SENATE BILL: Reforming Atlasian Public Health Act of 2014 (Debating)

[Fmr. Pres. Duke]

The goals I have in mind for our healthcare reform are that 1) I don't want to sacrifice quality of care 2) I don't want to nationalize all hospitals; we have many, many prestigious hospitals in universities in this country that offer some of the best care in the world; I don't want to lose that, 3) I don't particularly want to roll back our healthcare system though to where people lose coverage. If there is a way to accomplish all of those things, great.

I do believe that single payer may be the natural progression from where we are now, but I know very little about healthcare law and at the moment, I am in the middle of my final law exams, and I don't have time to research it till this weekend or next week.

[Fmr. Pres. Duke]

I just want to say I am open to any and all ideas so long as they can reasonably meet the criteria I set forth in my previous post. I am far from an ideologue on this because I know very little about it. I want what is best for the people in general, but I also want to preserve or even increase our quality of care in the process.

I think this is a discussion we need to have and we need to be open to all options. The facts show that our healthcare system is in dire need of an overhaul, and I want to make that a goal of mine before I leave office. Once I have more free time after this weekend when exams are over, I will do some research myself so I can better understand our options.

[Fmr. Pres. Duke]

How about we look at something like Singapore has? A system funded by a payroll tax, where the revenues are places into individual accounts that can be pooled and shared with families, and the government covers 80% of the costs of procedures performed in public hospitals? The remaining cost can be covered with these mandated health savings accounts where employers are mandated to pay into, much like a 401K. The government can also provide a disaster relief insurance plan where you can pay for its premiums using your savings account, if you chose to do so.

No healthcare procedure is "free" like it is under some countries, but adopting this type of system would ensure people don't overspend on health services, which cause the cost of something like this to go through the roof.

There is also an option for private insurance and private hospitals under this system for those who wish to purchase it, and employers can offer private insurance to their employees should they chose to do so. The government sets the prices and policies for these private insurers too.  

This idea appeals to me, but it is said that it could be difficult to replicate in other countries, so it may not work here.

[Fmr. Pres. Duke]

How about we look at something like Singapore has? A system funded by a payroll tax, where the revenues are places into individual accounts that can be pooled and shared with families, and the government covers 80% of the costs of procedures performed in public hospitals? The remaining cost can be covered with these mandated health savings accounts where employers are mandated to pay into, much like a 401K. The government can also provide a disaster relief insurance plan where you can pay for its premiums using your savings account, if you chose to do so.

No healthcare procedure is "free" like it is under some countries, but adopting this type of system would ensure people don't overspend on health services, which cause the cost of something like this to go through the roof.

There is also an option for private insurance and private hospitals under this system for those who wish to purchase it, and employers can offer private insurance to their employees should they chose to do so. The government sets the prices and policies for these private insurers too. 

This idea appeals to me, but it is said that it could be difficult to replicate in other countries, so it may not work here.

The poor and the unemployed just would not be able to pay that 20%.

Under the Singapore system, the poor have a windfall much like medicaid, so they would pay nothing. Whatever we do, I would never favor forcing the poor to pay for things they couldn't.

I think I explained the system better in my White House thread. These are just musings though. Tossing out ideas.

[Fmr. Pres. Duke]

I don't think we need a board determining anything. While I'm sure abuse will happen, as it always does when you're providing a public service, a board to determine whether you need something or not is unnecessary.

I'll wait to see what Yankee produces today before I comment further. I've been reading about Singapore extensively, but I plan to check out some other systems as well.

[Fmr. Pres. Duke]

The savings component in the Singapore model functions much like a 401K. Employees and employers make contributions to an individuals account, which they can draw on whenever they receive medical treatment. These accounts are all pooled and maintained by a government run entity, and they can be shared amongst extended family members if one account is not sufficient. These accounts are mandatory.

The government pays 80% of all medical costs for those who can afford to pay 20%, and if they cannot, then they are enrolled in a program much like Medicaid, where their healthcare is covered 100%. I don't know how to make it more "market based." But that is how it works in Singapore. 

[Fmr. Pres. Duke]

Healthcare is not, and never will be, like selling paperclips, the market is not particularly well equipped to supply it.

For one thing, insurance plans are very very complicated, by launching a brave new world where consumers (horrible word) choose their own care policy you'll leave behind the vulnerable, who'll be preyed upon by used car salesman who sell flashy but useless schemes. People don't want choice, they just want not to have to worry about paying for healthcare when they're suffering serious illnesses, and not be crippled with huge costs.

For another, a lot of healthcare is a natural monopoly- you'll only have one general practitioner in a remote town, you'll only have one A and E in a city, you'll only have one local oncology department. Most of the time choice is illusory.

The experience of almost all developed countries around the world is that the cheapest way to provide quality healthcare is not a pure market system, but comes through the economies of scale that one buyer provides.

Finally the idea of loosening regulations seems to me incredibly dangerous. I know enough about the NHS in both England and Scotland, and they are very different systems, to know that there is bureaucracy and waste. In Scotland, incidentally, the waste and bureaucracy is far less because there is almost no market in healthcare. No one is opposed to reducing that, but the idea of allowing vested interests to certify doctors is insane. I can guarantee that it would not be long before there was a scandal because an incompetent doctor ended up killing a patient due to lack of training.

My aim isn't really to loosen regulations. I think in some cases, especially in the healthcare market, we need regulations. But I also think we can and should have both a functioning public insurance market and private market for those who want to purchase private insurance.

In the Singapore model, the government heavily regulates the private insurance markets in so far as it sets both policies and prices they can charge. Of course, not everyone can purchase private insurance, but that's what the public system is for, everyone is enrolled in it automatically and everyone pays into the system so they can use it in the event they need it.

[Fmr. Pres. Duke]

I don't think anyone should advocate massive profits in the healthcare industry. There are some things that I believe should not be for profit, like education and healthcare.

But the system I am talking about is one that is heavily regulated where, yes, private insurance as a supplement exists, but the federal government will set the policies and the prices to ensure there is no price gauging or profiteering off the backs of sick people and the poor will not pay a thing to have access to healthcare.

Of course, taxing the rich is not the answer. Yes, they must pay more because I believe in a progressive tax, but I will never enact a tax that takes 90% of someone's income because they are rich despite knowing some in this senate would want that. Anyone who knows anything about laffer's curve knows that isn't good policy.

[Fmr. Pres. Duke]

I've been reading a book on the Singapore system and how it got started, and they did begin it using clinics. Through these clinics, they charged a small fee to whoever used it, and they noticed that if a patient was charged a fee, they were more likely to listen to their doctor instead of ignoring them because they had a vested, financial interest in the pills they were given. Thus, their society became healthier because they pushed personal responsibility when it came to their health, not putting it on the state.

I understand some here want a "single payer" that is entirely taxpayer funded and in return, everyone receives unlimited care, but that is not sustainable or financially feasible. We either make a massive tradeoff of quality or we rework this system so the poor have adequate care and those who can pay are asked to pay more for their healthcare.

Remember, single payer systems like the ones in Canada have a severe resource problem. I believe I read somewhere that the state of Rhode Island has more MRI machines than all of Canada. We don't want that in Atlasia. Imagine the troubles we'd develop with preventive care.

I am also reading about the French system, which is more single payer. I will share my thoughts on that once I know more.

[Fmr. Pres. Duke]

https://docs.google.com/document/d/1ZXjgQvLF91-ov0zqcC7X9uV9_s89gatl1N-ciSAyCWM/edit?usp=sharing

Starting to put pen to paper. Not sure where this is going but I think it's time we starting going somewhere with this. I will update this as the days go on.

[Fmr. Pres. Duke]

I'm going to do more work on this today, so I'll let you know as soon as I figure that part out.

[Fmr. Pres. Duke]

I have begun to include some of the limits on withdrawals for kinds of procedures now, but the bill is still far from finished. I'm about to get to the portion for the low income people.

[Fmr. Pres. Duke]

I'm not going to be able to do much on this until this weekend given my bar studies. If anyone else was to help work on this, feel free. I don't want to do this alone.

[Fmr. Pres. Duke]

Are the MediSave accounts supposed to be instead of the payroll tax?

How do we currently fund our healthcare system? Do we have a healthcare tax or is it funded by a payroll tax?

[Fmr. Pres. Duke]

Healthcare Payroll Tax and a tax on Health Insurance.

The former of which is the vast majority.  How does MediSave fit into this?  Having mandatory accounts on top the payroll tax just adds to the financial burden.

I don't have the exact rates or what type of taxes are taken out under this model yet, but I highly doubt it's more than what we are doing now given government funding in Singapore accounts for 3% of their GDP.

I don't have a lot of time to work on this alone right now with my bar preparations, so hopefully you and/or Yankee can help me, but if not, I will just let the next administration tackle this in a few weeks when they take office, whether it be this type of reform or all out single-payer like TNF wants.

I'm fine scrapping this plan if it won't work in a country the size of Atlasia and moving back to a more market based system with a competing public option, but I have no clue how to put that onto paper. My knowledge of healthcare law and how the system works in general is pretty low. I can't do this alone.

[Fmr. Pres. Duke]

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where y is the subsidy (measured in terms of full cost of public option coverage) and x is defined as household income (measured in terms of poverty line).

2. Funding for the subsidy shall be derived from the healthcare payroll tax set at 6.1% as amended by Residential Taxation Reform Act of 2014.

3. Limits and/or guidelines for premiums, co-pays, deductibles:

a. The total out of pocket payment for co-pays and deductibles for an individual and/or household for the whole year may not exceed beyond 5% of the total income of that individual and/or household.
b. This co-pay limit shall apply to all services mentioned in Part II, Section 2 of this Act.


Part II - Changes to ANHC

The New Atlasian Healthcare Act is to be amended and replaced with the following text:

Section 1: Eligibility and Benefits

1. All individuals residing in Atlasia are eligible to enroll in a plan offered by the Atlasian National Health Care Program (ANHC), which shall all entitle them to a high standard of care at a low cost.

2.The health care benefits offered by ANHC plans shall cover all medically necessary services, including at least the following:

1.Primary care and prevention.
2.Inpatient care.
3.Outpatient care.
4.Emergency care.
5.Prescription drugs.
6.Durable medical equipment.
7.Long-term care.
8.Palliative care.
9.Mental health services.
10.The full scope of dental services (other than cosmetic dentistry).
11.Substance abuse treatment services.
12.Chiropractic services.
13.Basic vision care and vision correction (other than laser vision correction for cosmetic purposes).
14.Hearing services, including coverage of hearing aids.
15.Podiatric care.
16.Contraceptive services
17.End of Life Care - Shall be limited in hospital settings up to the cost of such care when attained through a hospice setting.

3. Healthcare professionals shall be licensed according to the laws and policies of their respective regions.  Only licensed professionals shall be allowed to offer such services and only such licensed professionals will be eligible for reimbursement from the ANHC program.

Section 2: Finances

1. The levels of reimbursement to licensed professionals and medical facilities shall be determined by the CHPs, considering the cost of providing such care and ensuring the integrity and preservation of the providers.

2. The CHPs shall determine the level of premiums, co-pays and deductibles in accordance with the levels of reimbursement as established in the previous section of this act and any other limits as proscribed by law.

3. Licensed health care clinicians who perform a covered service under the ANHC, to any patient enrolled therein, may not bill the patient for the portion of the bill covered by the ANHC.

Section 3. Administration

1. The ANHC program shall be administered by the Health Directorate, made up by a Chairman and the Executives of the regional CHP boards.

2. The provision of healthcare and the administration of budgets and services shall be the responsibility of independent Community Health Partnerships (CHPs) congruent to the existing Regions, these shall be established as public sector corporations. Each CHP shall be headed by a board consisting of one Executive and further non-executive members.

3. CHP members shall be selected by the Health Directorate and shall be a non-partisan gathering of experts in the medical, pharmaceutical, and health insurance and administration industries.

4. All boards shall be required to have an audit committee consisting only of non-executive members on which the chair may not sit. This committee shall be entrusted with the supervision of financial audit and of systems of corporate governance within the CHP.

5. All members, directors and associated bodies shall be accountable to the Health Directorate as outlined in this section.

Part III: Coverage for Special Populations

Section 1: Coverage for Military and Veterans.

1. All active duty military personell shall be eligible for full coverage under ANHC, fully paid for by the Atlasian Department of Defense with no premiums, co-pays or deductibles.

2. All Veterans shall be eligible for full coverage under the ANHC, with no co-pays or deductibles, with subsidies for premiums as described in Part 1, Section 3 of this Act.  Cost normally associated with co-pays and deductibles shall be covered by the government through the Veterans Benefits Administration.
 
3. A “veteran” is defined for the purpose of this section as any person who served on active duty in the armed forces of Atlasia and received an honorable or general discharge.

Section 2: Pre-existing Conditions and High Risk Populations

1. A Comprehensive Insurance Equality Pool (CIEP) shall be established within the ANHC so that those with pre-existing conditions can receive affordable care without discrimination.  Those with pre-existing conditions or other factors such as age or gender which may increase risk to health or risk of health related cost shall be covered under ANHC at the same cost to the consumer as those without these conditions.

2. The CIEP shall be subsidized out of funds derived from the healthcare payroll tax to the extent necessary to achieve cost parity to the consumer.

3. The CIEP shall have open enrollment periods determined by the ANHC Health Directorate.  Those with changes in condition or subject to increased premium cost at their current insurance provider may enroll in the high risk pool program through special enrollment so long as they have maintained coverage through ANHC or another insurer prior to such change in condition.

4. A Risk Adjustment Program will be established to involve private providers with annual net income greater than $50 million. Plans with lower actuarial risk will make payments to plans with higher actuarial risk to adjust for variation in distribution of high risk patients. This program will be administered by the Health Resources & Services Administration.

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x Duke

I want to thank all of those who put in the time and work into making this bill a reality. The problems in our healthcare system were real, and something needed to be done. While this legislation may not be perfect in everyone's eyes, it is certain better than what we had, and puts us on solid foundation moving forward.