I originally wrote this piece in 2011, sitting on the porch of our place at Calistoga Ranch in California’s wine country. What is striking today is that I still believe we can create this care system using the parts we have today.
In my last book, The History and Evolution of Healthcare in America: The untold backstory of where we’ve been, where we are, and why healthcare needs more reform, I took the reader on a journey of how we got to where we are today in America’s healthcare system. I showed the critical decisions we have made throughout our history as a nation and illustrate both the needs at the time they were made and why they often are providing a negative impact on our system today. I discuss the Affordable Care Act, what it attempted to do, where it succeeded and where it has fallen short. In the Epilog I try to paint a picture, a vignette of the healthcare future, a dream if you will, a small look at what kind of system we might consider and how it could work in my own son’s life in the not so distant future. The following is a revised version of the Imagine section of the Epilog. I added a bit more detail that was edited from the book to keep the length down. I hope it will give us all something to wish for and outline some of the items we should consider required in any system we dream for.
Imagine . . .
The long road seems endless as you and your wife make the torturous drive from Dulles Airport in Virginia to St. Mary’s County. At 4:30 this morning, you’d left your apartment in San Francisco for the last time. The five-hour flight was uneventful, but traveling with your new wife next to you was a wonderfully fresh experience. The middle seat was free, so the two of you were able to spend the flight snuggling. Only a week since your wedding, you truly are on a great new adventure together. Not just the adventure of life with which all marriages begin, you both are moving all the way across the country to start your new life together in a new place.
It all seems to be happening so fast. Just three years ago, you had met Elizabeth Manning at Santa Clara University during your senior year. You simply could not believe she agreed to go out with you after you told her that stupid opening line when she introduced herself. You still remember saying, “Wow, your name is Elizabeth Manning? My great, great, great, great grandmother’s name was Elizabeth Manning!” You also still recall how utterly lame you felt when she said, “You think I look like someone’s grandmother?” And, you also remember actually looking at her tall, slender, very attractive frame and thinking first, “Hell no, she doesn’t,” and then “Man, what an idiot I am!!!”
But then, Beth laughed at your flustered awkwardness, and since that first moment, it had just gotten better and better. She was interested in who you were as a person. She wanted to know everything about you, your family, your doctorate in paleontology, and how you could ever know about such a distant ancestor as the original Elizabeth Manning. At first, it seemed as if you were in an interview that never ended.
The first year with Beth was the best of your life, and the second was even better. You remember the first day that you took off your shirt and let her see the zippered scar down the middle of your chest. You worried that she might dump you, judge you to be defective because of your history of open-heart surgery as a kid. But she was right there with you, never wavering and always supportive. And, now, as you are making this long two-and-a-half-hour drive to your new job and new home, you still can’t believe she is now Mrs. Aleck Ford Loker.
When you told her you’d landed an interview for an assistant professor position at St. Mary’s College, you wondered how she would react. But, her interest in history and the fact that your family history is tied to this place so tightly have left you both feeling as if it is fate drawing you here. Beth found a job with the St. Mary’s City Historical Society, and despite the long drive from the airport, you both really feel like you are coming home.
Your heart problem has haunted you most of your life. Even though you haven’t had any symptoms for years, there is always the worry—what if? And, then there was the perennial concern over whether you’d be able to get affordable health insurance when changing jobs. That part is so much easier now that the law has changed, and you can take your health insurance with you.
When you turned twenty-five and got your first job, you logged onto the National Health Marketplace (NHM) and signed for your basic health insurance from Blue Cross of Pennsylvania, even though you lived in California at the time. The NHM listed base policies from insurers across the country were all at the same basic competitive price, with the same basic LifeCare coverage. You were able to pick any policy you wanted and chose according to the pricing and features of Pennsylvania Blue Cross’s enhanced services options. Your first employer offered you a tax-free benefit bonus of $500 per month to help pay the premiums. You weren’t obligated to buy insurance at all, but federal law made it a desirable option. That $500 monthly bonus would be taxed at 80 percent unless you spent it on an NHM-approved health plan or put it in an approved Health Savings Account (HSA). It made no sense to do anything else with that money. And since you purchased the policy when you entered the workplace, you locked in the lowest premium cost and deductible for life. Since the premium and other costs go up for every year that you do not purchase the policy after twenty-seven, the first year you were not covered under your parent’s policy, who in their right mind would not have bought a basic plan. If you waited till you were thirty-five, the basic plan costs would have doubled. It was, as your dad would have said, a “no-brainer.”
Beth’s policy was with Anthem of California. Still, when you reached the annual open enrollment, she changed to your plan and kept the same rate, and since all the base policies were the same coverage, her new policy was the same price. Now that you are married, you also receive the marriage discount, and you can afford the enhanced maternity option at the same price as you paid for the two individual base plans.
Everyone enrolled in the NHM base plans is a member of that insurance company’s base policy in one giant coast-to-coast insurance pool. The risk for all basic coverage is absolutely shared equally. Now that you are making better money in your new job, you will be able to purchase some additional optional enhancements. Since it is all nationally available, you can shop on the NHM for just the combination of services and price you want. With your medical history and the easily affordable options now available, it makes no sense for you not to have insurance. While a few years ago, figuring out and purchasing insurance was just overwhelming, now it is straightforward. Since all base plans from every insurance company are the same everywhere in the U.S., and the plans all require just one simple, standard, online enrollment form, everyone has insurance. You can simply select which company you want based on the attractiveness of their options, their reputation, and their service offerings. And as long as you keep paying the premium, the policy follows you for life no matter where you go, no matter who you work for. No one you know goes without insurance nowadays.
This is so much better than the old system. With your heart worries, you have always wanted a bit more hand-holding from the doctor, and in this structure, you can purchase just the level of additional service you want. When you got your first policy a couple of years ago, you bought the basic policy like most young people right out of college. While broad in scope, the provided services were all at the minimum level, but you had the necessary protection if something unexpected happened. After all, you have a few friends who have had serious accidents. The thought of crashing on your bike, or while skiing, and being left a quadriplegic—well, who in their right mind would take this risk anymore? Now you are incentivized to buy insurance, not take foolish risks. If you purchased when you entered the workforce, your cost was locked in as long as you maintain your coverage. It was also good that the rules allowed for cessation of coverage due to hardship and even federal payment of the insurance premium if you became unable to pay for reasons beyond your own control. Every year you pay for insurance, you receive more time for a grace period if you suffer a financial disaster. And even if you suffered an early financial crisis, the government Medicaid program would pick up the premium cost as long as you were eligible. They now really can support the helpless while limiting the clueless and the fraudsters.
At first, the idea of two distinct categories of care was off-putting. LifeCare (basic survival care), on the one side, was effortless basic coverage that was now available to everyone on a national basis, and it offered no frills. When it first was proposed, people complained about the idea that if you have prostate cancer or breast cancer, it only covered the elimination of cancer and not remediation of the non-life-threatening effects like incontinence and erectile dysfunction in men, and cosmetic remediation in women; but once people understood how it worked with the other system—Quality of Life Care—and the ability for people to afford more coverage based on their own efforts and personal choices; soon people accepted this approach as not only fair by offering good coverage to everyone in a fair system but also much better as it allowed for the tangible benefit for hard work and good life choices. The Life Care system is coupled with the Quality of Life Care system where people who worked hard and saved could purchase the additions to the basic care insurance in a flexible and cost-competitive system. In the Quality of Life Care system, people could either purchase the additional care directly at the time of service, buy enhancements from insurers on top of their basic policies or take advantage of other private annuity policies to augment their LifeCare policy. And all these payments could be made from their Health Savings Account tax-free.
The Health Savings Account now provides a great way for people to save for the extra coverage they want in their life and the kind of quality of life treatments they may want when they pass into retirement where the basic insurance coverage options begin to restrict care due to cost. With the new HSAs, you can save each year a significant amount tax-free that can be paid for any health and wellness-related services. And since there is no cap on how much you can save in your lifetime, you can put up to $4,000 in the account each year, and that amount will rise indexed at one-half of the amount of annual healthcare expense. So each year, in effect, you can save one-half of the average annual health care cost for an America in this account tax-free. And you can continue to accumulate funds in this account with no cap until you reach either retirement or the average American Life span age (currently 81).
Once again, the system balances need and personal responsibility, with a great incentive to be responsible while removing the financial burden from the rest of America to disproportionally cover all the increased cost people used to demand quality of life care in their last five years or so. Now they get basic life care, and if they want treatments that will give them a few more years of good quality life, they can pay for it through their HSAs.
Even the basic plan protects you and your new wife from what could be financial ruin. The base plans covered all the basic life care you need cost-effectively, sure it doesn’t cover all the quality of life things you may desire, but at least everyone is covered for the things they need to survive a catastrophic illness or injury. The additional options just bring added choice. And the ability to put away a good chunk of money in the tax-free HSAs allows you to save a nest egg for all the quality of life care you may want later in life for the extra procedures not covered under the basic LifeCare policies available cheaply to all. Best of all, St. Marys’ is offering you $600 per month as a benefit bonus, in addition to your higher salary.
Now, you are in a position to get just the combination of additional Quality of Life services you and Beth want along with the basic items you need. You know Beth is a very private person, and she will prefer the comfort of the “extended consultation time” option. You also want extended testing and prevention options. Each company has so many optional choices, and you can add them as you go, with only a few exceptions. When you have both the mandated basic LifeCare coverage for everybody and the ability to choose those Quality of Life services you prefer based on what you are willing and able to afford from every insurance vendor in the country, you can’t blame anyone but yourself in the long run if you don’t like what you get.
When you have little, the base policy sees that you are cared for, perhaps with few frills, but you don’t have to worry. If you want the frills, you can go out and earn and buy them. How did people deal with these issues years ago, when the employer provided you with whatever they wanted to? You remember your dad telling you that you would have been in a high-risk pool if you lost coverage and had to purchase insurance. The premiums, despite the government subsidy, were still higher than you could have afforded. However, the years of work by the National Healthcare Supply Chain Task Force (NHCSCTF) finally paid off in the end. Now you, and everyone else, can get both what you need and, optionally, what you want.
As you enter St. Mary’s County for the first time, you both have this eerie sense that you have been here before many times. You remember your dad’s stories about “the county,” and as you drive down the old “Three Notch Road” towards St. Mary’s City, you recognize many of the landmarks he used to speak about. Beth is so excited that you will be staying at Bard’s Fields Bed and Breakfast in St. Michael’s. Ever the history student, she went online to look up everything available about the original Thomas Loker and his wife, Elizabeth Manning. The state historical society has recognized Bard’s Fields as one of the oldest private residences in Maryland.
As you pull into the long, oyster-shell driveway and first see the farm at the back of the property and hear the tires crunch on the shells, you feel as if you have a bit of vertigo. It seems for a second that you are displaced in time. For an instant, you imagine that you see mules pulling plows in the field, driven by the “original teamsters,” workers chopping the weeds out of the rows of tobacco, and a tall woman in a dark, long, broadcloth dress, with a bluebonnet, tending to a garden on the side of the house.
The B&B proprietors are happy to see you and eagerly take you on a tour of the home. They know your family history and add to the already exhaustive knowledge that your wife has accumulated from your dad and the internet. As you both retire for the evening, you feel as if you are at home.
After breakfast, the next morning, you arrive for your first day of work at St. Mary’s College. Your new office is in Kent Hall, the same building where your dad worked years ago. After settling in, you go to the bookstore. There you gaze upward at the ceiling rafters that your dad and Bobby Abell installed so many years ago. You realize that your ancestors were all here, on this very ground, and you know this is your destiny. This is where you and Beth were meant to come to raise your family. When your dad left to find his fortune, he was the last male Loker in the county. While there are many cousins over the past fifty years, there are now few Loker surnames left. Yours is the first to reappear in many years. You don’t know it yet, but you will be the start of a new generation of St. Mary’s County Lokers . . .
“Aleck, it’s time to go!” Beth is shaking you awake. “Aleck . . . Aleck, get your ass out of bed! We need to go, or this baby is going to be born right here in the bedroom!”
Quickly, you are up and moving. “OK, baby, let’s get in the car and get going,” you say.
“Don’t tell me, mister!” Beth replies. “I was ready before you got out of the damn bed!”
Your first child enters the world at St. Mary’s Hospital at nine pounds and six ounces, roaring like a lion for all to hear. She is named Teresa Elizabeth Loker, after your mother and your wife.
Her birth is picture-perfect. You and Beth could choose the doctor, the anesthesiologist, and the pediatrician you wanted because all doctors in the county accept any of the basic NHM plans, and almost all would take the extra coverage from your optional enhancements. In the end, you and Beth were able to choose options providing your choice of midwife delivery teams and extended consultations with a pediatric nutritionist. Surprisingly Beth decided against the private room since she didn’t want to put your hard-earned dollars into “such a frivolous want,” as she put it in her succinct and direct manner. Most importantly, you got just the delivery team you wanted. Further, they were able to coordinate the care your family receives because you could link them together in your Virtual Care Team available through the NHM. Not only can they easily communicate with you and Beth, but they can also communicate with one another just as easily.
At the last minute, as you grew more anxious about the delivery, both you and Beth decided you wanted a doctor to be present at the birth, even though the plan called for a nurse-midwife as most people have nowadays. Since Beth really wanted that extra personal attention, she could use the online tools to research each of the providers in the area. She also interviewed most of them online and, in the end, settled on Dr. Jarboe as the one she felt most comfortable with. And, since he has been a pediatrician for a long time, you both knew he could deliver—pun intended!
However, your optional enhancements did not cover Dr. Jarboe’s fees, so you paid his invoice price through hospital billing. Either way, the cost was the same; you did not worry that the fee was fair because you could check online and compare his fees, education, and efficacy against any other doctor in the area. It was the same with all the people in the room. The pricing was easily available, and it was exactly the same whether or not it was paid to the hospital or the doctor. You could be sure the price you paid was within 10 percent of what the insurance company would pay to the doctor or the hospital—now that there was fair and transparent pricing due to the new healthcare supply chain system.
The supply chain system allowed each provider to set its own price for services and required publication of those prices on the NHM. As a result, now the published pricing had become a fair and accurate representation of what everyone in the supply chain was paid. Also, since they rationalized the scope of services offered by all the professionals in the supply chain, it became legal for lower-paid nurses and pharmacists to provide more of the simple and routine healthcare services that don’t require a doctor’s attention. It also opened up much more access for care because some of these providers, like pharmacists, are always available and do not require appointments.
A few years ago, it was hard to get a simple check-up. It could take weeks to get an appointment. For some, getting an appointment was almost impossible because many doctors were unwilling to accept the available reimbursements from insurers. Your congenital heart condition meant that you had to drive two to three hours to Washington, DC, or Baltimore even when you could get an appointment. In those days, specialists were all part of a hospital or large group. They simply could not get paid enough from reimbursement, so they would not practice in rural areas where people traditionally were earning less money. Also, they could not afford the liability insurance individually.
If specialty docs did not have a hospital or some other big entity backing them, they could not afford to practice. Now the doctors are free to see the patients who need the higher level of care they are trained for. Tort reforms have lowered insurance costs, so now doctors can seek smaller practice options. And, most importantly, they all can earn both the basic plan coverage flat service rates and they get a market rate for the optional coverage services. Now, there is more easy access to care for the small, simple issues from the other licensed providers. Also, there is greater availability of doctors—for the more complicated and serious issues—since they are not tied up with the small stuff.
Last year when you cut your hand on the old steel fence in the backyard, you were able to get the wound cleaned, disinfected, and stitched up by a nurse practitioner at the local pharmacy. You left the pharmacy with a “theranostic kit” in your bandaged hand. All this was provided quickly, inexpensively, and without an appointment, and all under your basic coverage plan for $45. Of course, you could have gone to a doctor, but you would have had to pay for the extra charges—as high as $450—yourself. Or, you could have purchased an enhanced option in your insurance plan to help cover the extra cost of seeing a doctor for this kind of service. According to the theranostic kit instructions, you took the antibiotic pills for three days. You took the automated test, which came up negative for infection, and then you finished the remaining pills as instructed. This is so much cheaper than going to the emergency room and then following up with a doctor, the way they used to do these things. Of course, if the test had reported infection, you would have gone back to the pharmacist, who would have given you an alternate kit.
And, while Beth was pregnant with your new daughter, she only saw the doctor a couple of times during the entire pregnancy to review some tests. The rest of the time, she went to the local community clinic and saw a nurse who performed all the routine exams, injections, and blood tests. You were never worried because you knew the nurse at the clinic was in direct contact with the doctor and all the other members of your team through your Virtual Care Group. You could see all their reports and communications, and you knew they were all well informed and fully coordinated on any issues that arose. They could not have been better coordinated if they had all worked in the same office.
The AMA had squealed when this new system began, but, in the end, most doctors got on board. They realized, soon enough, that their time would be worth so much more once they stopped basing their business on the low-cost routine tests. Once they began seeing sicker and higher-risk patients, their reimbursements per patient grew much higher. Before the change, many doctors were quitting practice or struggling to make money because they could not predict their income and expenses from one month to the next. Today, they have predictable businesses, and they can actually set their price accordingly to what people are willing to pay for their services. They are no longer held hostage to the biggest discount that the cheapest doctor will take. Service is better and more people are getting care.
As you leave the hospital to take your new daughter home, you and Beth are filled with the anticipation of what this new life will bring for your daughter, Teresa, and where your lives together will go. Everything at the hospital went smoothly, and, unlike your ancestors, fear and worry about how you would pay for the birth are not there. You know, they are covered because of the simplicity of the system and the choices you have made. And, you know that the funds are there in the system for you and your family because everyone else has the same access and the same requirement to make good and fair choices. You and Beth arrive at your home with your new daughter fully prepared to enter the parenting phase of your lives.
Years pass. It is a Saturday, and you’re having lunch with Beth and the children. Teresa, now 9, has darted away from the table to return to her art project in the rec room. Little Aleck, 5, is still propped in his chair, pawing at his sandwich. Baby Rebecca is cuddled in Beth’s arms.
The phone rings and, before you know it, you answer the way your father taught you 35 years ago: “Hello, Loker residence—Aleck speaking.” Old habits die hard; you tell yourself as you listen to the voice on the other end of the line. It is Jimmy Pratt, the current resident of Bard’s Fields, the Loker family’s ancestral home.
“I wanted you to know that my job’s taking me outside the county, and I’m looking to sell the house,” Jimmy says. “My dad always told me that once he was gone, if none of us wanted the house, we should give you a call before putting it on the market. He always felt that you and your family belonged here and that your kids should grow up here. He liked the idea of returning the property to the family that first found it.”
You are speechless—your mind reels with memories of Bard’s Fields. For a moment, you can’t feel your legs. You cup one hand over the telephone. “Hey Beth, I got something we need to talk about!!!”