Book Review

Total Cure: The Antidote to the Health Care Crisis

N Engl J Med 2009; 360:547-548January 29, 2009

Article

Total Cure: The Antidote to the Health Care Crisis
By Harold S. Luft. 318 pp. Cambridge, MA, Harvard University Press, 2008. $27.95. ISBN: 978-0-674-03210-1

The widespread conviction that a defining moment is at hand has led many to hope that the goal of providing universal access to health care in the United States may soon be realized. President Barack Obama has set forth his own plan and has stated that he welcomes other proposals as well.

Economist Harold Luft presents a thought-provoking and original proposal in Total Cure. His plan, which he calls SecureChoice, is intended in part to eliminate the dissatisfaction physicians often voice about the erosion of autonomy and professionalism when they deal with multiple insurers that can set fees and deny claims. SecureChoice is also intended to better reflect the principles of insurance, because health care under this plan would be separated into two components. The first would consist of expensive and generally unpredictable services (universally covered in this plan), and the second would be made up of relatively predictable and inexpensive services (paid out of pocket or by privately purchased insurance).

Luft believes that the high-cost services in the first component of SecureChoice warrant universal coverage, including all major and emergency medical and surgical services that are performed in hospitals or specialized centers as well as services that are provided for the ongoing management of chronic illnesses. Together, these services are estimated to account for approximately 62% of all health care costs. Inpatient and similar services would be paid for on the basis of an episode of care; all institutional and practitioner costs involved in the episode of care would be bundled according to an expanded system of diagnosis-related groups. The management of chronic illness would be paid for on a monthly basis.

A major feature of the first component of SecureChoice is the establishment of a universal coverage pool, which would be drawn from to pay for the episode of care, allotting the “sum required nationally for providers to deliver superior-quality care.” No premiums, deductibles, or copayments would be required from patients. Providers would, however, have the option to “decide to charge more” than what would be paid for by the pool, and patients could either buy insurance to cover excess charges or pay for them out of pocket. Luft believes that such a pool would be best financed by a combination of public and private means, including some employer contributions (employer health plans would not be necessary but could continue). He prefers this financing option because he believes that the public would not favor financing solely through taxes and because this option would be less subject to pressure from lobbyists.

SecureChoice's second component is a voluntary program that gives participants the choice of paying out of pocket or purchasing an insurance plan for the relatively low-cost services that are generally provided for minor or acute illnesses and preventive care in a physician's office. These services account for the remaining 38% of all health care costs. Each participant would be able to choose a primary care physician to serve as the patient's “medical home.” Each physician would be able to set fees and choose a payment intermediary; the intermediary would collect claims data, pay bills, and analyze the physician's practice style (fees, services, and referrals) to determine the premium that would be required to enroll with that physician. In effect, each primary care physician would become an individual health plan.

In any discussion of SecureChoice, two fundamental features of the proposal are likely to be singled out. First, the fact that physicians would be allowed to charge fees in excess of the amount paid by the pool raises a question: Would Congress enact any publicly funded program that had the potential of creating “platinum coverage” health care for those with the will and means to pay for it?

Second, minor and acute illnesses and preventive care, which make up the vast majority of health care encounters, are not covered by the pool. The fact that the well-publicized RAND Health Insurance Experiment found that the use of health care — whether needed or not — was influenced by out-of-pocket costs raises another question: Would Congress enact any publicly funded program that did not provide universal coverage for services that promote health and prevent costly hospital care?

The book contains a detailed discussion of the rationale for this plan and indicates that Luft is cognizant of certain concerns that his plan raises. He envisions, for example, “an income-based subsidy program that reduces the premium and out-of-pocket costs for all low-income people,” and that some preventive care might be covered by the pool. He also discusses how current health programs could fit into SecureChoice, using a vignette to illustrate the choices that people could make, including remaining in an employer's health plan. At times, Luft's detailed description of the options available in SecureChoice has the unintended effect of making the proposal seem excessively complex.

Now is the time to evaluate SecureChoice and other health care proposals. Swift action is crucial if policymakers are to take advantage of this defining moment to enact health care reforms.

Marian E. Gornick
3704 N. Charles St., Baltimore, MD 21218
mgornick@aol.com