Much is currently being written about how President Obama should re-shape the American Healthcare system. Most commentators agree that the current arrangement for healthcare in this country is too expensive, highly inefficient and provides unequal levels of care, including minimal care for the 47 million uninsured Americans.
As a physician with a longstanding interest in how health services are organized, and who has lived and worked in the USA, Australia and Britain, as well as consulted to many other countries, I have strongly held views on the types of directions America should take. And at one level they are remarkably simple, and can be summarized in three suggestions.
1. A public-private partnership philosophy has to be central to the whole re-engineering of the health system. America is founded on capitalist principals, where the profit motive is central, and any new approach to healthcare must combine this with the need to develop core public services that may be less likely to ever achieve a profit. There must be the potential for cross investment in all directions - and with funding for care provided on the basis of annual or episodic whole of person care provided, rather than on individual piece rates as at present.
Numerous studies have shown that if health systems can be given the incentive to provide quality care efficiently over defined time periods, and Kaiser Permanente is an excellent example, that they can do this. The primary importance of this approach is that it will force more resources into prevention of illness - to wellness promotion - rather than into the treatment of illness that has already commenced. Of course in such an environment anyone, no matter what their insurance, should be able to receive emergency care in any hospital at any time - public or private. The whole system must be developed with interoperable health information technology systems, including patient accessible electronic medical records and the provision of a unique health identifier for everyone. This approach will greatly improve the delivery of healthcare, and the security and privacy of health information.
2. The public component of the healthcare system would include universal basic health insurance (including catastrophic care insurance) and many emergency and isolated health services, as well as much more public health focus on prevention and health promotion. Public programs should also pick up much of pre/post natal and early child care (by far the most important care in the whole health system) to ensure all mothers and babies are properly looked after, and probably care of some special populations who cannot afford private health insurance such as the unemployed, some seniors and certain impoverished or geographically isolated groups.
3. The private component would be funded with the aid of tax incentives to encourage most people (or companies) to take out private insurance with aim that at least 80-90% of the population should have private insurance. It is crucial to reach this level of insurance to be confident that patients have "skin in the game" and are financially responsible for at least a good proportion of their healthcare costs, and do not see healthcare as something that is provided by the government for free.
The private sector should offer a full range of services from birth to death - with the ability to charge extra for certain "non-essential" services such as cosmetic surgery and other niche areas - but with regulation to prevent people being excluded on grounds of pre-existing conditions. A voucher system for certain groups, such as the chronically disabled, funded by government payments would allow all to access the private healthcare system depending on need. The insurance process for this private component needs a complete overhaul to reduce administrative overheads and simplify the payment process - my view of the simplest way of doing this would be to limit the number of private insurance companies and make sure that they are financially viable and large enough to offer reasonable regulated levels of healthcare services to their members.
These 3 steps to providing better care, and fairer access to care, for all Americans are taken from what I consider to be the best parts of the American, British and Australian health systems. No country has a perfect health system, and all are dependent on the core cultural philosophies held by the individual nation. America is the Land of the Free and can afford to choose the best of what other countries have attempted as it debates how to improve its healthcare system, and ultimately the strength and fortitude of its people.
New American Healthcare System Security