Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning. Winston Churchill, November 1942
When it comes to universal health insurance, we'll have to push the Churchill quote back even further. Senator Ron Wyden (D-Oregon) has proposed a new bill that at least brings us to the beginning of the beginning. The bill, entitled "The Healthy Americans Act," guarantees universal, private health insurance for all Americans. (For an introduction to the issue and some useful links, see Managed Care Matters here.) Under the Wyden bill, every family, indeed, every individual, will be assured coverage by any insurer they choose. Limits on coverage for pre-existing conditions will be prohibited. Insurers cannot reject anyone, regardless of their health or genetic dispositions. The Wyden bill will end our employer-based system, replacing it with a completely portable plan that is controlled by the individual. Employers will contribute financially to the plans, but selection will have nothing whatsoever to do with one's employment.
Universal health insurance is an issue of mind-boggling dimensions. We are not going to attempt a comprehensive discussion in one quick blog - especially on a Friday! It's fair to note that any proposed expansion of coverage, any dramatic adjustments to the current (dysfunctional) system, will have to confront a number of conundrums. Here are just a few:
Health Care Rationing: every plan has coverage limits. It's one thing to guarantee coverage to all citizens, it's quite another to figure out what is included in the coverage: Exotic treatment for serious illnesses? Number of chiropractic and physical therapy visits? At home kidney dialysis? Brand name medications?
The dilemma of personal responsibility: how will coverage deal with obesity? Addiction? Unsafe behaviors? (It's one thing to incentivize good behavior. Will insurers try to stigmatize risky behaviors?)
Catastrophic Illness and "End of Life" issues: who makes the decisions? who pays the bills?
The Comp Difference
If you glance through some of the initial reactions to the Wyden bill at Ezra Klein's blog, you'll see that workers comp is marginal to the discussion. Beyond that, it's misunderstood. Comp is and probably always will be different from conventional health care. So no matter how the dialogue on universal health care proceeds, the Insider will try to keep a steady focus on the implications for the workers comp system.
Here are some of the comp issues that impact the implementation of universal health care:
Comp is a state by state program, so any federally mandated health care mandates will rub up against a wide variety of state practices.
Comp premiums are experience based, so employers always have a financial stake in the outcome of a workers comp claim. (Unless they self insure for health insurance, employers generally have no direct financial stake in the outcome of non-work related medical issues.)
In most states. employers can require injured employees to seek treatment at specific occupational medical practices. This may run against the open choices of the Wyden plan.
Workers unable to work collect indemnity, usually about 2/3 of their average weekly wage. So it really matters whether a condition is work related or not.
The goal in workers comp is always the quickest possible return to productive employment. The goal in regular health insurance is a return to optimum health. The two goals are similar, but not necessarily synonomous. There are times when they are incompatible: for example, returning to a job that is inherently unhealthy.
Workers comp never requires co-pays or deductibles from the injured worker. No matter what shape the new universal health coverage takes, there will be significant charges - and incentives for cost savings - for the consumer.
Workers comp will always offer better benefits to injured workers than they can receive under conventional health insurance. Employers will always have to pay for it, with their costs running parallel to their losses. In exchange for providing the (state mandated) coverage under comp, employers will want to maintain at least some management control over the course of treatment for workplace injuries.
While it's far too soon to worry about the impact of universal health insurance on workers comp, it's certainly not too soon to speculate.This is not the end of the discussion, or even the middle. We're at the beginning of the beginning, which is a very interesting place to be.