American Intelligence Test: How Sick Is America’s Health-Care System?

Preface: The Affordable Care Act – ACA, aka: Obamacare has existed for the last 6 years, and by some counts there have been approximately 60+ attempts to repeal the legislation. This would appear to represent a significant investment in time and effort in addressing the profound ideological issues and problems that the ACA presents to those who oppose(d) it.

Beginning in 2017, those previous efforts will come to fruition with the expected … uh, now this is where it gets interesting since the clarity of direction to repeal has become just a touch ill-defined. But with the years of work that has gone into its repeal, or replacement, or redesign, or yet-to-be determined reconstruction there should be a high-level of information and understanding about the issues and problems with Obamacare and of necessity with America’s health-care system.

So, this AIT will obviously be easy to answer. What’s unclear is whether with 6 years of practice the test can be passed or not. If nothing else, you may wonder what our politicians have been doing for the last 6 years, the last decade, and the last quarter of a century in grappling with the nation’s health-care policy and system.

Question A:    What are essential elements to setting America’s health-care public policy and solving the health-care system issue? Select each principle or facet of health-care that needs to be part of any solution to the nation’s health-care issues.

(1). Single-payer system

(2). Competitive marketplace

(3). Universal coverage

(4). Voucher - based support

(5). Individual Mandate – based support

(6). Limited to a Basic-type of medical coverage only

(7). Limited to “Catastrophic” medical coverage only

(8). Block-grants to States to be managed by States

(9). Service/Treatment/Procedure – based pricing

(10). Outcome / Results – based pricing

(11). Prescription Drugs included

(12). Includes Medicare / Medicaid

(13). Safety-net for the poor

(14). None of the above

Answer - A:  2 and 3

Rationale - A:        These two elements are the only requirements in the above list necessary to achieving a rational, effective and sustainable health-care policy; but they are not the only requirements that are necessary. What is important about these two items is that they represent conditions that must be understood within the context of designing a health-care system as they are seminal concepts that when ignored, misunderstood or misapplied sow the seeds of ruin in any health-care system that is created. This explains why Congress has never been able to adequately deal with the issue. Congress is not up to the cognitive requirements needed to solve the health-care issue; beginning with understanding it.

The other choices are elements from which politicians pick their preferred subset to proclaim as a matter faith that their approach will solve the health-care system’s problems. But in lacking an understanding of the problem, our politicians will continue their propensity to fail at their jobs. This is not to say that some/any of these elements can’t be used to create a well-designed, efficient, lower-cost, and sustainable health-care, but simply including them is also no guarantee that they will produce desirable effects. A phenomenon that is beyond the ken of politicians.

Question B:   Who should pay for what the nation’s health-care system provides?

(1). Federal government

(2). State governments

(3). Federal and State governments

(4). Individuals and families

(5). Employers

(6). All the above

Answer - B:  4

Rationale - B:      This may come as a surprise to many people but there is only one group that can pay for a health-care system. This is because only people (individuals and families) can pay for anything. The only source of revenues is via taxation for federal, state, or any governmental entity.

Employers can be taxed as proxies for individuals and families but this only provides an indirect source since the companies that employ people passes their costs along in their products which ultimately end up at their customers who are people. Nothing wrong with taxing companies, but that doesn’t mean that you should think it isn’t being paid for by the people.     

Question C:   How should income-level get accounted for under a US health-care public policy?

(1). No accommodation. One price for everyone, either pay or no health-care

(2). A tiered price structure, something similar to proposed Tax-brackets, that sets a premium rate based on income-level

(3). A single tax-rate based on total earned income (no deductions or exemptions) that will support a ‘basic’ policy

(4). Government funding for poverty-level individuals/families

(5). Government funding for poverty-level children only

(6). The commercial marketplace will offer policies designed to provide plans that are priced to low-income individuals/families

(7). None of the above

Answer - C:  7

Rationale - C:      You cannot choose a pricing structure on to a health-care system without understanding and agreeing to what the health-care policy and the system are going to be. While Congress may not understand this, the reality of economics imposes an unavoidable balance sheet to the health-care system, just like it does for every other area of social existence.

That there must be some accommodation to income-level(s) in the health-care policy is essential. How that accommodation will be made and what it will means the cause and effect consequences are will depend upon the definition of the policy and its requirements.

If you’re a proponent from one of the other options, well then you’ve assumed a lot about the health-care policy that is most likely what you want it to be, not what it is going to be, nor what it ought to be if the nation wants a rational, effective, and sustainable system.

Question D:   Which would define one or more “direct measures of success” for the nation’s health-care?

(1). Lower federal expenditures for health-care programs

(2). Lower rates of increase to federal expenditures for health-care programs

(3). Fewer people dying under the health-care programs per dollar spent

(4). Less expenditures on last-year of life costs

(5). Lower cost-per-capita for health-care programs

(6). More individuals covered without increase costs to programs

(7). Lower premium prices for average individual

(8). Lower rate of increases to premium prices for average individual

(9). Increased ‘life expectancy’

(10). Decrease in ‘mortality’ rates for top-ten fatal medical conditions

(11). None of the above

Answer - D:  1, 2, 3, 4, 5, 6, 7, 8, 9, 10

Rationale - D:      Any of these, and thus all of them, would be a direct measure of success. There could be any number of additional direct measures of success for the current ACA, for its repeal-replacement, for a ‘fixed’-ACA, or for whatever Congress ultimately delivers.

Of course the possibility that there could be and should be well-defined direct measures of success for the nation’s health-care policy and system; there is little to no chance that Congress would understand this, and thus will not provide any.

Question E:    Should an individual’s health-care services’ cost or their health-care insurance cost differ for (answer Yes or No for each item):

(1). Age

(2). Gender

(3). Smoking vs. Non-smoking

(4). Number of years of active insurance coverage

(5). Obesity

(6). History of Drug-abuse

(7). Employment / Unemployment

(8). Occupation / Life-style choices

(9). Preexisting conditions

(10). Wealth

(11). Citizenship

Answer - E:  Yes, for every item.

Rationale - E:      The cost of health-care depends upon many factors and thus to provide it requires that a competent understanding of the influence that those factors contribute need to be incorporated into the planning, implementation and operation of the nation’s health-care policy and system.

Some of these factors are already part of health-care programs and there are others. Some new factors would provide useful tools and methods to assist in countering cost drivers. Others are a recognition that the health-care system is a societal construct and ought to hold the society accountable for its public policy and the cause and effect consequences of that policy.

Question F:    A leading element in some of the proposed ACA-replacement health-care policies is the use of vouchers in place of the ‘individual mandate’ for insurance coverage. Is a voucher-based approach better than the mandate approach?

(1). Yes  /  No

Answer - F:  No

Rationale - F:      A voucher system is an implementation choice that in and of itself doesn’t guarantee anything. Fundamentally, a voucher system is little different from an individual mandate system. It fundamentally comes down to a different form of taxation and where the funding is derived.

Question G:   Do emergency health-care conditions have a different public policy basis than general medical needs? What about catastrophic illnesses? What about pre-existing conditions?

(1). Emergency conditions:   Yes  /  No

(2). Catastrophic illnesses:    Yes  /  No

(3). Pre-existing conditions:   Yes  /  No

Answer - G:  1. Yes,  2. Yes,  3.  Yes

Rationale - G:     1. Since emergency rooms are treated differently under current law, they will require well-defined requirements and cost-support structure. If the care requirements are changed then the method of funding needs to be correspondingly addressed. If the requirement to provide emergency services is maintained, then the healthcare policy ought to address how it’s costs are to be accounted for in the funding.

2. Coverage or non-coverage of catastrophic illnesses needs to be spelled-out under the health-care policy and any costs accounted for in the pricing structure and revenue sourcing that will be tied to that policy.

3. There are numerous facets to pre-existing conditions that need to be accounted for under a policy. Whether public policy provides for pre-existing conditions or not, there are consequences to the health-care system; thus like anything else that is part of the problem, Congress can’t ignore it and the public can’t ignore it without there being consequences (acknowledged or not).

Question H:   Which of the following factors contribute to a high-cost, inefficient, and irrational health-care policy and system?

(1). Mandated emergency room treatment

(2). Medicare / Medicaid exclusion from prescription drug price negotiating.

(3). State-bounded insurance products

(4). HMOs, PPOs, POSs, EPOs, …

(5). Procedure-based pricing

Answer - H:  All the above.

Rationale - H:      These are health-care policy requirements or approaches that are not designed to accomplish socially beneficial health-care systems. They reflect decisions that have been made in the past to provide the health-care policy and system that we have today. If that system is flawed, broken and unsustainable then these items have a priori contributory.

Question I:      Indicate which of the following entities are/have been a contributing factor in increasing the cost of health-care? Select all that apply.

(1). Executive branch

(2). Congress

(3). Department of Health

(4). Insurance Companies

(5). Democrats

(6). Republicans

(7). Medical (health-care) Corporations:  hospitals, treatment facilities, pharmaceutical companies, assisted living facilities, …

(8). Medical products and device manufacturers

(9). Financial industry

(10). Physicians

(11). Special-interest lobbying groups

(12). The public

(13). All the above

Answer - I:  12

Rationale - I:        We did not arrive at this juncture with a broken health-care system without either the active or passive participation in creating the policies, programs and processes that have wrought the mess that we have today. It would be pointless to attempt to assess which entities (CONGRESS) have played the biggest role in causing the health-care crisis.

Question J:    Who does pay for health-care costs in America? Select those that apply.

(1). Individuals / families who buy insurance

(2). Companies / corporations that provide employee health-care as a benefit

(3). Federal government

(4). State governments

(5). Health-care Insurance companies

(6). Tax-payers

(7). Companies / corporations that provide executives or owners with health-care benefits

(8). Medicare / Medicaid participants

(9). Employees

Answer - J:  1

Rationale - J:       The answer to Question B and its rationale are unchanged. The public pays for the health-care it provides or doesn’t provide. The nature of the costs that are being paid are thus not necessarily what you would think of as health-care costs.

So how confident are you in Congress’ ability to ‘fix’ health-care? Well, don’t worry; it’s not like it’s going to cost you anything.