Senator Hillary Clinton launched her presidential bid this weekend talking about the issue she knows best–healthcare reform. While the plan she proposed as First Lady went down in flames through a combination of poor political management and intense interest group opposition, the problems she tried to tackle not only remain but have gotten worse, with tens of millions uninsured and the cost of care continuing to skyrocket. The big question I have is whether the horrible outcomes critics attributed to Hillary's proposal haven't come to pass anyway, and what alternative do we have?

For example, one of the big problems identified by opponents in the health insurance industry was the suggestion that under Hillary's program, people would no longer be able to choose their own doctor–that some faceless government bureaucracy would tell you where you had to go for medical care.

How is that different than what we have now under managed care? I know that under my own company's plan, while I retain the “choice” of doctors, if I happen to choose some provider outside of my plan's network, I get no reimbursement at all. Other plans offer similar “choices,” but force the patient to pay a much higher deductible and co-payment if they stray outside the approved list of doctors.

In reality, I don't have much of a “choice” at all unless I am willing (and able) to fork over big bucks out of my own pocket to see my favorite doctor. This becomes particularly dicey as employers flip plans to get the cheapest premiums–each new insurer comes with their own approved list of providers, meaning you won't know from one year to the next who you can afford to see. The same goes for diagnostic facilities, treatment centers and hospitals–it all depends on which have struck a deal with your company's health insurance carrier.

Therefore, while it might not be a faceless government bureaucrat telling me who I can and can't see for medical care, is a faceless health insurance company bureaucrat any better? The bottom line is that I really do not have much choice over who will provide my medical care.

In some cases, the choice is taken away entirely. For example, when told one needs a diagnostic procedure, one might use a doctor and facility in the carrier's network, only to find out afterwards–with a large bill in the mail–that the anesthesiologist working at that facility does not accept any health insurance…in fact, that anesthesiologists in general don't take private insurance because they refuse to live with the cost limits such plans impose on them. So what “choice” does one have in that situation?

Then there is the problem with drug coverage. “Choice” is limited by formularies imposed by the health insurer, with each having a different list of “approved” drugs. The list can change from year to year, with a change in carrier or in your current insurer's mood. In fact, a drug can be arbitrarily removed from the list in the middle of a policy year under most contracts these days. The insurers push you to take generics or allegedly equivalent (and cheaper) prescription alternatives, even if such drugs haven't worked as well (or at all) as the brand name one is already taking, but which has been tossed from the list, with little chance for appeal on the drug's effectiveness. What “choice” is there in these circumstances?

Then there is the fiction that maintaining a private market will drive down healthcare costs by forcing “consumers” (sick people) to “shop” for providers. First of all, the market isn't “free” if “consumers” are forbidden or financially discouraged from seeing certain providers in the first place. Second, people in dire need of medical care are not likely to spend a lot of time “shopping” for a provider. Chances are they will go with the recommendation of a primary care physician or even a family member or friend. Or, more likely, they will just check the list of “approved” doctors in their carrier's network purely to avoid being stuck with a huge bill, regardless of whether the provider is any good or conveniently located. The idea of “comfort level,” which is so critical to someone in need of medical care, is simply a luxury in this system we cannot afford.

Meanwhile, we are told we cannot buy drugs from Canadian providers (as if Canada is some Third World country that has a history of massive drug quality problems) or use the leverage of Medicare to negotiate for better prices (as large drug store chains and health insurance carriers commonly do)–more due to the power of the drug-maker lobby than any concern for costs or patient welfare.

What we are left with is a shell game in which care is still prohibitively expensive, real choice is a fantasy, and the quality of care is left to the not-so-tender mercies of the free market.

I am not some wild-eyed radical calling for socialized medicine. I know first hand from friends who have had trouble getting timely care in the nationalized Canadian healthcare system that the easiest answer isn't always the wisest, and that rationing of some sort is likely under any kind of medical care system.

But I also know the status quo is unacceptable, and I am anxious to hear presidential candidates from both parties present where they stand on reforming our cockamamie system.

President George W. Bush this weekend suggested taxing some predefined “excessive” portion of employer-paid health insurance premiums to fund a tax credit to make it more affordable for uninsured people to buy coverage. What do you think of that idea? Or any other out there?

My point is that people hammered Hillary for trying to “destroy” our time-honored healthcare system, when in fact we were working with a dysfunctional market that has only morphed further out of whack in the years since Hillary's plan crashed and burned. Do you folks have a better idea? If so, I'd like to hear it.

Special Reports /

What If Hillary Was Right About Healthcare Reform?

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