Mitt Romney was a Republican governor of Massachusetts with a legislature composed of 85% Democrats. He boasts that they passed a bipartisan health care reform by a vote of 198-2 in his state while he was Governor.

He recently gave a speech to the Florida Medical Association where he outlined what happened in Massachusetts and how he would apply the same thinking that led them there to the whole country if he is elected president.

He is opposed to a single payer system for the whole country, unless you are elderly or poor that is. He is not against medicare and says that 11 million of our 45 million uninsured people are medicaid eligible. They just need to be signed up.

There are 4 outcomes he wants to achieve - 1. Keep costs down 2. Get everyone insured privately except for medicare 3. Protect people from loss of insurance (and hopefully uninsurability) 4. Reduce the rate of growth in health care spending (from 11% of GDP 1980s to 17% in 2000s)

His plan to do this has these parts:

1. Federal incentives to deregulate and reform State insurance markets. - There are big disparities from state to state in the cost of premiums. Using the standard of someone 37 y/o and single in good health the premiums vary widely. In California the premium would be $1880 but in New Jersey $6000. Romney says the Federal Government has a role in getting this straightened out.

2. Redirect Federal funds (medicaid money) to help poor purchase health insurance and end free care by requiring everyone to be insured. In Massachusetts a single person earning $9800 per year would receive 100% premium assistance or close to it. Above that income level there would be a sliding scale of premium coverage and deductible amounts. Romney would like to see the insured bear a fixed percentage of all amounts of health care expenses. He wants to end any form of “free care”. He quotes an anonymous person that was questioned in a poll for Massachusetts residents as to why he had no health insurance (this person presumably could afford “something”). The reply quoted by Romney was, “Why should I when I can go to the emergency room and get it for free.” I don’t know how things work in all ER’s everywhere but where I have worked in North Carolina we we required by regulation to see all people seeking care. We were not required to treat all people seeking care. Each person was triaged as per usual protocol and seen in their turn according to the acuity assigned to their condition. That is to say if you came to the ER insured or uninsured and had chest pain that could be cardiac in origin, you went to the head of the line along with major trauma, pregnancy complications and any one of a dozen other serious conditions that could threaten life or limb. Some of the uninsured patients had waited at home a long time with serious conditions that needed treatment long before they arrived. They did receive care immediately. Whether it was free or not I don’t know. Those others with less acuity were screened meaning an ER provider (M.D., P.A., F.N.P.) took a history and a physical was done. If their problem was not emergent, that is, not going to hurt them if not treated another day or two, they were discharged and assigned to a medical staff member who would see them once as a follow-up to the ER visit in their office the next week. If a provider needed to do a test like a urinalysis or a rapid strep or monospot test, they could do it. If medication was needed, we gave a prescription for a generic drug as often as possible. If it was after pharmacy hours doses were dispensed until the pharmacy opened. Many people near one rural hospital used a pharmacy that accepted medicaid but was closed on weekends. We could only give medication until a chain pharmacy would be open the next day even though they could not use medicaid at another pharmacy that month. (They have to fill all prescriptions at the same pharmacy all month but can change pharmacies at the beginning of each new month in North Carolina) They used this other pharmacy because it delivered and this was a rural area, many people did not have cars and there was no public transportation. As for “free”, a single mom with three kids, one of whom has an earache and a low fever might have to sit for 2-3 hours on one rural ER where I worked and in some ER’s in cities nearby that wait might be 5-6 hours. Though there might not be any initial out-of-pocket expense, that is quite a price to pay in time and inconvenience.

3. Institute enhancements to HSAs. Health Savings Accounts are like flex spending accounts except they are for the self-employed. At least they were when I checked on them. The owner of the HSA buys a large deductible catastrophic insurance policy. They are then able to save pretax dollars in the health savings account and spend them on deductible expenses, medication and other medical expenses not covered by the insurance policy. The deductibles for these policies are high, in the $2500 range plus. I don’t know how he is going to enhance them but he did mention some applicable things in #5 below that deal with deductible premiums and medical expenses.

4. Promote innovation in medicaid. Romney says we are doing a good job with welfare. I thought Medicaid was part of welfare so I guess I need to understand more about it. Anyway, he says the feds “block grant” welfare money to the states. He wants to do the same thing with Medcaid. He wants to do it so they can use the money for subsidies for private insurance premiums and I presume help with co-payments.

5. Full deductibility (from your federal taxes, currently medical expenses must exceed 7.5% of your gross adjusted income to be deductible) of all medical expenses

6. Medical liability reform - he wants a federal cap on all non-economic punitive damages from lawsuits

7. Bring market dynamics to health care. He was vague here in his speech but he only had a minute left. He made some, in his words, headline statements. These included EMRs (electronic Medical Records), single form claim filing and others.

Romney’s speech can be viewed here.

Based on our questions outlined in a previous article, how does the Romney plan measure up (on the Romney website there is no link to any detailed written material) as stated in his speech.

Is the plan comprehensive? The exact method of reining in cost isn’t clear from his speech, but everyone would be insured. Quality improvement, waste reduction, unnecessary care avoidance and improving the health of the population were not addressed.

2. Does he have specifics? Yes on how to get everyone insured, and how to get doctors and hospital paid. No on how to rein in costs. The center for Medicare and Medicaid as of 2003 says the government directly pays for 48% of our health care dollars spent. If we insure 11 million more citizens, they will be covered but who will wee them as more and more doctors opt out of this federal program.

3. Costs - Obviously it will cost more. He feels that we can privately insure medicaid eligible people for less than we pay out now while adding 11 million people to the roles.

4. Pain - is it evenly distributed? NO, he wants a % deductible for all medical costs for the patient. He thinks this negative incentive will cause people to make better choices about their health. What about coverage. Mental health coverage is quite limited under current insurance plans. Yet, it is well documented that mental health counseling is the most effective way to help people who are obese loose weight. What about dental care? Gum and tooth disease is directly related to good dental care. In the Netherlands, general dental care is free, if the person goes to the dentist every 6 months. He did not mention dental care. It is one of the best ways to improve the health of our population along with mental health services. I am in the sick care business and have to say, much of what I treat everyday probably would get well without my help. The majority of the pain would be on the citizen and some on the vanishing primary care physician.

5. Where have proposals been tried and what was the outcome? Only in Massachusetts and it is way too early to tell how things have gone there.

6. Does he answer complex questions with complex answers? He had 45 minutes to give this speech. For at least 3 minutes he had microphone malfunctions which cut him to 42 minutes of actual speech and one minute more of homage to the local yokels who had to be acknowledged so 41 minutes of speech. Twenty minutes of the speech were a review of what happened in Massachusetts and he ran short of time so his sixth point was presented in 1 minute. Really only time here for the basics and no written material available yet.

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