Follow-up on health care policy: Actually, let's not talk about a 'mandate,' but about incentives

Over the last few weeks and months, this paper has printed numerous commentaries, letters and editorials encouraging public officials and health care leaders to address costs and universal coverage, consider single-payer options and ponder the value of an insurance mandate to protect the individual marketplace.

I recently authored a commentary supporting a discussion of any and all ideas, including a mandate, as possible remedies to the crisis of unmanageable premiums and deductibles for the uninsured ("Why we should start talking about a state mandate," Dec. 28).

Follow-up letters and social-media responses have made it plentifully clear that the concept of any kind of "mandate" is a lightning rod for folks from all political persuasions. I now believe the word "mandate" is misleading as applied to the kind of incentives and supports I envision for individuals seeking insurance.

With Obamacare (the Affordable Care Act, or ACA) kicking in over the last few years, much has been learned. One unfortunate consequence included the dramatic undermining of the individual marketplace with premium increases greater than 50 percent in a single year. Promises such as "you can keep your doctor and enjoy reduced premiums" were nothing more than political noise.

As a family doctor in the trenches, it pained me to watch Obamacare casually promote the corporatization of medical care, fracture millions of trust-based patient-doctor relationships, and compromise independent practices through mergers, acquisitions and empire-building.

An especially thorny problem within the ACA was a mandate — ill-advised from the start — that called for comprehensive Cadillac plans for all (heavy-laden with presumed essential benefits and heedless of affordability) and that included a financial penalty for people not buying what government bureaucrats decided they needed.

When Obamacare unveiled its mandate to force citizens to buy something they neither wanted nor could afford, a decadelong battle erupted, culminating recently in the mandate's demise. For many, the mandate was seen as a dismaying infringement on personal liberties. I agree. The law presumed to tell millions of Americans who didn't have insurance that they would buy the "qualified plan" or pay the consequence.

Incentives might include state deductibility of insurance premiums (employer premiums are not taxed, so why should individually paid premiums be taxed?), an increase in Health Savings Account contribution limits and the capping of out-of-pocket medical expenses at 10 percent of adjusted gross income. Such steps could make it easier for many to obtain insurance.

For those still unable to buy or maintain insurance, the consequence might be nothing more than allowing insurance companies the option of delaying coverage for six months when there has been a gap in coverage. This would prevent "gaming" the system — waiting to purchase insurance until after a crisis has developed, like buying flood insurance when the river is at your doorstep.

The removal of the Obamacare fine for not buying a "qualified plan" has created an opportunity for states to craft their own solutions regarding cost, quality and access. Minnesota has led before with innovative ideas such as a special insurance pool for high-cost patients, safety-net facilities for the indigent, and MinnesotaCare for those not quite eligible for medical assistance — and we can lead again.

Key ingredients of a good solution should include: (1) providing basic coverage for critical care for every Minnesotan, including mental health coverage, (2) protecting the individual right to choose what to buy, and (3) preserving the right of all people to champion their own care.

Tasks demanding immediate attention include the need to require price transparency, address exorbitant pharmaceutical costs, seek full disclosure of health care profits and administrative fees, analyze executive salary schedules for health care systems and insurance carriers, reduce low-value services ordered by doctors and hospitals, expand the benefits of advance directives, recognize the impending shortage of primary-care physicians, discuss the impact of malpractice concerns as a cost driver, and aggressively support initiatives to reduce opiate addiction.

Cost is the elephant in the room, and nothing should distract us from the challenging task of bending the health care cost-curve down. Americans are now heavily engaged in the health care dialogue, and it's time for legislators to brainstorm with constituents at town hall meetings and on the campaign trail. We should be willing to discuss any and all ideas.