be covered by Federal RE. That does not mean another vehicle cannot be refocused, whether private or public, to assist in those few cases percentage-wise which require the latest cutting edge medications not charted as buy able.

III. Medical Treatment under Federal RE conditions

Medical treatment at this juncture is now available for all Americans, and in almost all cases their prescriptions are covered also. But now that we are prepared to fill up every clinic and major hospital with patients, how do we control the clinically insane costs of running that clinic or hospital? We can stave off socialized prescriptions via creating a powerful buyer in the market Through Federal RE, and having simple cost-overrun standards that are non-negotiable and consistent. But the clinics, hospitals, and emergency rooms didn’t get any cheaper. Since all Americans (at a minimum) are covered by the best type of major medical insurance money could previously buy, the billing systems and related bureaucracies are naturally streamlined over time. But sadly, medical charges have very little to do with the actual cost of a procedure, and everything to do with what the various hospital and clinical administrations CAN charge in each situation. If we govern the pricing of each procedure too closely, then we are mimicking the socialized policies of countries who we do not wish to be.

I would argue that the same way maximums were set in item #B above, a geographically mapped system to avoid over-charges could be applied. What constitutes an overcharge is again decided by committee at Federal RE in much the same way that pharmaceuticals are banned when costs are unreasonable to both the insurers and the government. Because 100% of the American population is insured with Basic (unless they foolishly “opt out”) the CUSTOMER is now the dual processors of Federal RE and the private insurance company involved in each case. If cost controls are unreasonable by today’s standards to any given clinic, the quality of health care will suffer tremendously when the operating units do not get to charge whatever they want, or whatever they used to feel an insurer will pay. But when medical organizations get 100% continuity in payments through a single-payer style system with few errant delays in the simplified processing, they will actually make far more money than they do now in the world of constant claim disputes, and zero consistency. The monitoring committee, as with the prescription committees, are comprised of qualified professionals at Federal RE who understand the true economics of a hospital or clinic. Severe overcharges that are way beyond scale cannot and will not be honored. Plenty of money will still be spent for procedures (especially at the onset when the system is brand new) but the whole key to controlling price is actually not price controls as the system matures…but rather the lower cost of running a hospital and clinic when the payments are made for services with lightening speed. That’s right..there is no reason to hold up funds under the new program once the services are provided. Medical billing will be a snap, and the incredible amounts of money spent on corrective systems can be lessened for each institution. Speed of payment to medical facilities is a major factor for overall success. So is having a fairly large and very intimate accounting system to track abuses. Frequent audits will replace much of the former aggravation of charging insurance companies, and will be a much more regular event at hospitals. A strong governmental role in auditing each facility regularly is actually a pillar of this plan, and will be gone in to more detail in later articles as to who and how this occurs, and how frequently.

The American dream is still a wonderful thing. We do not have to take away the profit motive from professionals who seek their fortune through honorable health industries, medical jobs, and insurance work. We simply need to define the rules of a new system that uses the age old insurance RULE OF LARGE NUMBERS to create a national group. The same talent required to be a preferred doctor, dentist, or insurance provider still exists in a more comprehensive form. State programs and the endless bureaucracy that encompasses them are eliminated and replaced by the new system. Welfare mothers and low-income households are fully sponsored for the coverage they really need, and the investments of Federal RE: over long period of time pay for most of the built-in deficiency. Hospitals, clinics, insurers, and drug companies all have to compete on the basis of quality and product provided instead of what HMO or PPO they belong to, or what “level of care” is minimally chosen. You will find that in practice it is an absolute fact that Federal RE will actually show a small profit when the smoke clears away, and medical care will improve through TRUE COMPETITION, not the bureaucratic version of it most of us suffer with today.

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