Editor’s Note: Memo to the New Guy

Dear Mr. President:

Congratulations on your historic election. Americans of all political persuasions should be inspired by your amazing achievement. Now, about that lousy healthcare proposal of yours …

Mr. President, you’ve sought to build a reputation as an open-minded post-partisan pragmatist. Most politicians talk hollowly of “reaching across party lines,” but I’ve begun to think (perhaps naïvely) that you actually mean it. I hope so. Because it is with this image of you in mind that I note a few flaws in the plan you proposed during your campaign.

The first is your plan’s failure to offer a coherent healthcare finance system that gives patients control over the direction of their care. I find the Geico gecko TV commercials as irritating as the next guy, but when my parked car was hit a few months ago by a 4 a.m. joyrider, Geico’s claims-center staff were courteous, effective, and fast. If only my group health insurance was half as good. The difference is that one company knows I can fire it, and the other company knows I can’t, and their respective corporate cultures reflect these facts.

Your plan, though, would seek to expand the current system - that is its second flaw. Your primary objective of expanding access is noble, but expanding a dysfunctional system is like adding a new floor to a crumbling apartment building.

What’s needed is a way to replace our current employer-group system with an individualized health insurance market that people can actually afford to buy into. Such a market would force insurers to compete for consumer business rather than large-group contracts.

If your goal is merely to expand access to a dysfunctional system, growing the number of people with some form of insurance - however inadequate - then your strategy of threatening most employers with penalties if they don’t offer group-health insurance, and creating a new, public plan to cover almost everyone else will probably do the trick, though at what cost to the larger economy remains to be seen.

But that would be a missed opportunity.

The employer system - a relic of the World War II era, when businesses offered healthcare, cheap in those days, as a perk to lure scant workers - is raising labor costs sky-high and killing businesses’ ability to compete globally and hire more workers (see: Motors, General, et. al). It has lasted this long only because no one has figured out another way to pay for care without prompting charges of “socialism.” Hogwash. Instead of trying to grow this half-baked system, you should be figuring out how to end it, replacing it with something consumers control. (You ridiculed John McCain for this suggestion, but he had the right idea, if not the right plan.)

How to do that? There are various ideas, but we’ll need to start by getting real about a couple of things: First, an affordable individual market can’t be achieved without subsidies. A combination of business, government, and individual contributions is probably the way to go. Nor can such a market be managed without some type of government oversight. State or regional organizations, á la Massachusetts’ Connector, could help consumers find insurers and make sure the companies function within the rules - while creating a “group” large enough to bring down costs in the individual market. The plan offered by Oregon Sen. Ron Wyden is a start.

Finally, you’ll need to take the insurance companies up on their recent commitment to cover everyone, regardless of pre-existing medical conditions, if you’ll commit to a health insurance mandate for individuals. Your refusal so far to make that commitment is the last major flaw in your proposal. Though painful, healthcare can’t be truly reformed without everyone being in the system, because those who stay out will simply wait until they get sick to seek coverage, or just use the emergency room as their primary-care office, then ditch the bill.

There are many choices before you, Mr. President. On healthcare, none is bigger than this: Will you seek merely to increase healthcare “access,” or will you strive to fix the healthcare system, at last?

Bob Keaveney is the executive editor of Physicians Practice. Join the conversation he’s started on this topic at forum.physicianspractice.com, or e-mail him directly at bob.keaveney@cmpmedica.com.

This article originally appeared in the February 2009 issue of Physicians Practice.