Uwe Reinhardt waxes poetic on the the American rugged individualist deferring health insurance as a constitutional right, as well as buying the same over state lines (you will recall we are unable to do that presently):
In principle, a free people should be able to buy health insurance in any state of the union they wish. But why just state of the union? Why not the Cayman Islands or Guernsey. Monaco or Honk Kong? Presumably, that’s what freedom means.
John lists his reasons for doing this. I agree with some of them — especially the argument that many mandates at the state level were put there to create economic turf for particular providers, rather than they protect consumers. My main reason, however, would be to get this argument behind us once and for all and to move one. I am just tired of it.
As to the regulations that really are intended to protect consumers, there are many self-professed rugged American individualists who profess to disdain any protection from government. Why not let them have their freedom from our government?
But I would require that anyone who buys an insurance policy somewhere, anywhere – effectively just shopping around for regulations they can live with, not cheaper health care — must sign a waver promising two things.
First, not to mooch off the rest of us through uncompensated care when an insurance policy does not cover medical procedures he or she now thinks should have been covered. Let them sell their house or car or yank a kid out of college instead to cover the bill – or give providers the freedom to refuse them service, certainly the next time they seek succor from a provider whom they stiffed previously.
There is something truly sick in an arrangement that looks to hospitals and physicians as catastrophic insurers of last resort, letting these providers of care figure out how to finance it or just absorb the cost of providing the benefits. They deserve to be paid for their work, like everyone else. Rugged individualists do not warrant protection from EMTALA which, of course, they would disdain, too – should they be principled.
Second, I would require people who buy health insurance anywhere to promise not ever to kvetch, on TV or in USAToday, when they encounter troublesome issues over renewals, recissions or erratically rising annual health insurance premiums. I am tired of these pitiful and pitiable vignettes, too, perhaps because I grew up in countries where people just don’t do that. Americans may not realize it, because they grew up with it, but they do whine an awful lot about this and that.
In short, I would require such people to sign a waver promising that they will really, really act like the grown up rugged American individualist they profess to be. There is something unseemly in that strain of American culture – last exhibit by our bankers – that decries socialism when things go well but seek refuge in it when things go badly. That is not freedom loving. It is opportunism.
Finally, I would just love to witness the dramatic moment when a New Yorker buys health insurance in Iowa for his or her family, at a premium of $5,609, and when subsequently that hapless Iowa insurance company gets the first bill from a New York physician or hospital. The scene would be something for the Jon Stewart show.
Just as entertaining would be watching the New Yorker get his or her first renewal notice, should he or she get one, with the new, much higher premium, this one based on the actuarial experience not in Iowa but in the New York market for health care. It would be a classic Harry and Louise vignette, albeit one with many, many bleeps.
So let’s get this done, each for our own reasons.
Dr Reinhardt, with an always sharp and on target message (SHM members might recall him as our annual meeting keynote speaker some years ago). As docs, I cannot figure out those of us who endorse a system where folks are permitted to go bare or are underinsured. Can you envision a scenario other than that described above whereby patients seek care without a safety net in an “all in” system and not be perceived as anything but a pilferer to those who play fair. I cant. Something to think about as reform rolls out on the national stage.
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.
Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.
Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.
He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.