Thinking "out of the box" regarding health care coverage

Commentary. By Leonard J. Marcus, PhD, and Barry C. Dorn, MD, amednews contributors. March 18, 2002.

COMMENTARY

Observations on the state of medical practice and medical life

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In the course of complex negotiation or problem solving, one misguided assumption often can become an obstacle to forward movement. Even if well-intended, such an assumption obscures root causes of a problem and therefore pragmatic options for its resolution.

In this column, we challenge the assumption -- swirling through the access to health services debate -- that everyone in this country must ultimately receive the same health services. Though it is well-intended, we believe this assumption is a substantial impediment to expanding insurance coverage to the 40 million or so in this country who are without.

"Three-basket model"

For the purposes of analogy, we use the seating arrangements of a commercial airliner to clarify the distinctions proposed in our "three-basket model." Passengers on the plane are divided between first, business and coach classes. No matter the class, each passenger enjoys identical core standards of flight: safety, security, reliability and a means of passage.

The first-class and business passengers receive better amenities in exchange for their higher ticket costs. For the airlines, these premium fares disproportionately cover operational costs, allowing the plane to be filled with reduced-fare economy passengers whose costs are subsidized by passengers up front. Even though back-of-the-plane passengers literally have to pass through the front cabin, one rarely hears resentment since most are content to be on board at a fraction of the price of a premium seat.

This is the customary model in our country for allocating goods and services and distinguishing their quality and amenities. It is how we distribute housing, food, clothing, entertainment and recreation. Nevertheless, we have been able to develop sound social policy to address inadequacies in housing and problems of hunger on behalf of low-income populations. Indeed, the country has made great strides in these areas, addressing deplorable disparities, though we still have a long way to go. We do so by developing a national consensus on standards of human decency that we uphold as a society. Paradoxically, on a matter as fundamental as health care, we have yet to achieve that same objective.

We propose here an "out-of-the-box" alternative: an imperfect yet far-better-than-nothing solution to the health insurance impasse. This plan assures that each person in the country has access to some level, though not the same level, of service. The explicit acceptance of different access to services and amenities is its distinguishing innovation.

We call this plan the "three-basket model," comprised of the "basic," "full" and "super" baskets.

The "full basket" is akin to what employers now provide in the way of coverage. It covers the full range of tertiary, experimental and end-of-life care. What it does not offer are the amenities, such as private rooms at hospitals and full choice in selecting doctors.

The "super basket" is supplemental coverage for which some wish to pay. It would add extra amenities, such as the choice of physician, plusher accommodations for hospitalizations or clinic visits, and quicker access to doctors in nonemergency situations.

The "basic basket" is just that. Experimental or heroic end-of-life care would not be included in the basic basket, nor would amenities such as private rooms and a full choice of physicians. Routine care would be provided in less expensive settings, such as clinics and offices, and not in emergency departments.

The basic basket would be provided as a mandatory benefit to all employees: Like salary, the benefit is an across-the-board cost of doing business. Unemployed, partially employed or self-employed people who can afford to pay based on income will cover costs according to a prorated scale. For the indigent, elderly and homeless, the government would bear the costs, much as it is now through Medicare and Medicaid.

In this model, it would be the responsibility of the federal government to distinguish the different levels of service as well as to define services that are common to all. Private health care organizations, insurers and clinicians would manage, market and provide services that comprise the different baskets of care. Regulating and monitoring compliance with legal requirements and quality of care would be the responsibility of the state.

At its core, this proposal redirects the existing health system infrastructure toward a new and achievable goal. It would establish that everyone in our country is entitled to the basic basket of health care services.

Health insurance on the "must" list

And how might this process be started? Again, we borrow a concept from other realms of social obligation: certain things in life are simply mandatory. Taxes, education, a driver's license and a professional license to practice medicine are but a few of the "musts" to which we legally and socially comply. We propose to add "health insurance" to that list.

This will bring into the system the millions of people who could afford insurance but who consider this an unnecessary expense, until of course they require service. By incorporating the contributions of these "free riders," we add substantially to the resources available to the system. And for those unable to afford premiums, public agencies can provide coverage at what likely will be a savings on the current quilt of makeshift mechanisms used to bandage the system's shortcomings. It is up to Congress and the president to set a feasible future date at which health care coverage is mandatory for every U.S. citizen. That date becomes the target for this new system to be operational.

What about paying for this system? The American public has assumed a jaded attitude about health care costs. The "protections" of insurance have turned into a "shield," creating the false impression that health care is free. Like a hot potato, the costs of service are tossed from employers to individuals to the public. Ultimately, the country must come to grips with what it will take to keep its people healthy. This cost, in part, has to be about adopting healthy lifestyles and preventive strategies for keeping healthy.

One important point of clarification: This three-basket model of health care is distinguished from the private "concierge services" that are popping up around the country. These concierge services would be akin to all first-class passengers abandoning the airlines to buy or charter their own private, corporate jets (which is what they have been doing in recent months). Those private jets do not contribute to covering the range of budgets needing to be accommodated through air travel. We believe insurers could play the role of the airline, helping to balance the system by accommodating all who want to fly.

Certainly, from one perspective, this model is imperfect because it does not propose equity. It mandates broader participation -- in particular employer participation -- in financing the system. It is an improvement upon doing nothing or merely tinkering at the edges. Most important, it maintains that it is time to stop holding hostage to the debate those who are without insurance and access. People want the protection and comfort of knowing they are covered, and when they are ill, they want access and service without the worry of financial ruin.

How does this proposal pertain to the question of "Renegotiating Health Care?" Negotiation is about giving people reasonable choices and allowing them to exercise the choices that fit their needs and their budget. Negotiation is also about clarifying premises and adopting feasible options that best address the reasonable concerns of those with a stake in the outcome. We propose this option as a new take on a yet unresolved national debate, and with it, as a means to better align our country's health care system.

Note: This column originally appeared in print as "Renegotiating Health Care."

Dr. Marcus is director and is associate director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health, 617-496-0867. Dr. Dorn is CEO of Health Care Negotiation Associates 781-861-6116. The paperback version of their book, "Renegotiating Health Care: Resolving Conflict to Build Collaboration," is available for through Jossey-Bass Publishers, 800-956-7739.