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Vikke Andersen of South Haven Area Senior Services says:
February 9, 2009

Maybe I'm naive, but the families I know who either work for themselves or work in small non-profits would find it extremely difficult to pay over $8000 per year for health insurance, or, in the case of individuals, over $3000 per year, with or without tax credits. My question? Why does the United States insist on re-inventing the wheel? Investigate how programs work in other nations with affordable health care. I expect that one thing we never consider because of the holy bottom line is how to control and contain health care costs. Part of the costs obviously are due to the plethora of individuals necessary to manage insurance claims in the plethora of insurance companies which litter the landscape.

Charles Willson of Brody School of Medicine at ECU says:
February 9, 2009

"Building Blocks for Reform" seems like a sensible way to get from where we are (millions of uninsured and soaring health care costs) to where we want to be (all insured and better value for the health care dollar). The main problem I see as a primary care physician with a large percentage of Medicaid patients is "Who will care for the patients with newly purchased coverage?" The lack of adequate increases in Medicare rates for primary care over the past seven years and the continuing threat to cut rates by 10 percent has led to fewer med students choosing primary care and the aging primary care docs retiring early, especially in rural areas. The primary care "medical home" has great potential but will anyone be around to provide the care? Charles Willson MD, Clinical Professor of Pediatrics, Brody School of Medicine, Greenville, NC

william branch of Emory University School of Medicine says:
February 9, 2009

Your proposal, "Building Blocks for Reform," is the first common sense plan to adopt the obvious solution of including Medicare in the mix of third-party payors, thereby providing broader coverage, lower administrative costs, and an alternative to private insurers that will tend to keep their costs down by competing with them. Thanks for your efforts, William Branch, MD, Professor and Director, General Internal Medicine, Emory University

Susan Solomon of University Hospital says:
February 9, 2009

Interesting proposal, but I have some questions and concerns. Under traditional Medicare, medications are not covered, and there is the 20 percent that Medicare does not cover. What happens in this proposal for these two coverage issues? I am a social worker for liver transplant, and medications for our patients is a key problem. If medications are not covered, they would be a barrier to getting a transplant. Also, hospital clinics that normally are the source of care for persons with Medicaid are already overflowing and there can be many month delays for appointments. It sounds like this situation would be even more problematic.

Stephen Gregg says:
February 9, 2009

Consistent with Commonwealth's weighting of the "problem" being the uninsured, going very "light" on credible mitigation of controlling future health care costs. How will the reform control the compensation of the industry? The preservation of segmented entitlements (Group, Medicare, Medicaid, etc.) helps acceptability of reform, but doesn't it leave us with competing interests seeking to shift its burdens to another interest? As with all proposals deemed to have prospects, policy should insist on a proof of concept before a full scale roll out. Can't prove the concept, can't play...same rule we would apply to a new drug.

Richard Call of South Urban Region, Intermountain Health says:
February 9, 2009

It is not clear to me in what manner administrative costs will decrease. In past times this has meant that the work involved is shifted to the provider office, with such things as pre-authorization, Medicare verification, drug substitutions etc., so I worry from that standpoint. The majority of the burden falls upon the cognitive specialties, who have to work with patients as far as compliance with medication and lifestyle changes, and for the most part this is already uncompensated time. With decreasing reimbursement to providers, the squeeze will be on the family docs and the internists, whose "margins" are already the lowest. So I foresee progressive shortages in provider numbers, as is historically the case when wage and price controls are applied. And in as much as many one- and two-provider practices are already small businesses, the increased cost of provision of benefits to employees will certainly hasten the already progressive shift to larger multi-specialty practices. Having said that, these concerns are common to all the plans presented, and I applaud your effort to develop a proposal that is workable and compatible with much of the existing infrastructure.

james mcniff of montefiore medical center says:
February 9, 2009

A recent report by the NIHCM foundation segmented the uninsured into various income categories. They stated that 12 million of the uninsured could be covered today but are not enrolled. For the FPL of 100 percent to 200 percent, they believe there are about 14.4 million. If we assume that 50 percent of the 14 million will now be eligible, there will be 19 million eligible to enroll (40 percent of the uninsured). You mention that people over the 150 percent will be required to have coverage. If we have 12 million today who are not enrolled how are we going get 19 million to enroll voluntarily? The states and the federal government haven't made it easier to enroll, providers have been pressured to treat these as charity cases therefore creating a disincentive for patients to enroll, the IRS and advocacy groups want to see providers give more charity, so why would we think these 19 million would have coverage? What will happen is that the 19 million will become a greater number and the states and federal government will leave up it to the providers to have their own insurance called "charity care." We must first answer the question why the current 12 million are eligible but not covered.

Gary Maris of Stetson University says:
February 9, 2009

I have identified the following questions/possible problems: [1] Medicaid is not sufficiently funded by states and many doctors do not participate. Doesn't this plan leave a problematic system in place, which means the lower income, disabled, etc. end up with less "access" re: regular doctors, etc.? [2] Won't employers begin to opt out of the system since it will be less expensive than what they are presently doing? [3] Will there be a defined "standard package"? [4] How much administrative work is involved in establishing 5 percent of income, etc.? [5] Is the Medicare option to be traditional Medicare and, if so, doesn't this need to be worked out to get rid of the current expensive problem of Medicare Advantage plans and fee for service?

Deb Matz of Benequant says:
February 9, 2009

It saddened me to see the emphasis still on insurance coverage rather then health education and accountability. As third parties started to pay more of our health care costs, particularly basic care, the more unhealthy we have become as a society. Insurance does not improve health. Insurance cannot change a person's lifestyle or behavior to more effectively manage their condition. In fact, it has had the opposite effect if we look at our health outcomes over the past fifty years. We were once a society of health (1960s), now we are at the middle of the pack for developed nations today at a cost of more than two times what any other country spends. We must focus on accountability and health improvement. Will insurance encourage one to get off the sofa to get exercise? Will it stop obese people form eating a whole bag of potato chips? Hmm....We need to start dealing with the problem and stop looking at band-aids that only prolong the problem.