Девятого января 2017 г. я послал будущему правительству записку о реформе здравоохранения. Позднее разослал ее в прессу и еще нескольким членам Конгресса и ассамблеи штата Нью Йорк. Я (пока?) не получил ни одного ответа.
Для тех, кому это может быть интересно и кто может прочитать по-английски, размещаю записку здесь.
Proposal of a Private Citizen
For the Proper Replacement of “Obamacare”
(An Open Letter)
Eliezer M. Rabinovich, PhD
To: January 9, 2017
President-Elect Donald J. Trump
Vice-President-Elect Michael R. Pence
Speaker of the House Representative Paul D. Ryan
House Minority Leader Representative Nancy P. Pelosi
Representative Dr. Thomas E. Price, The US Secretary-designate of Health and Human Services
Senator A. Mitchell McConnell, Jr., the Majority Leader
Senator Charles E. Schumer, the Minority leader
Dear President-Elect, Vice-President-Elect, Leaders of the U.S. Congress and Secretary-Designate,
I venture to offer my proposal for the issue of health care reform. My qualifications consist of the fact that during the past 15 years my wife and I have been living in a “Wonderland” — a country of an almost ideal quality medical care. We are able to use the best surgeons, when we need them, without a long wait and for a very reasonable cost. We are free in the choice of our doctors, and once a year we may change insurance companies with no questions asked, including no questions about our pre-conditions. This system has never failed us. Therefore, are we not qualified to offer advice?
The country where we live is called the Unites States of America, and you are its present or soon to be leaders. The system that we are so fond of is state-sponsored Medicare in combination with private insurance. The most “Cadillac-style” insurance, Medicare A+B+AARP-sponsored supplemental plan F+AARP prescription Medicare D, costs in the NY area in 2017 about $430 per person (pp) per month, or $5160 per year, with no deductibles and no co-pays, and with about an additional $1000 spent on prescriptions. The above number of about $6,160 pp includes only our private expenditures, which exceeded $4,300 for an average American in 2010[i]. There are cheaper plans with co-pays and with a $183 deductible for the entire year. Also, there are Medicare Advantage (Medicare C) plans offered entirely by insurance companies that are significantly cheaper, but they, as a rule, require using in-network doctors.
The total medical expenditure in the United States in 2010 was 17.6% of the Gross Domestic Product (GDP), or $8233 per person. I assume it is now around $9,250, due to the rise in GDP: from 14.9 trillion in 2010 to 16.77 in 2013.
[A diagram follows that was taken from:
Before I continue, I want to touch briefly on another side of the matter: to compare our health care system to that of another country, e.g. our friendly neighbor Canada. Opponents of single-payer health care say that Canada’s care is inferior, and cite examples of rich Canadians who come to the US for surgeries that would require a months-long wait in Canada. This is due not to poor organization, but to Canada’s choice to spend about 60% ($4,445 vs. 8,233 pp) of the money that we put into our health care (see the chart above).
So why can this superb model not be offered to everyone from cradle to grave? Its opponents respond: how would we finance such a huge enterprise? My response is: just redistribute skillfully the funds that we are using at present.
My plan does not propose lower spending, unless it results from cutting waste, because I do want our superior care to remain. I hope that incorporating the 15% who were uninsured before Obamacare can be achieved without significantly raising the total expense, but in general I see no reason why the richest country in the world cannot continue having the highest-quality healthcare that we have enjoyed for two or three generations. The Medicare that I described above fits the bill. But if we look at the chart, we see that not only do we spend much more than the other civilized countries, but we are also the only country where public and private expenditures are about equal, while in all other places the public share is much higher. Their taxes are higher as well (as a rule). In this sense we should follow them. Also, I propose that Medicaid – insurance for the poor – should be incorporated in Medicare, while assistance to them should be offered through reduced premiums and deductibles.
Nevertheless, our very complicated pricing system definitely needs revision. Two personal examples will illustrate this statement. Recently my wife went to the emergency room of the Northern Westchester Hospital. My wife was left for observation overnight and in total spent about 36 hours in the hospital, with many tests.
The total bills (rounded, in $): 30,452;
Medicare approved: 26,443;
Medicare paid: 3,289;
Our secondary insurance paid: 480;
We were billed: 50.
In all, the hospital and doctors received: 3,289+480+50 = $3,819, or 1/8 of the original bill.
How can this ridiculous original bill, exceeding 3.5 times the average YEARLY cost of medical care, even be presented? Who does the hospital expect to pay it? Poor patients may simply ignore the bills.
But there is no public pressure for cost reform, because the well-insured majority, like us, simply does not care; there is no incentive for us to protest if we are asked to pay just $50 (in addition, of course, to our insurance premiums). In fact, I did not even know the details of the bills until I looked at them especially for this letter.
Another example: the difference between negotiated and retail prices of medications. On Jan. 4, I unexpectedly needed 7 pills of one of the major generic medications. According to my Medicare D insurance I was expected to pay a “full price”, still a full NEGOTATED price. When I came to my pharmacy I found out that my insurance company erroneously rejected my claim, and I needed to pay the full retail price of $12. When the misunderstanding was cleared up, the price was just $4.73 (!), still without the insurance company putting in a cent for me. In my opinion, this difference should be eliminated. There is no possibility of competition in the case of drugs; it is difficult to search for the cheapest prices in different pharmacies. All retail prices should be negotiated between the pharma companies/pharmacies on one side and either the government or the health insurance companies on the other.
Is this not a call to socialism? To some degree, of course, yes, because capitalism is based on competition, while there is little competition possible for medical services. I believe that the government needs to stay away from choice of doctors but should be responsible for financial side of the medical enterprise. I trust and hope that this is the case where the both parties may put aside their ideological differences and unite the nation with a sort of consensus. More of that, I think that a conservative government, led by President Trump, would be better able to take the country in this direction, just as another conservative leader – President Nixon – felt strong enough to open the door to China. President Obama tried to twist the arm of private insurance companies, forcing them to accept all people with pre-conditions, with no discrimination. Those people could not be insured in the framework of the relatively small private enterprises, because it is obvious that someone else must pay for their care. Who? All the other people insured by the same company. The result of this so-called “affordable care” has been a hugely unaffordable care, due to the increase in premiums, with deductibles that used to be in the low hundred dollars rising to several thousands. Some insurance companies have simply exited the health insurance business.
Our Western philosophy and moral code does not allow us to leave people behind without access to high quality care or to be completely bankrupted by this care. There is only one insurance company that can accept the sick people with pre-conditions – the nation as a whole, the government. The insurance premiums in this case we call “tax”. Of course, this reform will result in a rise in medical taxes, but this would be politically acceptable to the population when they see that the take-home pay after taxes and, most importantly, after paying ALL medical bills, would be not lower, and probably higher, than today.
At present the majority of pre-Medicare people are insured through their employers. Two examples:
A senior researcher in one of the companies in Silicon Valley pays for insuring himself, his wife, and his two children $3,640 per year, or about $304 a month. His company adds about the same amount. The plan includes co-pays, but the total out-of-pocket maximum is $3,000 per family. Another family of four on the East coast pays about the same monthly premium but the company has a deductible of $5,000 per family with a maximum of $6,000. So, as we see, the plans now are rather diverse.
Every employee pays 1.45% of his or her salary into the Medicare fund, which is used to pay for current recipients of Medicare; the employer adds another 1.45%. A self-employed person pays 2.9%.
When an employee loses his job, he is offered the same insurance for 18 months under COBRA, but the former employer adds 102% to the premium, making it very expensive.
I suggest that the 2.9 % Medicare tax from employers and employees be at least doubled or even tripled to create a pool of all the money formerly used by companies to subsidize medical insurance. Instead, the employers would be relieved from any additional care about medicine. COBRA and private PRIMARY insurance would be eliminated and transferred to the government. Private insurance companies may be encouraged to offer a secondary, supplemental insurance. Everyone would be expected to pay about $200 pp per month but not more than $600 per family, with yearly deductibles of up to $800 per family, with co-pays for every single service but with the maximum expense of $5,000 per family; medications would be covered by separate insurance as they are now. The same criteria that are now used to determine Medicaid eligibility would be used to provide governmental assistance to the poor for meeting the above expenses.
The new Medicare should negotiate fees with doctors, medical facilities, pharmaceutical companies and pharmacy chains. I believe that the public part of medical expenditure should be raised to 60-70%.
I believe that the first steps of this reform – “Medicare from cradle to grave” — can be implemented as early as January 1, 2018, with the gradual resolution of financial problems over the next two to three years.
I consider this letter to be an open one and may distribute its copies through media.
Eliezer M. Rabinovich,
A retired Materials scientist (PhD)
[i] Health Costs: How the U.S. Compares With Other Countries,