Drop Medicare, Medicaid and costly insurance

Medical insurance for every American is a laudable goal. Politicians at every level are lined up in support of it. But an equitable system of providing such coverage is not possible in our confused political climate.

San Francisco is poised to offer health care coverage to 82,000 residents, but the plan only fiddles around the edges of a failing system. What we need is a federally funded, comprehensive program of vouchers that provides basic health coverage for everyone.

Ideally, every person in America would have personal health care coverage from childhood, through school and a career, and into retirement. Coverage would no longer depend on employment or pre-existing conditions. Basic health care would be free, and additions to standard coverage would be available for a price.

This would mean the end of the Medicare and Medicaid bureaucracies, the dissolution of worker's compensation insurance, and, most significantly, a dismantling of the system of employer-based health insurance.

It's going to be expensive to provide basic health care to everyone, but it makes sense, not just as a matter of social justice but because we can prevent more-expensive care later.

You can hear the cries now: Seniors giving up Medicare? Workers giving up health benefits? No way!

Perhaps only the poor would welcome such a comprehensive overhaul. Health industry lobbyists would crowd onto the podium to denounce changes in health care financing. The AARP would howl in concert with labor. Government agencies would be threatened. Politics would doom reform at its core.

But one litmus test for fairness and integrity is whether every constituency is willing to compromise, even when the first reaction is to resist change. Reform will happen only when it is orchestrated across every sector simultaneously, fitting together at one time the pieces of the health care puzzle.

Until now, we have tried to fix the system one piece at a time. Insurance reform, improvement in the quality of medicine, patient privacy protection: All these measures were intended to help. But a pyramid isn't built one wall at a time. Disjointed efforts collapse.

The actors in the American health care drama -- medical providers, the health insurance industry, government and patients -- must change their roles simultaneously.

Patients must change their expectations of what medicine can do and assume more responsibility for their own health. Unlike the medical miracles routinely portrayed on television, science can't restore everyone to robust health. Despite medicine's wonderful, life-enhancing techniques, everyone will eventually succumb to disease -- if they don't die from accident or trauma first.

Patients also need to recognize that the young and healthy cannot opt out, shifting a disproportionate share of costs to the sick and elderly.

Doctors, hospitals and pharmaceutical companies would have to give up their distorted system of payments in which economic incentives reward those who do the most testing, prescribe the most drugs and overtreat patients who are in fee-for-service plans now. HMOs, where the incentives are reversed, must also change. Now HMO providers try to retain the largest amount of their premiums, at least in the short term.

Instead, doctors would be offered incentives (including monetary ones) designed to promote the best patient experience.

Managing this system would require accurate and reliable data to coordinate care and assess outcomes and patient satisfaction.

Patients would control more of their health care expenditures, so patient satisfaction would play an increasing role in influencing physician behavior.

But nothing of this scale can take place without government playing a role.

Government should set a basic health care benefit required in every private health plan. It should also compel the health insurance industry to be accountable and reliable.

And government must finance the system, partly from billions of dollars saved from eliminating a multitude of overlapping government programs and bureaucracies. It could also tap tax revenues from the elimination of employer-provided health insurance.

Using refundable tax credits, government handouts, vouchers -- or something completely different -- we could go a long way toward paying the cost of a basic health care benefit for every one of us. But let's be honest: There would probably need to be some increase in taxes.

In exchange for their survival, insurance companies would have to make some serious changes. Most importantly, they would have to return to their basic purpose -- distributing and managing financial risk, not managing patient care in order to promote profit.

They would be required to provide a basic health care policy, which would be mandatory for every American. Every health plan would be free to offer upgrades beyond the government-paid basic plan. No health plan would be allowed to reject an applicant or reprice a health policy based on pre-existing illness.

Open to all and competing on features, reliability and upgrades -- these would be the hallmarks of the new private health insurance industry.

So where is the conductor in this medical symphony? Where is the energy that can make all the forces move at once? That's up to all of us.

Once it gets started, the effort will snowball. All the other issues -- malpractice liability reform, funding for medical research, education -- will be swept up in the movement. Change will happen; it just needs to find the energy to begin. Let's hope it doesn't come from the dead-cat bounce that will occur when the current system fails.

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William S. Andereck

Dr. William S. Andereck is co-director of the Program in Medicine and Human Values at California Pacific Medical Center in San Francisco. He has practiced internal medicine since 1979 and is a member of the Board of Trustees of the California Medical Association and the Emeritus Board of the San Francisco Zoo. Contact us at insight@sfchronicle.com.

©2006 San Francisco Chronicle