Given the advance publicity indicating a heavy focus on healthcare in President George Bush's State of the Union address last week, the actual time spent in the speech on this important subject was disappointing. After the "we are strong" and "let's stick to the mission" pronouncements that are standard fare in this ritual performance, the president offered a punch-list of initiatives, spending at best about a minute on healthcare.

His punch-list for provision of ongoing, affordable healthcare?

Expansion of Health Savings Account (HSA) systems, including the provision of association health plans for small businesses; a continued push for an electronic health records system; greater use of information technology to assist consumer choice; and a continued push for medical liability reform to crack down on "frivolous" lawsuits.

But these were fleshed out more completely in a five-page press statement providing details concerning these proposals, clearly intended to show that the administration is trying to expand access to good healthcare while continuing to dodge the all-inclusive, single-payer system (the single payer being the U.S. government) that was a stated goal of the Clinton White House and presidential wannabe John Kerry.

Here are some of those proposals:

  • Making premiums for HSA-compatible insurance policies deductible from income taxes when purchased by individuals outside of work.
  • An income tax credit to offset payroll taxes paid on premiums for HSA policies, stated as serving to "level the playing field for those who currently do not have access to employer healthcare plans, such as the self-employed, unemployed, and workers for companies that don't offer health insurance."
  • Extension of HSAs to low-income families, described as "vulnerable Americans" via refundable tax credits.
  • For those not working, such as retirees, premiums for the purchase of non-group HSA plans "would now be allowed tax-free from an HSA account."
  • Making HSA policies portable, enabling workers to carry them from one employer to another.

Altogether, these proposals would expand the use of HSAs from 14 million to 21 million Americans by 2010, ac-cording to the statement.

Bundled with the calls for greater use of information technology; capping of medical liability claims; and a pot-pourri of other offerings, the press statement bills this as "the President's Reform Agenda."

Reform? We don't think so.

It sounds very much like taking an Edsel, tightening all the bolts and screws, giving it a new paint job, installing a CD player and calling it a Jaguar. More like lipsticking a pig.

Besides increasing the use of HSAs to only 21 million over the next four years – a drop in a very large bucket – the proposals are simply a patchwork quilt of fixes, offering no systemic change.

While the HSA itself is a useful tool for many Americans, it is hardly usable by the uninsured who live paycheck to paycheck. And while an accountant might find the ins and outs of HSA plans a cinch to deal with, they offer a bureaucratic maze substantially more complex than the current muddle of Medicare drug coverage for seniors.

The fact is that HSAs and the other proposals for "reform" of healthcare only add more layers of administration to a system already burdened with administrative waste, estimated variously from 20% to 30% of total spending. And this waste is unlikely to go away until America develops some sort of single-payer system that provides a basic level of healthcare service to all.

Socialized medicine of the Canadian kind? We don't think so.

We think that the U.S. always will be able to find a mix of governmental and private services, with the single-payer system augmented by a second tier of Americans willing to pay for more than the basic services provided – through HSAs or simply out of pocket.

Governmental inefficiency? Of course – somewhat, but certainly less inefficient than what we have now.

As a New York Times columnist noted recently, the U.S. government already has a one-payer model with a fairly significant level of efficiency: the Veterans Affairs system, benefiting from uniformity of membership and continuity of record keeping.

A single-payer governmental system also is probably the only way for U.S. healthcare to reach the goal of a universal, portable EHR. The ideal EHR system is essentially impossible given not just a patchwork, but a crazy-quilt of insurers, billing providers, software technologies and coding variations.

Unfortunately Americans may have developed an addiction to this crazy-quilt that rivals even their addiction to oil. If so, it will produce ever-growing numbers of the uninsured and poorly insured and an exponentially more inefficient and random delivery of healthcare than what we have now.

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