Readers have sent notes to this blog asking, in essence, “Dr. Walt, what healthcare reform do you support?” And, in his labor day speech about healthcare reform, President Obama had sharp words for those of us who have loudly opposed his proposals in public forums. He said, “What’s your answer? What’s your solution?” Then he said, “The fact is, they don’t have one. It’s do nothing.” He could not be more wrong. So, here’s not only what I support, but what most American’s support.
I agree with the Four Pillars of Health Care Reform espoused by many others, including “Conservatives for Patients’ Rights.”
1) Choice
Yes, when it comes to healthcare reform, I’m pro-choice. A patient must have the right to choose their own doctor, and have the right to choose the health insurance that best fits their needs and budget. And, healthcare professionals must have the right to choose which plans, procedures, and prescriptions they will or will not participate in. The healthcare professional’s right of conscience must be preserved
2) Competition
Healthcare reform must level the playing field for doctors, insurers, and consumers in a way that will result in healthy competition that drives down costs and increases favorable outcomes. Healthcare professionals and institutions should publicly post their prices so healthcare consumers can shop and compare. States should eliminate burdensome regulations so insurance companies can compete equally across state lines.
3) Accountability
Making healthcare services more accessible, transparent, and open through standardized insurance claims forms and equal tax breaks for individuals and companies will control costs by helping consumers and businesses compare “apples to apples” across the health care spectrum.
4) Personal Responsibility
Meaningful healthcare reform must place the responsibility for healthcare decision making squarely where it belongs, on the shoulders of the patient. This type of reform will encourage individuals make to make healthy lifestyle choices and will assign higher costs to lifestyle choices that result in more healthcare costs. Infusing personal responsibility into health care reform allows us all to maintain our cherished freedom to live our lives without government intrusion.
I would add a fifth pillar.
5) Encourage a Primary-Care Based Healthcare System
A healthcare system based on primary care and the Patient-Centered Medical Home (PCMH) will achieve the simultaneous goals of enhanced health care access, improved quality, and lower costs. At the same time, it’s critical that any healthcare system have a sufficient primary care physician workforce to support a primary care-based health system. As long as reimbursements for primary care healthcare professionals are 50 to 75% below specialists, these goals will be difficult to reach.
In his labor day speech about healthcare reform, President Obama had sharp words for those who have loudly opposed his proposals in public forums and for the insurance industry. He said he will listen to critics, but wants to hear them offer alternatives. “What’s your answer?” Obama said. “What’s your solution? The fact is, they don’t have one. It’s do nothing.”
He could not be more wrong. Here are three plans that have been on the table for some time that have many components I think most Americans could and would support. You can find the details about these, and every other current proposal here.
1) Center for Health Transformation 21st Century Intelligent Healthcare Solution to a 300 Million Payer System

• Overall Approach = Focus on health information technology and electronic medical records.
• Universal Coverage = Yes
• Guaranteed Coverage = Yes
• Portability = Yes
• Voluntary Employer-Based System = No
• New Programs = Establish a private/public partnership that reviews rejected applications to determine if the applicant is truly uninsurable. Creation of an HSA eligible HDHP high-risk pool. (HDHP = high deductible health plan)
• Expansion of Existing Public Programs/Federal Law = No
• Insurance Pool
  • Require states to establish an HSA/HDHP (Health Savings Account/High Deductible Health Plan) “high-risk” insurance pool that requires participation in disease management programs and provides varying benefits based upon compliance with care and health outcomes
  • Allow HSA/HDHP approval reciprocity across state lines
• State Responsibility
  • Remove financial and bureaucratic barriers to new market entrants
  • Remove state legal and regulatory conflicts to offering flexible HSA-eligible HDHPs
  • Remove legal and regulatory restrictions on providing incentives and rewards for compliance with health management and disease management programs
  • Allow list billings through employers for individual policies
  • Allow state approval of limited use Health Reimbursement Arrangement Only plans so pre-tax employer contributions can be used to purchase HSA eligible HDHPs
• Individual Mandate = Not specifically addressed
• Employer Mandate = No
• Private Insurance Mandates = Required to accept an equal number from the screening process for the high-risk uninsurable pool
• Individual Subsidies
  • Financial incentives for participation, rewards for compliance
  • Provide “health scholarships” for the low-income uninsured using subsidized HSA/HDHPs
  • HDHP Premium Advancable Tax Credit for non-Medicaid eligible low-income families and individuals
  • Charity-subsidized HSAs for the low-income uninsured
• Individual Vouchers = Yes (SCHIP) (State Children’s Health Insurance Plan)
• Employer Subsidies = Not addressed
• Individual Plan/Provider Choice = Yes
• National Health Board = Not addressed
• Tax Changes
  • Eliminate state and other municipal premium taxes on HSA-eligible high-deductible health plans
  • Remove federal income and employment taxes on HSA eligible HDHP insurance premiums
  • Equalize the state income tax deductibility of premiums for individually purchased HSA-eligible HDHPs
  • Incentivize newly formed small retail, service, and restaurant businesses to initiate HSA/HDHP coverage for employees by providing a lower graduated sales tax submittal rate
  • Tax credits to small employers offering HSA-eligible HDHPs
  • Tax incentives to accelerate the use of electronic medical records (EMRs) and other electronic (non-paper) systems through investment tax credits or other similarly-situated tax incentives
• Premium/Co-Pay/Deductible = Allow annual HSA contributions to be the maximum out-of-pocket expense under HDHP guidelines
• Health Quality Improvement
  • Focus on health information technology and electronic medical records
  • Provide quality comparisons of hospitals with simplified consumer-friendly analysis capabilities
• Information Technology / Electronic Medical Records = Yes
• Individual Responsibility for Health and Lifestyle = Yes
• Preventive care = Focus on behavioral changes including wellness, prevention, early intervention, and compliance with proven care and treatments
• Transparency
  • Support the development of a “Health Travelocity” model for insurance products that would allow consumers to compare services provided by selling agents, covered benefits, and premium costs of products
  • Require hospitals receiving state funds to release information on risk-adjusted death rates and complication rates, with a guarantee that use of the data will include a fair risk adjustment
  • Support the “right-to-know” initiative, requiring providers to disclose cost and quality information on all discharges as a condition of participation in the Medicaid or other state-sponsored programs
  • Provide quality comparisons of hospitals with simplified consumer-friendly analysis capabilities
• Drug Reimportation = Not addressed
• Medicare Rx Drug Price Negotiation = Not addressed
• Medical Personnel Education = Not addressed
• Mental Health Parity = Not addressed
• Other Provisions
  • All government programs converted to private market insurance though “insurance scholarships,” health insurance “Pell Grants,” or other advanced tax credit voucher programs
  • Allow the use of HSA funds for the payment of health insurance premiums
  • Allow HSAs to be attached to any health insurance plan
  • Allow HSA eligible policies approved under the laws and regulations of any state to be sold in other states
  • Limit SCHIP coverage to children in families with incomes at or below 200 percent of poverty
  • Fix incentives that reward states at a higher level for enrolling higher-income SCHIP children over poorer Medicaid children
  • Aggressive outreach and education campaign to enroll the 8,280,000 Americans who qualify for Medicaid and the State Children’s Health Insurance Program (SCHIP) and are not signed up
• Cost = Not addressed
• Cost Containment
  • Competition in an open free market is the best solution to lower prices
  • Controlling demand for services by engaging participants in healthy behaviors and providing rewards and incentives for cost effective purchasing of healthcare services
• Financing = Current federal and state funds used to cover the uninsureds should provide direct subsidies to low income uninsureds

Source R. E. Bachman and N. Desmond, “A 21st Century Intelligent Healthcare Solution to Creating a 300 Million Payer System,” Center for Health Transformation, April 1, 2008
2) Coburn Patients Choice Act

• Overall Approach = Competition through State Health Insurance Exchanges
• Universal Coverage = Yes
• Guaranteed Coverage = Yes
• Portability = Yes
• Voluntary Employer-Based System = Yes
• New Programs
  • Federal government partners with states to create State Health Insurance Exchanges Federal assistance to states to address medical liability reform
  • Establish Independent Health Record Bank Accounts
  • Creates Independent Risk-Adjustment Board to ensure insurer competition
• Expansion of Existing Public Programs/Federal Law
  • Medicare assumes state Medicaid responsibility
  • Allows private facilities to provide Veterans health care
  • Allows American Indians to access medical care outside of the Indian Health Service
  • Restructures the Agency for Healthcare Research and Quality [AHRQ] to provide cost and quality transparency [renamed Healthcare Services Commission]
• Insurance Pool = Yes – State-run/Regional Health Insurance Exchanges
• State = Responsibility State Health Insurance Exchange Medical Liability Reform Insurance Oversight
• Individual Mandate = No
• Employer Mandate = Requires transparency from employers regarding the value of health benefits that could equal higher employee wages
• Private Insurance Mandates = Requires all participating insurers to offer coverage to any individual – regardless of patient age or health history
• Individual Subsidies = Assistance to low-income families with dependent children to purchase higher quality private plans
• Individual Vouchers = Not addressed
• Employer Subsidies = Not addressed
• Individual Plan/Provider Choice = Yes
• National Health Board = Not addressed
• Tax Changes
  • Creates a Medi-Choice rebate of $2,300 for individuals and $5,700 for families
  • Allows individuals with with a high-deductable health insurance plan to invest in an HSA any additional tax rebate not used to pay for the premium
  • Allow health insurance premiums to be paid tax-free from an HSA Increase allowable tax-free investments to HSAs
• Premium/Co-Pay/Deductible = Not addressed
• Health Quality Improvement
  • Quality through competition
  • Creates a Healthcare Services Commission to make public and enforce quality and price information
  • Provides Accountable Care Organizations within Medicare with bonuses improvements in quality and patient satisfaction while lowering costs
• Information Technology / Electronic Medical Records = Proposes the creation of Independent Health Record Bank Accounts
• Individual Responsibility for Health and Lifestyle = Not addressed
• Preventive care
  • Calls for the development and coordination of a national strategic prevention plan
  • Creates a web‐based prevention tool that would create a personalized prevention plan for individuals
  • Lower Medicare premiums for Seniors who adopt healthier behaviers
  • Provides Wellness Bonus Grants to states that show progress in reducing disease rates and risk factors and increase healthy behaviors
  • Awards bonus grants to states with 90 percent vaccination rates
  • Prohibits the purchase of junk food through the Food Stamp Program
• Transparency
  • Creates Healthcare Services Commission to establish uniform and reliable measures by which to report quality and price information
  • Requires employers to share the value of health benefits that could equal higher employee wages with their employees
• Drug Reimportation = Not addressed
• Medicare Rx Drug Price Negotiation = Not addressed
• Medical Personnel Education = Not addressed
• Mental Health Parity = Not addressed
• Other Provisions N/A
• Cost = No tax increases or new government spending
• Cost Containment
  • Competition
  • Prevention Programs
  • Reduced Medicare reimbursements through competitive bidding
  • Medicare Means-Testing
  • Medical Liability Reform Health Information Technology
• Financing = Not addressed

Source “The Patients’ Choice Act” Comprehensive Summary, Official Website of Sen. Tom Coburn (R-OK), May 20, 2009
3) Heritage Foundation Design Principles for a Patient-Centered, Consumer-Based Market

• Overall Approach = Six principles for patient-centered, consumer-driven health care reform:
  • individual consumers as key decision makers;
  • individual ownership;
  • individual choice;
  • wide range of available choices;
  • price transparency; and
  • regular opportunities to make coverage choices.
• Universal Coverage = Yes
• Guaranteed Coverage = Yes
• Portability = Yes
• Voluntary Employer-Based System = No
• New Programs = Not addressed
• Expansion of Existing Public Programs/Federal Law = Not addressed
• Insurance Pool = Not addressed
• State Responsibility = Not addressed
• Individual Mandate = No
• Employer Mandate
  • May include automatic payroll deduction
  • May include assisting their employees with information and guidance in making health care choices
  • May include provision of workplace clinics; health promotion programs; information on the costs, risks, and benefits of common treatments; and comparative data on the quality and results of health care providers
• Private Insurance Mandates
  • Prohibited from increasing rates for change in health status
  • Required to accept all customers regardless of their individual health status
  • Required to adhere to a standard set of basic rules for reporting premiums
  • Individual Subsidies Provide disadvantaged individuals with the necessary funds to buy into the same consumer-centered system that everyone else uses
• Individual Vouchers = Not addressed
• Employer Subsidies = Not addressed
• Individual Plan/Provider Choice = Yes
• National Health Board = Not addressed
• Tax Changes = Not addressed
• Premium/Co-Pay/Deductible = Not addressed
• Health Quality Improvement = Not addressed
• Information Technology / Electronic Medical Records = Not addressed
• Individual Responsibility for Health and Lifestyle = Yes
• Preventive care = May include premium discounts for participation in wellness or disease management programs, or cash rebates to subscribers who successfully meet agreed-upon health improvement goals
• Transparency = Establish basic pricing rules for both provided services and insurance premiums, which enable consumers to comparison shop effectively
• Drug Reimportation = Not addressed
• Medicare Rx Drug Price Negotiation = Not addressed
• Medical Personnel Education = May include inducements to health professionals to practice in rural or economically depressed areas
• Mental Health Parity = Not addressed
• Other Provisions
  • Limit provider rules beyond those necessary to ensure basic provider competence and patient safety
  • Limit regulations that needlessly micromanage providers, stifle innovation in clinical practices, or favor one set of providers over another
  • Limit micromanaging the market by imposing coverage mandates for specific conditions or treatments or by stipulating how plans must contract with providers
• Cost = Not addressed
• Cost Containment = A consumer-centered system begins to control costs because it creates increased pressure to justify costs better in terms of demonstrated benefit
• Financing = Not addressed

Source Edmund Haislmaier, “Health Care Reform: Design Principles for a Patient-Centered, Consumer-Based Market,” Heritage Foundation, April 23, 2008