Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD


Should Sicker Patients Pay More for Health Care?

By Rob Tenery, MD on May 10, 2017

The most contentious point on reforming or replacing Obamacare is funding for pre-existing conditions. The first concern is what maladies should be included and what should be excluded. It is obvious that diabetes and congestive heart failure should be covered, but what about mental health problems or a rash from poison ivy? The additional diagnoses are what have sent the Obamacare premiums skyrocketing. Several questions must be dealt with in order to create a health care delivery system that is both affordable and available to the most number of patients. Any shortfalls in reimbursement from the patients, insurers (federal and private), taxpayers and charity contributions, must be addressed.

The major reason Obamacare is in trouble is the lack of buy-in by the younger healthy individuals, whose funds would then go toward covering the increased costs of the sicker individuals. The elderly and the disadvantaged should already be covered under the existing Medicare and the state run Medicaid programs.

One relatively straightforward approach would be to raise the Individual Mandate penalties in the current law to the level that it is more cost effective to pay the premiums for the coverage rather than fork over the fines. The extra revenue from either choice is used to offset the increased costs for care of the sicker patients. The current penalty under Obamacare is set too low to be an incentive for obtaining coverage.

Another option is to draw in monies from those in the general population that have no coverage. This would be in the form of mandatory health care coverage for catastrophic events (cancer, automobile accident injuries, etc.). The added advantage is the patients are protected from filing for bankruptcy and the taxpayers from bailouts.

 Should the sick be responsible for the higher costs of their health care? If the answer is no, then the only affordable answer is through a single payer system. With these delivery systems, the long-standing concern is the tradeoff that universal coverage models potentially compromise quality of care due to limitations of resources.

If the answer is in the affirmative, then the follow-up question is to what extent are the sicker (preexisting conditions) patients responsible? In a just society, the answer is to the extent these individuals can afford. That option must then come with some combination that would include an affordable basic benefits package and additional options that could include medical savings accounts, premiums with pretax dollars, and vouchers as necessary. The treatment of some maladies must fall back on the patients--- stress related headaches, topical antibiotic creams and simple bandages are examples. 

A just society has a responsibility to protect its inhabitants from harm that is beyond their control and undue pain and suffering. In turn, these individuals shoulder certain responsibilities. Those are to avail themselves of less costly preventive care services, complying with treatment measures to decrease morbidity and participate in the available funding mechanisms, rather than dumping their more serious problems on hospital emergency rooms by putting off their care.

The least complex option is to expand the penalties on the Individual Mandate clause of Obamacare and limit the extra diagnoses added to a well-defined basic benefits package. Can the Republicans come together to create a better plan? In the next several months, they will be put to the test. If they can’t deliver, the single payer option looms even closer.





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