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A RECENT DISCUSSION OF INCREMENTALISM
Part Three - Comments from Dr. Ramon Castellblanch
YOU CAN'T GET THERE FROM HERE
Given the principles by which for-profit medical insurance operates, I doubt that pushing the HIAA - Families USA proposal is a step toward universal coverage. One key principle for the success of for-profit insurers is avoiding risk. In this regard, they try to enroll mostly healthy people. This is what the industry is doing in pushing CHIP; it is targeting largely a healthy population, children.
Another principle of the industry is to be as stingy as possible when paying for the medical care. For decades, the industry has used co-pays, deductibles and other arbitrary measures to reduce its costs. Starting in the 1990's, it made wide use of "utilization review" and other "managed care" techniques. It has become so good at using these techniques, that it may have greatly undermined the value of having coverage, including CHIP coverage.
The industry has a record of abusing public health care funds. Look at Medicare HMOs. The insurance industry tended to enroll healthy seniors and used managed care techniques to impede their access to medical care. For a while, it made large profits doing so. As the government wised up and began demanding more for their money, the industry began bailing out of the program.
CHIP insurers may, eventually, go the way of Medicare HMOs. They may tend to rip off the program until the government figures it out. Then, reforms may be demanded and the industry may bail out.
I believe that health insurance must be run according to the principles of public programs to be able to expand to universal coverage. They must pool the coverage of high-risk and low-risk people like Medicare and Medicaid. By not breaking off low-risk people, they can afford to give coverage to high-risk people.
They must be directly accountable to publicly elected officials. That is why Medicare and Medicaid maintain their benefits. Unlike for-profit insurance, it is hard for their overseers to summarily dismiss concerns of people needing medical coverage. Both Medicare and Medicaid have shown the capacity to expand. Medicare was able to cover people with end-stage renal disease. In the 1980's, Medicaid enrollment and benefits grew greatly.
I'm for incremental change toward universal health coverage. Expanding programs like Medicare, Medicaid, and public hospital systems would be that kind of change. It is fine with me for folks to promote CHIP. It certainly will help some people. But, when it comes to universal coverage, I don't think that you can get there from here.
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