The most important thing we need from health care reform isn't insurance for the uninsured or lower costs of care. It's the ability to tell a health insurer, Trump-style, "You're fired."
Health care consumers don't have that ability today, and the so-called public insurance option that liberals favor won't give it to us, either.
Look, hardly anyone thinks our health system doesn't need to change. And government can have solutions — to the problems it's created. Just don't create any more problems along the way.
Give us "fire" power, and watch the other desired changes fall in place.
Why don't we have fire power now? Easy. In our current, employer-based system, health insurers don't answer to patients. They answer to HR departments.
If I don't like the co-pay I have to make, or the list of "in-plan" doctors, or the service I get when I call the insurance company, there is precious little I can do about it. I can't fire that company and choose another one.
The customer may still be right, but the customer — that is, the HR decision maker — is only one member out of hundreds or thousands in the plan.
I don't mean to bash HR folks. They presumably do as well as could be expected given the pool of employee/patients they have to work with — people who mostly chose to work for their company for reasons entirely unrelated to the health care plan on offer.
However, consider that most employers only offer a handful of health plans. In what other area of life do we have so few choices? Not in cellphone service, not in washing machines, not in churches, not in Mexican restaurants, not in auto insurance.
Merely giving Americans a public option won't bring any real change. First, there is the high likelihood that a public plan would lead to the elimination of private plans for millions of people. Obama advisers no longer even try to discount this possibility. They simply make clear it would be only an effect of their program, not a requirement.
Private plans will be particularly endangered if Democrats pay for the public option by removing the tax subsidies that employers currently get for providing workers' health coverage. Barack Obama raised that specter all too effectively against John McCain during the campaign, only to open the door to it now.
Once private plans disappear, or are available only to the superwealthy, you'll have nowhere to turn if you fire the government insurer. Having checked in to the public option, you would never leave the government's Hotel, er, Hospital California.
What we need is true mobility in health coverage, with tax breaks going to citizens rather than employers. (A smart Republican would use the opportunity of Obama's 180-degree turn on taxing health benefits to explain and sell the free-market alternative better than McCain did.)
Freed from their health insurance obligations, employers would be able to shift compensation to wages — a more transparent and efficient medium. It might not happen immediately, what with the recession and high unemployment. But soon it would happen for the same reason that employers began offering health insurance originally — to attract the best talent.
Other changes would be necessary, such as allowing private insurers to compete across state borders and to decide for themselves which health services their plans included, rather than adhering to government mandates for certain types of coverage.
And surely it would be better to form patient pools on bases more relevant to health care than a common occupation. Online social-networking tools would empower people to form more appropriate pools of health care consumers across the country.
Personalizing the purchasing of health insurance would remove tens of millions from the ranks of the uninsured — employees of small businesses that can't afford to subsidize insurance, or young people who want more basic-insurance options. With these reforms in place, Democrats would have a more sound basis for finding ways to accommodate the few people still left out.
Just give us health reform that the Donald would appreciate.
Kyle Wingfield, an Opinion columnist, appears Thursday and Sunday. Reach him at firstname.lastname@example.org.
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