For the best Medicare model, look down under

The idea of insurance is simple: Knowing how often a bad event (emergency hospitalization) might occur in a large group of people, you can charge each person a premium to cover for those losses.

The key is that it has to be an event that no one wants to have happen. If you begin providing insurance coverage for things that people want to have happen then the cost skyrockets. Imagine what your car insurance would be if, in addition to covering accidents, it covered oil changes, tire rotations and repairs on worn parts.

In large part our health insurance cost crisis has been fueled by the fact that what started out as insurance to protect people from the cost of a crisis hospitalization has morphed into a means for funding routine health care services.

While the Affordable Care Act (ACA, also know as Obamacare) was a major step in making health care accessible to more Americans, its Achilles heel is that it still uses the concept of health insurance to fund routine care.

Today the major debate occurring among Democratic presidential candidates is which direction to take: build on the ACA, go with Medicare-for-all with elimination of private health insurance or go with Medicare-for-all with the option of private health insurance still available.

I suggest that Medicare-for-all with the option for some types of private health insurance is the best route to take. I am going to use the Australian model as an example of why this is the best option.

In Australia, everyone pays a tax levy of 2% of income into their national health care system (Australian Medicare) in addition to their progressive income tax. All outpatient services are provided under Australian Medicare.

So basically the Australian Medicare program promotes good health care practices: getting routine preventative health care, seeing a doctor early in an illness to prevent costly complications and keeping follow-up appointments so chronic conditions don't worsen.

Just as in the U.S., Australian consumers can check before they make an appointment whether a physician either accepts Medicare payment as full payment for services (accepts assignment or sometimes called bulk billing) or expects the patient to pay the difference out of pocket. Some 86.3% of Australian primary care providers and 41.3% of specialists accept assignment. The number increases steadily because patients prefer physicians who accept assignment.

Hospitalization and emergency room services are another story. These are things that in general people don't want to happen to them unless absolutely necessary and thus work very well under the principles of insurance, making the rates much more affordable.

So Australia offers people the option of using Australian Medicare for hospitalization at public hospitals or purchasing private insurance used at private hospitals. Currently 45.8% elect to purchase private hospitalization insurance and they qualify for a rebate from the Australian government that is usually paid as a premium reduction.

Why? When Australia went towards a national health care system for all citizens, there needed to be a balance between existing private hospitals and those in the public system. If people only went to public hospitals, the pressure on public facilities would be enormous. By making private hospital insurance available and providing a rebate to make it more affordable, a balance was struck between Australia's public and private hospitals.

In Australia the government also takes a very tough stand on what a pharmaceutical company can charge if it wants to be on the Australian Medicare list of drugs resulting in markedly lower out-of-pocket medication costs.

In a recent study by the Commonwealth Fund, Australia was rated first in health care outcomes and spent the smallest percentage of its Gross Domestic Product on health care of any developed nation.

So when watching the debates, listen for the candidates who promote Medicare-for-all with a limited private insurance option. These may be the candidates who have the best grasp of what is likely to work best in our country.

Stephen Soltys of Springfield is a retired physician who still teaches on a volunteer basis at SIU School of Medicine.

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