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Dr. Bill Roy: Need to get everyone in health care system

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I have slowly realized that the fiasco going forward in Washington, D.C., under the rubric of health care reform is severely handicapped by the failure of the people of this nation to decide whether of not everyone has a right to health care.

Congressional Republicans do not seem to care how many people are left out of the system, and Democrats have a tolerance for leaving about 20 million on the outside looking in. And no one has the courage to do anything about costs doubling every nine years.

So I was delighted to read an interview with Kansas Insurance Commissioner Sandy Praeger in the Topeka Capital-Journal. Praeger is a Republican and chairwoman of the National Association of Insurance Commissioners' health care committee.

She began by saying that "the most positive part of the health care discussion is talk of getting rid of the ability for insurance companies to deny a person insurance because of pre-existing conditions. I would love it if we could get rid of that."

It's a great line, one too many politicians are prone to let stand alone after the applause subsides. But not Praeger.

Her next lines were: "Now you can't do that without saying everyone has to have coverage, because if they can't deny you coverage based on your health status, then people would just wait until they got sick to buy health insurance. The whole idea behind insurance is that everyone is buying it. You want to spread the cost over the broadest population.... Being able to have everybody in the system is key to making it work. We're the only country that doesn't require everybody to have coverage."

In two succinct responses, Praeger stated plainly what should be the essence of American health care reform: guaranteed issue and universal coverage. Everybody pays and everybody plays. Health care for all and costs shared by all.

That's pretty much the way health insurance began in the 1930s and 1940s when state-chartered Blue Cross Blue Shield companies were nearly the only game in town. They were founded on the principles of open enrollment and community rating, which meant they accepted all applicants, including those with pre-existing conditions, and everyone paid the same premium.

These principles made early BCBS plans more prepaid health care programs than they were insurance companies, which are identified by underwriting risk, assessing premiums accordingly and setting aside reserves to pay anticipated, inevitable losses — all under the regulation of state insurance departments.

But BCBS plans were also sitting ducks after the expansion of health insurance as an employee benefit during World War II. Traditional insurers figured out pretty quickly that some groups insured by BCBS were a lot healthier than others, and that they could offer employers or individuals health insurance at a much lower rate — and let the higher risks land wherever they may.

In order to compete, BCBS plans were forced to fragment their risk pools of nearly everybody into smaller risk pools or more selective risk pools. This brought us to today, where health insurers prosper by insuring the young and the well, while refusing to insure the old and the not so well, and use a thousand tricks to refuse or delay payment.

After her observation that everybody should be in the system, Praeger used state-mandated car insurance to illustrate what might be necessary to get everyone to buy health insurance. In other words, Praeger recognizes that some people are not going to carry their load unless they are mandated to pay premiums or taxes. And the rest of us will have to pay for their care when it becomes necessary.

If Republicans and Democrats would begin with the key principle that everyone must be in the system, they could quit playing silly games.

Bill Roy is a retired physician and former member of Congress who represented northeast Kansas.

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