Frist! (No, really)

Back in May, Senate Majority Leader William H. Frist, M.D., gave the annual "Shattuck Lecture" at Charles Emerson Winchester's beloved Massachusetts Medical Society, entitled "Health Care for the 21st Century." The lecture was published in the New England Journal of Medicine last week.

Senator Dr. Frist is optimistic indeed. In 2015, his imaginary friend Rodney, from Woodbury Tennessee, "lives in a world in which America's leaders years ago made tough but wise decisions." Oddly enough, these tough but wise decisions did not prevent Rodney from having several preventable diseases: diabetes, hypertension, and high cholesterol. He also smoked, it seems, until 2007. But Rodney was as wise as America's leaders: "In 2005, Rodney chose a health savings account in combination with a high deductible insurance policy for health coverage." Yes, Rodney was smart, he bought into the ownership society. None of that pinko homosexual comprehensive health insurance for Rodney!

Frist is not afraid to recite the problems with our current system: highest health care spending of any "industrialized" country; average premium for a family policy is 21% of median household income; 45 million uninsured people; racial, ethnic, geographic disparities in health; etc. "We must agree on a guiding principle: all Americans deserve the security of lifelong, affordable access to high-quality health care."

It's nice to have a princple that says people deserve it, but it's even nicer to have a plan that will give it to them. This, it turns out, Senator Doctor Frist does not have. His system of "consumer driven health care" is driven by consumers in the sense that they pay for it, out of their own pockets. This means that people who earn more than $40,000 per year "should be enouraged, through changes in the tax policies, to buy themselves and their children high-deductible catastrophic insurance coverage." They would then pay for routine care through Tax-free health savings accounts (HSAs). Frist also wants to eliminate the tax policies that encourage employers to provide insurance. He says that the system of employer-provided health care "has been universally blamed by economists for inflating health care costs." However, the reference he gives says no such thing. (Read it yourself at Sheils and Haught.) It does say that the system of tax subsidies is regressive in that it disproportionately favors the wealthy, but the authors do not blame employer-provided health care for inflating health care costs.

It is correct that economists blame our fragmented system for the higher costs here than in other countries, but Frist's solution is to make it even more fragmented. Even for long-term care (which accounts for 30% of Medicaid expenditures) his solution is to make premiums for long-term care insurance tax deductible.

In the real world, which is quite unlike the fantasy world of Republican politicians, the people who establish Health Savings Accounts and buy long-term care insurance -- with the benefit of the tax subsidies Frist wants to extend for these purposes -- will disproporionately be the healthy and the wealthy. These people will no longer be in the pool for comprehensive insurance, the price of which will then rise. Although Frist appears to believe that insurance will be more "affordable" because of competition among providers and health plans, the fact is, they already compete in a market with many large, powerful buyers. By phasing out employer-provided insurance, and leaving individuals to go out and try to buy insurance on their own, this concentrated purchasing power will disappear. Frist's world is a jungle in which the fortunate will be rewarded and the less fortunate will be on their own, unable to pay for health care as young adults or nursing home care should they need it. It is all served up in a confection of sweet lies and distractions, but the real nature of the Ownership Society is clear: We own you.