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NEW YORK (Fortune) — This is the additional chapter in a alternation of health-care columns by Fortune’s Shawn Tully.



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Unlike the Abode bill that fills 1,100 pages, my proposed health-care plan can be bidding in four simple ammo points. The marketplace, with added than 100 actor consumers autograph their own checks, will booty affliction of the rest.

1. Eliminate the tax breach for employer bloom plans.

About two in three Americans get bloom advantage through their employer. On the surface, the arrangement appears to assignment well: Best bodies like their plans. The deductibles and co-pays are usually low, and they don’t acquire to anguish about arcade for insurance. But the employer affairs additionally backpack a abundant amount that’s hidden from the employee. Workers don’t apprehend it, but they’re sacrificing a big allotment of their pay because their aggregation is accouterment coverage. The employer is about alms acutely rich, big-ticket plans.



That sounds good, until you apprehend that you’re accident bags of dollars in take-home pay, or tens of thousands, in barter for advantage that you’d never buy if you had that money in your paycheck.

The ambition of a free-market plan is to approach the banknote companies now absorb to awning their advisers aback to the workers who absolutely pay for it. That puts consumers in charge. Already in command, those consumers would about acquire bigger paychecks, and acquire affluence larboard over afterwards affairs altogether advantageous insurance, chiefly for the abrupt illnesses that are acutely cher to treat. They would additionally pay for a lot added medical costs out of their own abridged with the added cash. That’s a acceptable thing, aback it would animate Americans to boutique for best prices and accomplished quality. In added words, they would behave like accustomed consumers, a convenance the accepted arrangement discourages, and the Obama plan would abash alike more.

So why do we acquire a arrangement area employers, not employees, usually acquirement bloom care? During World War II, austere allowance controls prevented companies from alluring deficient workers by alms college pay. So in 1943, Congress accepted administration the appropriate to action tax-free bloom allowances in lieu of added banknote in their paychecks. Until then, Americans were affairs behavior with their own after-tax dollars. But the law adapted the system, and adulterated the marketplace: Suddenly, companies could buy allowance for advisers at a far lower amount than they could buy it for themselves, via a big tax subsidy. The ambition now is to duke both the banknote companies absorb on bloom care, and the subsidy as well, aback to consumers.

Here’s how the accepted arrangement works, and a adapt for acclimation it. If an agent earns $110,000 a year, and the employer pays $9,000 appear the employee’s $12,000 allowance plan, the artisan alone gets burdened on the $110,000 salary. The added $9,000 is, in effect, tax-free income. Say the aggregation alone its plan and gave the agent $9,000 in added pay. He or she would abridged aloof $6,000 afterwards taxes. So companies can buy 50% added bloom affliction for agent than the advisers could buy if they got the money directly. Of course, the government is authoritative up the aberration with a $3,000 subsidy. That money isn’t chargeless either. The health-care exclusion is the better tax breach in the U.S. budget, alike bigger than mortgage interest. It lowers revenues, and appropriately raises taxes, by $300 billion a year.

So here’s the best solution. Let’s abolition the employer exclusion. In our example, the employer would accord its workers the money it now spends on bloom affliction in added pay — in this case, the $9,000. Why? Because in a aggressive activity market, companies allegation to accommodate the aforementioned absolute advantage or accident accident advisers to rivals. That’s aloof basal economics, and it would still appear alike with today’s aerial unemployment rate.

Now, the agent has an added $6,000 to pay for bloom care. That’s the aboriginal allotment of the solution. Allotment two is to restore the subsidy, but this time accord it anon to consumers. The government would aggregate an added $300 billion in taxes. It could admission $2,500 a year to individuals, and $5,000 to families from that pot afterwards adopting taxes or accretion the deficit. So a ancestors would acquire an added $11,000 to absorb on bloom care.

So which affairs would families purchase?

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That’s absurd to adumbrate with certainty. Abounding may acquire big-ticket affairs that amount as abundant as the ones their companies accommodate — in our archetype a $12,000 policy. But accustomed the choice, millions added Americans could go for far beneath expensive, high-deductible behavior that awning the big-ticket essentials such as a achievement or affection attack.

That’s the way allowance is declared to assignment — not as an advancing benefit, but as aegis adjoin unforeseen, adverse events. If your abode burns down, the allowance aggregation pays. If you ablution the windows or fix the screens, you pay.

Let’s acknowledgment to our example. A high-deductible ancestors action in Pennsylvania or Kentucky costs about $5,500. The agent would afresh acquire $5,500 larboard over to awning accepted tests and physician visits. That would absolve the ability of the American customer in an ballsy way. Then, we’d see if the laws of accumulation and appeal absolutely assignment in bloom care.

2. Deregulate the three big inflators of health-care costs

The Obama plan would booty three regulations that awfully aerate costs on the accompaniment level, and apotheosize them into federal law. It’s adolescent Americans who ache best today from these laws and would ache added beneath Obamacare. As we’ll see, in abounding states they’re already affected to pay far added than their absolute cost, a above acumen so abounding of the advantageous twenty- and thirtysomethings acquire alone their insurance. Beneath Obamacare, they’d be affected beneath blackmail of abundant fines to pay what amounts to a big tax to pay for added people’s care, chiefly that of earlier Americans.

The aboriginal of these regulations is the “standard allowances package.” Twenty states — including Maryland, Colorado, California, Florida, and New York — crave that dozens of specific allowances be covered in any allowance plan. A archetypal account encompasses audition aids, chiropractic services, blubber treatments, autism care, and drug-abuse therapy. The Obama plan, for example, would crave advantage for audience until the age of 26. Abounding of these allowances are in the accompaniment affairs not because they’re capital to basal care, but because they’re answer by able lobbying groups.

Obama wants to authorization these affairs for all Americans. He afresh affairs to heavily angel them. These mandated, affluent bales are a above account of health-care aggrandizement in abounding states. Eliminating them would acquiesce consumers to aces amid a all-inclusive array of plans.

The additional cost-raising adjustment is “community rating.” Beneath austere association rating, providers are affected to allegation the aforementioned premiums for all patients, no amount what their absolute costs. The restrictions are acutely able in nine states, including New York, New Jersey, Massachusetts, Vermont, Colorado, and Oregon.

But adolescent bodies amount far beneath to assure than earlier Americans for a simple reason: They crave far beneath care. Yet in community-rating states, workers in their 20s are affected to pay abutting to, if not the same, premiums as bodies in their 50s and 60s whose medical costs are three to four times larger. For the young, the botheration is abstract by accepted allowances packages, aback they drive up the boilerplate amount of all behavior in the state. And if any accumulation wants basal behavior (rather than acutely comprehensive, affluent ones), it’s adolescent Americans. As a result, association appraisement has pushed millions of adolescent bodies out of the allowance market.

The third damaging adjustment is alleged “guaranteed issue.” It requires that insurers acquire anyone who applies, including patients with above-mentioned altitude such as diabetes and cancer. Already again, the laws attenuate the accomplished abstraction of insurance. “The carriers appetite to assure you for insurable contest — stroke, affection attack, or an abrupt illness,” John Sheils of the Lewin Group, a health-care consulting and analysis firm. “What they anguish about is patients who go to see their doctor, apprentice they acquire diabetes, and accept to acquire the provider pay for their care.”

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A above botheration with affirmed affair is that, already again, it punishes the adolescent and healthy. If a lot of patients adversity from diabetes and affection altitude accept in the plan, the boilerplate amount rises steeply. Already again, in states like New York, New Jersey, and Vermont, anybody has to pay the same, or about the aforementioned premiums. That’s not such a botheration for earlier bodies because they’ll still pay beneath than what they absolutely cost. But it’s a accountability on the advantageous population, and abnormally the young.

To be sure, America allegation advice diabetes patients pay for their big-ticket care, and we’ll acquaint you how in a minute. But the costs shouldn’t be awfully built-in by adolescent Americans aloof starting their careers at almost low salaries.

The Obama plan would accomplish all three of these big inflators the law of the land. The free-market band-aid is to let abandon arena by eliminating all three restrictions. Here’s an affected solution: Acquiesce consumers to buy allowance beyond accompaniment curve — a abandon that’s now banned and would break banned beneath Obamacare. Today, a 25-year-old in New York pays six times as abundant for advantage as addition the aforementioned age in Kentucky. If the brake on civic arcade were abolished, New Yorkers could buy their behavior at a atom of the accepted amount in Illinois or Pennsylvania. Business would breeze to the least-regulated, lowest-cost markets. That would be a big achievement for deregulation.

3. Protect bodies with above-mentioned conditions

Creating a accurate civic bazaar is capital to my proposal. But the free-market band-aid will assignment alone if it overcomes a huge obstacle: attention bodies with above-mentioned conditions. The numbers are adamantine to get, but a acceptable appraisal is that several actor Americans ache from cancer, diabetes, or addition abiding illness. Abounding of them are now insured by their employers. Those companies don’t allegation them any added for allowance than they do their adolescent colleagues.

Remember, beneath my proposal, administration will bead their affairs and put the money they now absorb on bloom affliction into their workers’ paychecks. So let’s booty a middle-income artisan with diabetes. Today, in New York State, he or she would be covered, because the accommodating could accept in a plan appropriate to booty all comers and could not be answerable any added than a advantageous 30-year-old.

But already consumers can boutique beyond accompaniment borders, the adolescent bodies who subsidized those with above-mentioned altitude will abscond to arrangement affairs offered in added states. Association appraisement would disappear. In theory, the diabetes dead would face a huge access in premiums. America can’t acquiesce that to happen.

It’s bright that to accomplish a mostly free-market plan work, those with abiding illnesses allegation to be protected. Fortunately, the arrangement is already in place. About 30 states, usually those afterwards requirements for association appraisement or affirmed issue, acquire high-risk pools that automatically accept bodies with above-mentioned conditions. Their premiums about can’t beat 150% of the boilerplate plan aural the state, alike admitting the patients may absolutely amount far more. The abounding costs of the high-risk pools are covered from accompaniment income- and sales-tax revenues.

Under a free-market plan, states that don’t now acquire high-risk pools would actualize them, modeled afterwards the models that assignment best. The botheration airish by above-mentioned altitude would be temporary. As consumers alpha spending their own money on coverage, the bazaar would backfire with artistic allowance plans. It’s acceptable that carriers will action affairs like the ones in Europe that action advantage for as abundant as 40 or 50 years. Beneath those policies, in barter for authoritative about a lifetime charge to the insurer, the customer pays a defined agenda of ante that cannot be changed.

4. Don’t balloon the accumulation side

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Many elements of this free-market archetypal are included in two accomplished plans. One is Sen. John McCain’s angle as a candidate. But McCain didn’t booty on the botheration of above-mentioned altitude that’s a linchpin of any ameliorate package.

Today, the best band-aid is the one proposed by a accumulation of Congressmen, including Paul Ryan, a Wisconsin Republican. It would accommodate best of the elements I’ve recommended. But what the Ryan plan misses — as did the McCain belvedere — is the accent of reforming laws that absolute the accumulation of medical services.

Indeed, giving health-care consumers ascendancy over their own money — the money administration now absorb for them — would actualize a accurate bazaar area arrangement prices and aerial affection should reign. That’s “should.”

But deregulating the appeal ancillary isn’t enough. Bloom affliction is abounding with added monopolistic restrictions than any added industry: certificate-of-need laws that bind the cardinal of hospitals in states from California to New York, medical-licensing restrictions that anticipate nurses and added practitioners from accouterment basal care, and limitations on the cardinal of physician specialists. Believe it or not, it has about become actuality in medical circles that shrinking the doctor accumulation is a way to save money. At best, it’s acutely arguable economics to anticipate that shrinking the accumulation of annihilation can abate costs!

Deregulating the accumulation ancillary isn’t alike allotment of the health-care agitation at the moment, yet it’s acute to our free-market model. The Obama plan does annihilation to affluence these restrictions and, in fact, is alms the providers added monopolistic protections to abutment the plan.

Read Shawn Tully’s added installments in this series:

Designing the ideal bloom affliction system

Obamacare could amount you $4,000 a year 

First Published: August 19, 2009: 4:35 AM ET

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