Matt Miller - The Archives
To Save Health Reform, Cut Congress' Benefits
New York Times, July 22, 2009
A surprising way to make universal health care affordable

EVERYONE who wants universal health coverage (me included) finds irresistible the rallying cry that all Americans should have the same health benefits that members of Congress have. But Congress's health insurance—that is, the heavily subsidized preferred provider plan that most members have—is not an ideal model, because it is quite rich. As with other fee-for-service plans, it does little to encourage people to be smart health care shoppers.

Congress's health plan pays for routine expenses like office visits and vaccinations, for example, which is like auto insurance covering oil changes or new windshield wipers. As a result, the premiums are steep—upwards of $13,000 a year for a family (69 percent of which is paid by the government). To provide the 50 million Americans who are now uninsured with such a plan would require scary tax increases.

When faced with staggering cost projections, advocates of universal coverage often suggest something less grand for the uninsured; after all, it's better than the nothing they have now. But that approach violates the as-good-as-what-Congress-has standard. Plus, it makes uncomfortably explicit the dread possibility of a "two-tier" system in which influential or better-off Americans have lavish health insurance, and the less affluent make do with a slimmed-down plan. (To be sure, we now have multiple-tier care, but in a democracy we like to pretend that's not the case.)

The obvious answer—conveniently overlooked by the 535 well-insured members of Congress—is to stick with our rallying cry, but give Congress a more cost-effective plan.

A new insurance plan for Congress would blend the sensible conservative desire to put a brake on costs with the equally sensible liberal goal to protect all Americans. Conservatives have proposed tax-sheltered health savings accounts paired with high-deductible insurance plans, but these are typically burdensome for the poor, who cannot afford a $5,000 (or higher) deductible. And by luring healthier people away from the broad insurance pool, such plans risk raising premiums for the sicker people who maintain traditional coverage.

Liberals, meanwhile, champion Cadillac plans that provide no incentive for people to care about costs; whether the charge for a doctor visit is $150 or $400, the co-payment is the same.

But the best of both sides' impulses could be combined into a new basic health plan for Congress, and here's how: First, make sure all members have primary and preventive care. This means regular checkups and health screenings, timely attention for injuries and other urgent medical problems and the kind of wellness coaching that can help people quit smoking, lose weight and reduce stress. If all Americans were provided such primary and preventive care, the country's total medical bill would gradually come down.

One approach would be to require senators and representatives, most of whom earn $174,000 a year, to maintain tax-sheltered health savings accounts, which they would use to finance their primary and preventive care. Today, families may put up to $5,950 annually in such an account—and any amount they don't use on health care that year can remain in the account.

To make such an approach work for all Americans, we'd need to supplement the accounts of people who couldn't afford to save the full amount, and of less healthy people, whose costs are higher.

An alternative strategy for Congress would be the new "fitness club" model offered by some doctors, in which members pay $65 a month for same-day or next-day access to primary care services. This would involve no insurance companies, so it would save administrative expenses.

We could then pair one of these primary care plans with high-deductible insurance coverage for catastrophic care, but limit total annual out-of-pocket payments to, say, 15 percent of family income. For a member of Congress whose family had no other income, that limit would be $26,000. If this kind of plan were extended to other Americans, a family earning $25,000 a year would have a limit of $3,750.

This kind of hybrid plan would honor the values of both parties even as it cut the cost of covering each politician by perhaps one-third. It would give members the incentive to shop for less expensive health services, thus encouraging doctors and other providers to compete to offer better value. At the same time, members would know they are protected in the event of a costly illness. Those who wanted greater coverage could pay for it out of their own pocket.

If all Americans were to have such a hybrid plan, the nation would be healthier, costs would grow more slowly and medical bills would no longer be a leading cause of bankruptcy. Rarely do members of Congress get the chance to make a small change that can have such a big difference.