My first diary,
Retired M.D. & HMO administrator speaks out, outlined the three mandates to a new single-payer health care plan: 1. birth to death health care insurance, 2. free health insurance to nineteen years and 3. that it be self-funded and that
all governance be done by citizens. The second diary,
Health Security America: kicking the donkey, outlined why it is necessary to have citizens do such things as determine premiums and coverage (that is, to wrest control of health care out of the hands of special interests and put them directly into the hands of citizens).
This third diary shows you the first step of two that that Health Security America plan will take. Step #1: setting up a governance structure.
Excerpted from the
book:
THE FIRST STEP TO REALIZING THE THREE MANDATES
Congress will set up a non-profit quasi corporation to begin, as well as set the level of income that identifies poverty, but after that it will be hands off, unless specific help is asked for by the governance structure of Health Security America (HSA). Initially, Congress will authorize the start-up funding (for office space, reserves, and initial salaries which will be paid back over ten years from premium revenue) for the corporation and authorize it to use any Medicare information, Social Security information, government sources and facts needed to implement HSA. Initially, HSA will use the Medicare fee schedule, coverage, regulations and actuarial, audit, software and technical staffs, and use of any vendor contracts that the corporation may need. If there is need for another resource besides money to run the HSA corporation the first year, Congress will furnish it.
HSA will initially cover everything that Medicare covers, adding any procedures that might be necessary to furnish comprehensive health insurance coverage from birth to death for every American. Eventually, the new corporation itself will determine the premium and plan coverage. Every HSA recipient will be responsible to pay his or her premium, as required by the third mandate. (Medicare recipients who have money paid into Medicare from the past should expect this to apply to their premiums until past monies are used up). Subscribers to HSA could well have their employer pay their premium as a benefit if this was mutually agreed upon. Premiums and coverage will be dependent on 150 regional determinations and citizens' input via the hearing process. The plan, coverage and premiums will be the same throughout the U.S. This all will be addressed in detail.
The actuarial accuracy of HSA should be high, since it will be based on the entire U.S. population of 295 million people. It is going to take perhaps eighteen months to two years to get this plan up and running. In the initial few years of operation, Congress will be asked to stand by to fund any mistakes that are adverse to the premium. There could be normal actuarial error due to the plus or minus percentages attached to recognized actuarial numbers as the system gets going and the reserves might not be robust enough early in the life of HSA. Such funding errors, if any, will be made up the following year by adjusting the premiums of HSA. One of the mandates requires that HSA be self-funded and not add to the nation's budget deficit. This author hopes that the mandate be bipartisan, as well as all of HSA.
There will be the usual officers: President, Vice President, Secretary, Treasurer, and a Board of Information, which will have definite functions but will not rule or dictate. It will implement, not decide, plans for care, medicines, salaries, premiums and coverage. The orders to implement plans on issues will come from the decision making body--the regional representatives.
REGIONAL REPRESENTATIVES
The regional representatives will be the decision making body of this corporation. The public in every state will elect them in a publicly financed campaign. There will be three regions in each state, and each region will elect one representative for a six-year term. After the first election they will draw straws to determine in which rotation they will serve, since there will be an election every two years. The United States would have 150 people in this body. The representatives would all work out of offices in their home districts. I am leaving to Congress to determine the fairest way allocate the three representatives in each state. It could be by population, area or combination of both.
CORPORATE JOB DESCRIPTIONS
President, Vice-President, Secretary and Treasurer
The President and Vice President will be the public face of this corporation, much as they are in private corporations. The Secretary and Treasurer will perform the same jobs as in any other corporation. The regional representatives elect these officers.
Board of Information
The Board of Information will have the special full-time task of sending to the 150 regions questions that they will need answered in order to proceed with the three mandates, change rules, premiums, coverage and other items. They will forward to the 150 regions all the information they have on a given topic. Included would be items such as effect on premium, effect on coverage, difficulty in implementation, possibly the ethical opinions of experts--and simply anything else that the board of information thinks people would need to know before making a decision. The board of information will be a source that will receive any information that other agencies of government or any source at their disposal can provide to the regions on a region's request. The model that will serve as a starting point is present-day Medicare coverage, Medicare fees and rules. HSA will inevitably modify some of those rules. As an example--and a controversial one, to test the system--a question before the regional representatives might be whether HSA would pay for aborting an unwanted pregnancy. First, the board will obtain the number of abortions done yearly in the U.S., as well as the professional fees, hospital fees and also the actuarial cost and effect on the premium. The process will include discussions of known objections from religious groups as well as discussions of arguments from abortion proponents.
All of the pros and cons of abortion have been debated for years in this country on a federal level, but this is simply the decision of whether this citizen-funded insurance program will cover this procedure; it will not be issued from a central government authority. And the abortion coverage question would come up early, since Medicare does not currently cover the procedure. It will be a decision that each individual will have to make before voting, asking him- or herself, "What is my responsibility to my neighbor and his responsibility to me on this health issue?" And the responsibilities of making such an abortion coverage decision will run the gamut from ethical to financial. It is hard to "wear someone else's moccasins" with ease, if one is not 15 years old, poor, unmarried, living in the inner city or a minority, and the decision may well be a difficult one. Citizens will cast their votes, and the regional representative will pass his or her vote back to the board. If 76 of the 150 representatives, a majority, vote in favor of coverage for abortion then nationwide coverage will be implemented by the board of information. I present more on the hearing process later in the chapter.
Regional Representatives
As part of their governing duties, regional representatives will have the task of holding hearings in their area on the topics that need to be decided, as forwarded to them by the board of information. Some further examples of issues that they might receive other than the abortion example would be:
- Do we start all new cases of hypertension (high blood pressure) out on generic drugs before going to branded drugs? (branded drugs are drugs with patents still in effect and are much more expensive)
- Do we pay for cosmetic breast surgery after breast cancer?
- What level of psychiatric care do we pay for?
The board will have the best available information on items such as these and will present them at the regional hearings. The information made available to the regional representatives will consist of items such as these:
- Cost changes to the premiums based on actuarial findings
- How many people are affected by the problem?
- Is there a downside by using generic as opposed to branded medicines?
- Are there social implications?
- Are there ethical concerns?
Every item of reasonable and accurate information will be posted in the media, including a web site, so people will have the opportunity to stay well informed and involved in the decision making.
The people who attend the regional hearings (or view pertinent material on the HSA web site) will always be balancing the coverage and the premium. The regional representatives, having followed the hearing process closely, will then vote on the issues, determining peoples' desires, including the effect on the premium and the tradeoff--coverage. The majority vote of the regional representatives will rule, and the results forwarded to the board of information for implementation. There will be complete transparency in the process. The implementation will be nationwide.
To reiterate, the regional representative will be answerable to his or her constituents--not to HSA or Congress. The regional representatives' vote will be the one passed on to the board of information. The votes of the people at the hearings are designed not to bind but to inform the representative of the peoples' desires on premiums and coverage. Any one regional representative can bring a resolution before the 150 members, and if a majority vote yes, the question will be brought before the board of information. They will accumulate all the information as previously described and forward it to the regional representatives for the hearing process. This is simply a check available in the system.
I am encouraging only one other check to be placed in the by-laws of the corporation at its inception. After its seventh year of operation there will be a vote of the people, all 295 million of them via the web site. Button one offers the choice: Continue the decision process as we have for the last seven years? The other button will offer: The decision process will be by direct vote of the people on issues presented in the hearing process. Such a vote, electronically secured, provides a vital check on a vital process. The two checks included in HSA will prevent undue influence by interest groups. In our democratic society, interest groups sometimes have an overriding influence. Another function that I expect will be asked of the regional representatives by the board of information is to advise Congress on a related health issue not associated with the ordinary business of HSA, which would tend to be governance of HSA, coverage or premiums. The regional representatives will take the health issue question through the normal hearing process. An example: what cap should be placed on non-economic damages in medical malpractice lawsuits? These are the awards for pain and suffering, and punitive damages aiming to discipline the provider for negligence. I expect the populace to vote on the matter, but since HSA will be an insurance company, and not a legislative body, the voting will be advisory only. My guess is that Congress will hear the wishes of the people and will approve a damages cap. I also suggest that congressional representatives will want to vote accordingly on an issue such as this, or they will not remain in Congress. Although malpractice awards are important in protecting the health care consumer, capping awards is one of the crucial items needing to be visited to help reduce health care cost.
The 150 regional representatives are the governing body for HSA; I can not stress it enough. Regional representatives will also address items such as salaries after hearing from their constituents. I have great confidence that million dollar executive salaries will never be a part of HSA.
EXPECTED QUALIFICATIONS OF THE BOARD OF INFORMATION AND REGIONAL REPRESENTATIVES
Qualification of the Board of Information
People on the board of information will come from active operating positions. (These are people now actively working in their fields.) There will be four practicing physicians, and of these four, one will be a family doctor, one a surgeon, one either a pediatrician or internal medicine, and a psychiatrist. There will be three current hospital administrators, two practicing nurses and one pharmacist, three insurance actuaries and two insurance company CEOs. These people will be asked to leave their present posts and will have a full-time office in a central location that may or may not be Washington, D.C. The regional representatives will elect the board members, announcing the board's salaries before the election. The board members will have field assistants to research the information the board member will need to perform his or her function. The terms of the board will be six years and will be staggered, as are those of the regional representatives, on a two-year schedule. None of the board members will be permitted to enter into or maintain any consulting contracts with lobbying groups, drug companies or device manufacturers while on the board or for a period of three years after leaving their board position.
Qualifications of the Regional Representatives
I have great confidence that the citizens will vote for people in the health field that have the knowledge necessary to understand what is being discussed and pass on clarifications to constituents. The initial salaries of these people will have to be set by Congress, but once they are elected, the following year those salaries can be adjusted as with any other issue at hand.
THE HEARING PROCESS
The hearing process will be a busy one, with the representatives holding hearings virtually continually. There will be a schedule for deciding issues and a deadline by which citizen votes must be cast. The regional representative will have assistants to help with the process. The HSA web site will post all pertinent hearing information and be interactive, permitting each HSA participant the opportunity to cast a vote online. The site will be secure and the participant will use his HSA number as his password to vote yea or nay on the issue at hand. There is no question that there will be an eventual decrease in public hearings as people become more involved with computer technology. It would save money to start with the computer, although I am not sure that our populace is quite ready to do it right now. Currently our eighth graders are able to manage the voting process on the internet, so I doubt that it will be long before all business can be tended to this way. On one's nineteenth birthday it will be a new responsibility to be involved with HSA. This is the date when one will start paying premiums.
NEXT UP
The second step will be to add a set of eight rules to the by-laws that can not be broken if HSA is to function. The rules form a core of cost-constraining measures that any feasible single-payer program should adopt. These will be described in the fourth diary.
Fred Bannister, M.D.