Governor Schwarzenegger has announced, with the usual great fanfare, that he is going to reform California’s health care system in 2007. He has assembled a blue ribbon team of experts within the administration and has started the dialogue among the many affected interest groups necessary to address such a monumental task. Within this cadre of health care policy gurus are veterans of the “managed care wars” of the late 1990s that resulted in sweeping reforms that are still in operation today. It also has caused the revival of that time honored, oft-studied and never implemented concept – 24 hour coverage.
Here we go again boys and girls.
Twenty-four hour coverage is the notion that all medical care should not be different simply because an injury or illness occurs on the job. Proponents of such a concept also claim that there are gross inefficiencies from the current bifurcated system that would be eliminated if there was one universal health care policy covering all medical conditions regardless of the occupational causation of the condition. Wow – sounds simple enough. Why hasn’t this happened before?
Well, there was an effort at such a merger in 1994. It came from the now Senior Senator from New York, Hillary Rodham Clinton, and the other from the wellspring of all great ideas (just ask him), then California Insurance Commissioner John Garamendi.
It would appear that these proposals are en vogue once again, only this time with Republican patronage. In 2004, the RAND Institute for Civil Justice opined that there should be a pilot project for 24-hour care, acknowledging that potential considerable legal issues that are involved in this concept – including the question of whether such a program can even be regulated by the state due to the requirements of the Employee Retirement Income Security Act (ERISA).
There are a few other impediments to this concept as well. The claims of greater efficiency are based in part on the notion that once a medical condition occurs there is no need to deal with causation issues. What happens when the injured worker files a claim form? Wouldn’t that suggest that maybe there still needs to be a determination of whether the injury or illness arises out of employment? Doesn’t the doctor still have to file a first report on injury for OSHA? How are all the indemnity benefits of the Labor Code to be determined if the treating physician doesn’t care whether the injury is work-related? Shall all injuries (work related or not) create a reimbursable time lost disability payment?
By the way, workers’ compensation benefits are liabilities of the employer at the time of injury, whether the employer is insured or self-insured. Are we going to create a portable medical benefit while the employer at the time of injury continues to administer the indemnity benefit? How are employers going to be able to chase workers as they move through the workforce when a claimant is claiming new and further disability? Sounds like a causation issue to us, but then we won’t have to worry about that under 24-hour care, will we? Let’s just let the State Fund pay all claims for all medical in the State shall we? And transfer the indemnity / disability portion over to EDD.
There are a few other issues, such as whether this new system will provide for cost sharing with the worker and how that can be reconciled with the Constitutional provisions regarding a complete system of workers’ compensation, that may need to be looked at before the switch is thrown.
While there has been considerable angst over the transition of medical care from the old provider-driven system to the evidenced based system under SB 228 (Alarcon) and SB 899 (Poochighian), moving all medical care under the “medical necessity” standard in non-occupational health isn’t going to alleviate those complaints. Unnecessary and harmful surgeries or lifetime physical medicine services aren’t anymore acceptable in that world than they are in this – unless, of course, proponents of 24-hour care want to roll back that clock across the board, too.
Before launching a new 24-hour pilot project, the gurus of 24-hour care should look at the one already done in California a decade or so ago. Before embracing what one New England state, Massachusetts, did on health care reform, the gurus should look at what happened when another New England state, Maine, tried to launch a pilot project on 24-hour care – a lawsuit from the AFL-CIO claiming that state regulation of the plan was preempted by ERISA and belong with the feds.
Maybe then, before we go down this path yet one more time, will people realize this is not the Grail, it is new wine in old bottles.
Perhaps before we look at 24-hour care we should look at the costs of providing medical care to those in need. Perhaps we can start with Universal Health Insurance, separate from workers’ comp and find new ways to fund that.
Here’s one: How about allowing private health insurers to bid on the provision of health coverage to the poor. The bids could be by geographic or demographic parameters and the low cost bid providing the “standard” medical care wins the bid.
The result? The State gets out of the insurance business, medi-care and its so low reimbursement levels are gone, thousands of bureaucrats will be ‘redeployed’ to more urgent areas and the costs of quality medical care for everyone will decrease as the $22 aspirin (50+% of which covers the service for which providers do not get reimbursed) goes away.
But then, we Publius are just columnists.