The model we envision will serve over 320 million people. Its administrative oversight will be an enormous operation, whether served by for profit or nonprofit agencies under contract to a federal department, or administered directly by the U.S. Department of Health and Human Services (HHS). Reaching consensus on the goals of our model was easy, but as in America at large, we may differ on the degrees to which governments should be involved. For that reason, we offer an alternative link on the subject of administration.
One Option for Healthcare Administration
In this link we consider several administrative options. One is the recent proposal by Berkshire Hathaway, Amazon and Morgan Stanley to collaborate in devising a for-profit model of care. They are so smart and successful that many presume they will know how to do it. They have not declared, however, an intent to serve indigent and high risk patients, so there is a risk they might skim the market for young, low risk customers. This might disqualify them as administrators of a universal American model, but they could play roles under contracts to nonprofit agencies such as the National Institutes of Health (NIH) or the Center for Disease Control (CDC).
A Second Option for Healthcare Administration
Another option is to assign management oversight to an experienced nonprofit private foundation, or to a collaboration of several foundations who might share leadership. Of several such foundations operating in various parts of the country, the largest is Kaiser Permanente. It serves over 12 million enrollees in eight states and the District of Columbia, owns 39 hospitals, 680 clinics and employs 22,000 physicians. Replicating Kaiser Permanente to serve 230 million citizens is beyond comprehension, but it might make significant contributions by setting standards of quality and economy for other contract holders.
A Third Option for Healthcare Administration
The premium collector, paymaster and manager of our model must be the U.S. Department of Health and Human Services (HHS), allowing it to subcontract when needed with private nonprofit, state or local agencies. Critics believe HHS is an overblown, inefficient and wasteful bureaucracy with its recent budget of $1.3 trillion and eighty-thousand employees. Some in Congress would press a “delete” button on HHS including its components Medicare and Medicaid. Some perspective, however is gained by comparison with the Department of Defense that has 742,000 civilian non-combat employees. Most of the operating responsibilities of HHS are essential and would need to be carried out under some other authority if it were not HHS. The largest of HHS’s operating agencies and their 2014 budgets are listed in the following table.
|Largest HHS Operating Agencies||2014 budgets|
|Centers for Medicare & Medicaid||$607 billion|
|National Institutes of Health (NIH)||$80 billion|
|Children & Families||$51 billion|
|Food & Drug Administration (FDA)||$26 billion|
|Health Resources & Services (HRSA)||$10 billion|
|Center for Disease Control (CDC)||$7 billion|
Now within HHS are people and programs able to execute most of the purposes of our health care model. Programs will need revising and people retraining to meet new requirements such as standard electronic health records. Consolidating operations of Medicare, Medicaid, Children & Families and Health Resources should free employees to meet new requirements. Merging Medicare and Medicaid into our Basic universal plan would satisfy those who want “Medicare for all.” These details are beyond the scope of this website. They need deciding by experts within HHS, supported by the Congressional Budget Office.