14. A threshold health care program should cover services/items only if they are medically necessary. For example, cosmetic surgery should not be covered unless it involves a major life-affecting issue. Procreation services should not be covered. A national health program should not extend to care for pets, but could cover the cost of pets for medical reasons (i.e., service pets).
15. We owe more service, including cosmetic surgery, to our wounded soldiers, regardless of how one feels about our wars.
16. People should not lose their insurance because they change or stop employment. Once insured, they should be able to continue to be insured at the same level continuously.
17. On the other hand, people should not be able to move from uninsured (or minimally insured) status to insured status whenever they wish. Allowing such a shift at any time encourages people to be uninsured until they need care. That’s why many countries require mandatory purchase of insurance.
18. It has been estimated that 30 percent to 50 percent of health care costs occur in the final six months of life in the United States, a rate that reportedly is very different from countries with nationalized health care. We must accept either these higher costs or changes that would reduce them. People should not be forced to accept undesired health care.
19. “Death with Dignity” could reduce health care costs noticeably, while protecting individual rights. Fear of losing control over their lives has led many seniors to commit suicide while in good health. If they knew they could control their destiny after their health’s deterioration, they would not feel compelled to commit suicide while healthy.
20. Unfortunately, strong controls on fraud are necessary in our society.
21. We need accountability, but must limit the impact of lawsuits. Fear of liability encourages unnecessary treatments and tests, and lawsuits cause liability insurance premiums to soar, fueling costs. Winning a liability lawsuit should not be the equivalent of a lottery jackpot. Rather, punitive damages against health providers should be used to offset the cost of health care. Plaintiffs should be responsible for the cost of lawsuits they lose, at least if the judges or juries determine that the lawsuits were frivolous.
22. We might choose to limit public health care services. Will we separate all Siamese twins? Will we give everybody organ transplants? If we limit publicly-funded care, people should be allowed to purchase such care privately. The private market might lead to improvements in care and cost reductions that permit expansion of the public care system. As noted earlier, a private-pay alternative might dilute support for a higher public threshold.
23. Health care innovation does a lot of good, but costs a lot of money. If we want continued innovations, we must encourage them. Patent laws are necessary to reward investment in research and absorption of related risk. We should measure such innovations here in the United States and elsewhere so we can track the impact of our programs.
24. Immigration policy might be significant in controlling costs. Immigrants can be a source of low-cost care providers. On the other hand, free or inexpensive high-quality health care can encourage illegal immigration. Limiting emergency health care for illegal aliens is difficult to enforce because of uncertainty as to status and fundamental beliefs that we should not stand by and watch people die if we can help them.
25. We should control the risk that insurers profit by declining justified claims. One approach, the independent review process that facilitates appeals, seems to work well, but should be monitored to ensure that it satisfies the need without increasing cost inordinately. Other possibilities would be to separate the insurer from the claims adjudication process or to publicize claims-denial rates.
26. Some issues should be controlled outside of the health care system. For example:
• If we don’t protect our environment, we’ll suffer health losses. It is my impression that a lot more young children are contracting leukemia and perhaps other conditions, which may be environment-related. Birth weights are lower in smoggy areas.
• Improving our educational system is critical. Better-educated people seem to incur lower health care costs on an annual basis (even if higher health care costs over the course of their lives because they live longer). They are more knowledgeable and can afford better diet, care, etc. A better education system would also develop more health care professionals, which would improve service and reduce cost.
It is not surprising that health care is an increasingly heated topic. Improved technology and greater longevity have combined to fuel tremendous increases in health care costs. Considering where we were in the 19th century, we are lucky to be able to have the debate we are having today. But we can reach successful resolutions if we establish fundamental principles and discipline ourselves to listen to each other and to question ourselves— as well as those we disagree with.