Saturday, June 24, 2017

A Realistic Healthcare Solution for America

by Thomas Hinton


While the United States arguably has the finest healthcare professionals and treatment facilities in the world, we are sadly lacking in delivering the finest healthcare to our citizens. Many Americans still cannot access healthcare because of the prohibitive cost, insurance restrictions, and arcane government regulations that work against health and wellness in our country.  The new proposals before Congress that are being touted as a “fix” for Obamacare are a step in the wrong direction. America's healthcare system needs major surgery not a band-aid solution!

The American Consumer Council has studied the healthcare needs and requirements of thousands of our consumer members over the past eight years. We’ve concluded that it’s time the Congress and president establish a national healthcare program in which every American can participate at little or no cost.

Our solution is the adoption of a progressive healthcare program for all citizens and legal  residents of the United States that blends the best of Medicare and private health insurance programs. And yes, the basic program described below would be paid for mostly by taxpayers like you and me, but we would also have a choice to buy-in to advanced coverage options similar to those currently offered as Plan F insurance options and Plan D (drug insurance plans) under Medicare. This new model would be managed by an independent, non-profit agency under the direction of the Secretary of the Department of Health and Human Services.

This voluntary opt-in basic health insurance program would be funded by the federal government and provide for primary and urgent care. This innovative approach would attract more than 80 percent all of medical professionals, universities, clinics, non-profit service agencies, and industry organizations that currently serve the healthcare industry in America. Such a program would set a precedent for other nations that wish to provide an advanced universal healthcare benefit to their citizens.
  
My motive in proposing a national healthcare initiative is this. I want access to the best healthcare in the world for the rest of my life -- whether I live a thousand days or 10,000 days; and, I don’t want to be told by some faceless individual working in a corporate complex, whose job it is to save his/her insurance company money, that a vital medical procedure, treatment, or drug will not be authorized because their bottom line is valued more than my life. It’s that simple!  Here’s a true story that illustrates my point.

I read a very disturbing front page story in the Wall Street Journal about a middle-aged woman who worked in a small town in Texas as a hairdresser. She discovered a lump in her breast and went to a private hospital for diagnosis and care. Unable to pay for the necessary treatment, she was shuffled from one doctor to another over several months until a free service could be found. Regrettably, she was denied the proper care because she was unable to pay the costs for her surgery. Furthermore, federal regulations that would have allowed for low cost treatment, were unknown to the patient and she was caught in a Catch-22 cycle.

Eventually, the woman died despite receiving a mastectomy and good follow-up care in Colorado where her daughter lived. The patient had to sell her home, relocate to Colorado, move-in with her daughter, and be subjected to the humiliating rules of the state and federal healthcare bureaucracy. Despite the heroic efforts by her daughter, who was a nurse, to get her mother timely and proper care, the patient died from the cancer. But, as I read this heartbreaking story, it occurred to me that the woman’s death was also expedited by insensitive people in the healthcare industry who made a series of life-and-death decisions to deny her treatment in the early stages of her diagnosis.

Had that patient been their mother, I am sure the roadblocks and outdated regulations would have been removed to facilitate the best possible care. This is not only a tragedy but a disgrace to the dignity of every American. Frankly, reading this story angered me because nobody should deserve to suffer and die -- let alone go broke -- when the best medical care in the world is readily available. There are certain national issues and causes whose interests are poorly served by the twin engines of capitalism and profit. Healthcare is one such issue.

So, here’s our proposal to ensure that every American receives the finest healthcare services available. This will make America's healthcare system great again!

Step 1.  Create the National Healthcare Foundation.
Congress should approve and fund a National Healthcare Foundation (NHF) within the Department of Health and Human Services. The role of the NHF would be to administer a national healthcare program through a network of state agencies that entitles every American citizen and authorized visitors (tourist, student, visa holder, etc) to unlimited primary and emergency healthcare services for any treatment that will enhance their wellness or extend their life.

At the core of this national healthcare program would be a network of medical facilities, hospitals, shelters, clinics, and providers who would all be required to operate as independent, self-operated, not-for-profit entities. In other words, for-profit businesses that provide healthcare services would not be allowed to participate in order to protect the integrity of the new, not-for-profit national healthcare service. Obviously, this would require some for-profit medical facilities and hospitals to change their status to “not-for-profit” if they wanted to participate. Individual physicians and other medical professionals would be exempt from this requirement and eligible to participate in the NHF provided their billings were directed through a not-for-profit entity such as an eligible hospital or clinic.

Step 2.  The National Healthcare Foundation (NHF) will be funded and paid for by the United States Government through its taxpayers.  We believe that every American citizen has the right to primary and emergency healthcare under the same Constitutional protections that ensure “life, liberty, and the pursuit of happiness.”  But, it costs money.

In 2015, the Kaiser Family Foundation estimated that families in high-deductible plans paid more than $2,600 out of pocket, or $4,332 on average. Once workers surpassed their deductibles, they paid an average $24 co-pay for a primary care office visit, $37 for a specialty care office visit, and $308 for a hospital admission.

In 2015, Zane Benefits reported the average company-provided health insurance policy totaled $6,251 a year for single coverage. On average, employers paid 83 percent of the premium, or $5,179 a year.

Using calculations from the United States Congress and the Congressional Budget Office, the estimated annual cost for this program would be $350 billion in its first year. Frankly, we think this figure is low. Our calculations place the estimates a bit higher, closer to $400 million. It would not be cheap; the cost of good healthcare never is.

But, consider that employers now spend over $350 billion annually on health insurance for their employees, dependents and retirees. Healthcare costs for large employers are expected to increase by more than ten percent annually and insurance premiums will rise by the same amount. The burden on American businesses and individuals is causing America to lose its competitive edge in the many competitive industries and major manufacturing arenas, especially where unions are involved and they have negotiated excellent healthcare benefits for their members. 

This proposal is also a way to control the spiraling costs of healthcare; and, as you’ll read, it is possible to achieve a significant return-on-investment within four years of this plan through some innovative cost-saving methods and self-funded programs. In five years, I estimate that this program will actually cost us less than we are currently spending on healthcare today. And, it will reduce the current burden on companies and small businesses that must pay for healthcare insurance in order to compete for good employees .

As part of the new NHF, all participating physicians, nurses, clinicians, pharmacists, researchers, technicians and other healthcare professionals -- as well as all participating healthcare facilities such as hospitals, teaching universities, clinics, and laboratories -- would be paid an above average, competitive wage or fee for their services based on a schedule of current professional wages and fees-for-services in various regions across the nation. These wages and fees would also be reviewed annually for cost-of-living adjustments. This proposal does not ask anyone -- doctors, dentists, nurses, clinicians, teachers, administrators, or technicians -- to take a pay cut. Nor, would this program limit a healthcare professional from earning additional income through private services they offer outside of this program. These people are professionals and deserve to be paid a premium wage for their services. Also, participating medical facilities deserve to be paid a fair fee for their services including in-patient, out-patient care, and relating support services necessary to meet the accreditation requirements of the Joint Commission. Under this proposal, participating healthcare organizations would receive a flat fee for reasonable and customary administrative services and operational overhead from the NHF.

As part of this proposal, Congress would create an independent Healthcare Compensation & Insurance Commission (HCIC) consisting of 15 individuals nominated by the president and confirmed by the Senate from the private and public sector who would establish a code of ethics for all NHF participants and an annual compensation and fee-for-services schedules that ensure fair compensation for all participating medical professionals and non-profit healthcare and educational institutions. The HCIC would also establish regional malpractice insurance rates and set limits for financial awards against medical professionals and institutions that are sued for malpractice claims. This would dramatically reduce the exorbitant cost of malpractice insurance that hampers both treatment and medical services.

Step 3.  The National Healthcare Foundation (NHF) would consist of ten divisions. The purpose of these divisions is to ensure all Americans receive primary and urgent healthcare as well as foster the research, education, and advancement of the healthcare profession. Each division is described below in general terms outlining their major roles and responsibilities. Additional divisions could be created as warranted.

1.  Primary Care
2.  Urgent Care
3.  Assisted Care, Long-term Care, Child Services, Shelters, Hospices, and  Physical Therapy
4.  Research & Technology
5.  Organ Donor Programs
6.  Education, Training, and Accreditation
7.  Optional Treatment and Wellness Programs
8.  Licensing, Regulations, and Insurance
9.  Payment, Audits, and Enforcement
10. Administration

1. Primary Care would include areas such as pre-natal, pediatrics, dental, oral surgery, family physicians, orthopedics, chiropractics, and other traditional medical practices (there are many more than should be listed here) that care for patients through office visits and preventive disease treatments.

Primary Care would also include care for the developmentally disabled, mentally impaired, and treatment programs for diseases such as alcoholism and drug addiction. The NHF would pay for one hundred percent of these services based on a regional formula that fairly reimburses physicians and/or medical providers such as hospitals, clinics, and social services agencies. In other words, a family physician in New York City might be reimbursed using Schedule A while a community clinic in Albany might be reimbursed according to Schedule B. The adoption center in Macon, Georgia might be paid according to Schedule C and so forth.

2. Urgent Care is defined as any medical treatment that requires emergency room-related services and ambulatory services to treat life-and-death situations such as heart attacks, seizures, car accidents, shotgun wounds, drug overdoses, etc. Such care would be provided by licensed emergency rooms or 24-hour emergency care clinics located across the nation. This non-profit network currently exists with the exception of several rural and poor communities that desperately need medical professionals and local facilities. The NHF would pay for one hundred percent of these human services based on a regional formula and payment schedule that fairly reimburses the medical providers for their services and procedures.

3. Assisted Care, Long-Term Care, Child Services, Shelters, Hospice, Addiction  Treatment and Physical Therapy. This division would advance the needs of those persons who are unable to independently care for themselves including persons suffering from mental illness, Alzheimer, AIDS, drug/chemical and alcohol abuse, and terminal illnesses. This division would also be the champion of children who require adoption, foster homes, and day-care services for working parents. This division would also support the needs of persons requiring mental or physical therapy.

This division of services also would include those patients who require assisted care living or long-term care situations including hospices and mental health treatment. Also, it would apply to those patients who are under psychiatric care, medical counseling, the aged, infirmed, developmentally disabled, persons suffering from physical injuries including paralysis, or persons requiring rehabilitation treatment and therapy. To ease the burden of the Veterans Administration backlog, veterans could be treated under this program at the VA or at a private healthcare provider approved by the VA.

This division would also fund homeless shelters, runaway shelters, and homes for victims of family violence or spousal abuse. The NHF would also provide greater grant funding to support various state and county government social service agencies.

The NHF program would pay for ninety percent of these services. The other ten percent would be funded through private contributions, grants, and fundraising activities. Patients or family members would not be charged any fee for receiving these services.

4. Research and Technology would advance and encourage the development of innovative medical practices including new medical procedures and treatments, product design, drug research, and other such developments that would enhance the advancement of medicine and its treatment of patients. The NHF program would pay for eighty percent of these services to bona fide, not-for-profit institutions and research centers. The other twenty percent would be funded through private and public sector grants, individual contributions, and fundraising or advancement campaigns. For profit entities including drug manufacturers would fund their own research and be eligible for grants under federal agency programs as is currently the case.

5.  Organ Donor Programs. This division would advance the existing international network of organ donors, recipients, maintain a national database, and work to promote public awareness and support for organ donations while expanding the international network. These services would be completely funded by NHF including the costs associated with transporting patients, family members, and organs for a medical procedure.

6.  Education, Training and Accreditation. This division’s mission would be to advance enrollment and the training capabilities of teaching universities and hospitals as well as all other certified and licensed not-for-profit educational institutions that train medical professionals including doctors, nurses, and technical professionals. The NHF would pay for eighty percent of a student’s educational and medical tuition, or training that requires a medical degree or healthcare professional certificate.  The remaining twenty percent would be paid for by the student or through scholarships and work-related grants. The cost of continuing medical education programs would be borne by the individual unless it leads to a medical degree or post-degree certification.

A scholarship program (amount to be determined based on size and NHF contribution) would be required of each participating not-for-profit teaching institution to fund “special need” applicants and non-residents (foreign citizens). Institutions would be required to fund all non-educational programs and services such as administration, facilities management, and human resources as is currently the case. All students receiving funding support from NHF would be obligated to serve-with-compensation in an NHF-certified healthcare facility or a practice of their choosing for a period of time equal to the funding they received from the NHF. The current system for accrediting medical colleges, schools, and universities would remain in place and not be funded by NHF.

7.  Optional Treatment and Wellness Programs. This division of the NHF would be responsible for overseeing and advancing those medical treatments that are deemed non-life threatening but enhance the physical and mental health and/or self-esteem of individuals. Cosmetic surgery, plastic surgery (not required from a related illness or medical emergency such as an auto accident or burn incident), and wellness treatments such as spas and weight loss clinics would be covered under this section. The NHF program would pay for twenty-five percent of all such services with an annual and lifetime limit expenditure-per-person to be set by the HCIC.

8.  Licensing, Regulations, and Insurance.  This division of NHF would be responsible for overseeing three key areas -- licensing, regulations, and insurance programs associated with the NHF including the administration of the Malpractice Insurance Fund.

In the Licensing area, all not-for-profit medical facilities seeking to participate in the NHF program, or receiving any federal funds through the NHF, would be required to be certified by NHF or its designees. For example, a not-for-profit medical lab in St. Louis would have to apply for “NHF Licensing” in order to participate in the volunteer NHF program. Certain licensing reciprocity would be available -- including any hospital, laboratory, or medical facility that is accredited by the Joint Commission -- so long as that facility maintains its Joint Commission certification.

The Regulatory unit of NHF would oversee two major reforms that effect healthcare. First, the creation of a national malpractice insurance fund to protect all practitioners and facilities; and, secondly, oversight for the regulation, distribution, and enforcement of all “Re-classified Prescription Drugs” including many of those drugs that are currently deemed illegal today such as marijuana, cocaine, and heroin. These particular reforms are urgently needed in order to curb excessive malpractice insurance rates and end America’s fledgling war on illegal drugs which is costing taxpayers hundreds of millions of dollars. Here is how these two reform programs would work in concert with other federal agencies.

A special Malpractice & Medical Claims Insurance Fund (MMCIF) would be established by Congress as part of the enabling NHF legislation to cover all medically-related lawsuits or malpractice claims against program participants. Why? Because this program of the NHF is the “hook” that will single-handedly encourage an estimated 90 percent of all physicians, dentists, and other healthcare practitioners, who must pay costly malpractice insurance premiums, to enroll in the NHF and support its success. Also, as a volunteer program, the benefits of participating in the NHF must be significant in order to attract widespread national participation among medical professionals and medical care facilities. Regardless of their status as not-for-profit entities or for-profit businesses, medical professionals and healthcare institutions will follow the money! It’s the American way.

Under this proposal, the MMCIF would pay up to ninety percent of all medical malpractice insurance premiums -- as established by the HCIC -- and have the power to cap the dollar amount for all malpractice claims as part of their independent administrative law authority. Participants (physicians, dentists, and healthcare facilities) in the NHF program would pay the remaining ten percent which would sufficiently fund the malpractice program as well as other activities of the NHF. The NHF would be able to contract with insurance companies and agents across the country to administer this program and ensure all participants are in compliance. A reasonable fee-for-service, as approved by the HCIC, would be paid to these companies and agents for their services.

The second major reform deals with solving America’s problem with illegal drugs. Each year, the United States Government spends billions of dollars trying to stop the flow of illegal drugs into our country and arrest, prosecute, and imprison drug offenders and traffickers. While the merits of this effort are laudable, it is a costly war that requires a different solution in today’s global environment. That solution is not the legalization of drugs, but rather, a program that would allow for the reclassification, regulation, and distribution of those drugs under a system similar to our current prescription drug program.

Under this proposal, the Food and Drug Administration would authorize American-owned drug companies to manufacturer these “re-classified drugs” in various quantities and dosages -- including marijuana, cocaine, and heroin -- to ensure each prescription meets rigid federal guidelines for dosage and/or withdrawal treatment. Federal and state healthcare agencies that oversee current licensing requirements for pharmacies and other distribution channels for prescription drugs, would license those participating pharmacies and facilities to dispense medically-approved prescriptions for those drugs to persons who require them for medicinal purposes or to treat their addiction. As part of any prescription of a “re-classified drug” from a physician, each patient using these “re-classified drugs” would be required to participate in a licensed local counseling and treatment program which would be paid for by the NHF as part of its Primary Care Division.

This drug reform program would have many beneficial effects. First, it would severely reduce the illegal activities of street gangs and drug cartels in foreign countries, and cut the flow of illegal drugs into the United States. It should be noted that the sale and distribution of these “re-classified drugs” would remain illegal and subject to federal and state laws. Also, this move would allow the Drug Enforcement Agency (DEA) to focus its vital resources on other important activities. Secondly, it would reduce property crimes and felonies by drug users who must “feed their addiction.” Thirdly, it would reduce gang violence in major cities and reduce the need for youths to join gangs. Fourthly, it would allow the medical community to adequately treat people with addictions in a medical environment thus reducing such social problems as AIDS and other diseases contracted through contaminated needles. Fifth, it would reduce the prison population since more people will receive treatment for substance abuse in a medically-controlled environment and, thus, they will not be engaged in criminal activities nor be imprisoned for criminal offenses. This program would be funded completely by NHF. The cost savings to DEA and other drug-fighting agencies justifies this reform proposal. 

9.  Payments, Audits, and Enforcement. The NHF would establish a Payments, Audit, and Enforcement Division to handle all claims and funding requests from program participants. By law, payments for treatment and services would be paid within thirty days of billing to all approved, first-party payees (physicians, hospitals, clinics, etc) or the NHF would be required to pay interest to those providers. The NHF could contract out payment services to approved third party contractors or state agencies.

The Audit Division would be responsible for overseeing compliance of all NHF and HHS rules and requirements for billings and payments.

The Enforcement Branch would be given full federal law enforcement powers and be responsible for enforcing all NHF and HHS laws and regulations. Alleged violators would be referred to the United States Attorney for prosecution. Violators also would be fined, imprisoned, or banded from NHF program participation if found guilty of fraudulent activities or unethical conduct.

10.  Administration. This division would encompass the typical administrative and support functions of a major government agency including but not limited to: human resources, government relations, inspector general, legal, regulatory affairs, and budget.

In Conclusion.
This description is not meant to be all encompassing, but rather, it is an attempt to further the discussion on how to establish a progressive healthcare program that ensures all Americans will receive the finest medical care in a timely and affordable manner.

Certainly, there will be some people who do not believe in free primary and urgent medical care.  But, these voices represent a small minority of Americans. Others will argue the national cost for such a program is too high. I would strongly disagree with both arguments because I believe the facts tell us a different story. The financial costs of healthcare are soaring and we need a national program that provides a long-term national solution.

Also, I believe that every human being has the right to life, liberty, and the pursuit of happiness. I also believe that wellness and health play a major part in the core values of America. In fact, I believe health and wellness enhance America’s competitiveness and will allow businesses and institutions to be more competitive as a result of lower health costs.

Finally, I believe that a progressive healthcare program is the right thing to do given who we are as a people and what we stand for as a nation. Certainly, a network of not-for-profit healthcare facilities, staffed by America’s best-and-brightest medical professionals, would be money well spent and enhance the quality of life for all Americans. We're going to have to solve this problem one way or another; and, this solution is practical, fiscally responsible, and innovative.

Also, let me comment on the naysayers who are critical of other national healthcare programs such as those in England, France, Canada, Australia, and elsewhere. I am not suggesting those programs should become our model. Nor am I suggesting that we must adopt all of their practices. But, I am suggesting that if those programs were failing to meet the needs of citizens, you would see people taking to the streets in mass protests or certainly read about their failures in the media. So, there must be some merit to those programs. My question is this. What are their best practices? And, secondly, can we apply those best practices to a “Made in America” healthcare model?   The answer is "yes!"

In closing, I would not wish it upon anyone to be that person who must look your mother in the eye and tell her, “I’m very sorry, but they will not treat your breast cancer at this physician’s office or medical facility because you don’t have adequate insurance, and the doctors aren’t able to take on any more charity cases.”

Regrettably, those words are being repeated over and over every day in medical offices and insurance companies by otherwise caring people whose job it is to put profits ahead of the healthcare needs of human beings. It’s time we put an end to this unethical and inhumane practice in the United States of America. Through this proposal we can achieve something significant that all Americans will be proud of and benefit from for generations.

Let this initiative be our generation’s equivalent of landing a man on the moon.

About the Author:  Thomas Hinton is president and CEO of the American Consumer Council a non-profit consumer education organization headquartered in San Diego, CA. He can be reached at: tom@americanconsumercouncil.org

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