Consumer Questions

How does a consumer enroll in Balanced Choice?
Balanced Choice is a proposal, not yet in effect. If implemented in the future, you would need only to contact Balanced Choice or file a tax return to obtain enrollment identification (no age, marital, employment, or health status restrictions); then you would be eligible for health care. In an urgent situation, you could receive your qualification immediately. Once enrolled, it would continue for your lifetime.

What is the single payer system?
The single payer system collects health care moneys from all sources and funnels them through a single non-profit trust. This single trust fund would replace health insurance and multiple other health care entities that currently pay provider fees. It is an efficient means of funding the individual’s choice of provider.

What is the Copay Option?
This is one of two optional payment plans in Balanced Choice that functions much like the in-network services of a Preferred Provider Organization in the current health care system. Under this option, fees are set by the Balanced Choice Governing Board. Patients would normally have a small co-payment and providers would receive the remainder of the reimbursement from the Balanced Choice Trust. The Copay Option covers all emergency room treatment. Balanced Choice assists with co-payments for patients with low income and catastrophic medical expenses or chronic illnesses.

Why should I have to pay any gap payments?
Someone on the health care system needs to watch costs and be concerned about excessive spending. Without gap payments, either the government or managed care would be deciding what is an excessive cost and what treatments are worth the cost. When there are gap payments, consumers and the consumer-provider team are the ones concerned about costs, and the consumer-provider team retains control over health care decisions.

Would copays and gap payments keep me from getting necessary care?
Balanced Choice is a system that eliminates barriers to health care. To encourage early diagnosis and prevention, the first primary care visit each year in the Copay Option would have no copay. If you were unable to pay, Balanced Choice would accommodate your situation. Copay Option providers would inform patients that, if needed, assistance is available. The medical office could give you a simple form requesting Balanced Choice assistance with copays or gap payments.

What about emergency care?
There is often no time to ask about the cost of treatment or to make choices in an emergency. You would always be covered by the Copay Option for treatment at emergency rooms and trauma centers.

What about long-term care?
Essential long-term medical care is no different than any other medical service in Balanced Choice. Even in the current system, Medicaid pays for most long-term care. In Balanced Choice, you would be expected to pay the residential portion of your care as long as you are able, but the medical portion would be paid on either the Copay Option or the Independent Option. Independent Option long-term care benefits might include a greater staff-to-patient ratio and additional services.

Provider Questions

How do I know that I will receive adequate reimbursement from Balanced Choice?
In Balanced Choice you are able to earn an income that is commensurate with your training, expertise and hard work. Balanced Choice addresses your income needs in both Plans. The Copay Option is mandated to maintain a high enough fee schedule so that, collectively, providers voluntarily treat Copay Option patients 60% of the time. You may refuse new Copay Option patients if you believe that the reimbursement is not satisfactory.

In the Independent Option, you can raise your fees higher than the Copay Option. Providers with strong reputations, special training, and greater expertise can be compensated with greater income. The Independent Option also allows you to charge higher fees if you offer services that persuade patients to pay the gap fees.

Why would consumers pay the Independent Option gap when they can receive quality care in the Copay Option for a small copayment?
Consumers value choice. They have demanded that insurance plans have out-of-network coverage because they do not want to have their choices restricted. Many consumers will pay a premium for services from a highly recommended professional, a professional with additional training, a highly experienced professional, or a professional who shows special interest or caring.

Is Balanced Choice a government-run health care system?
Providers have justifiably resisted the idea of a government-operated health care system. This is not an abstract ideological position, but one that is based on experience with government systems. Medicare has a history of unilaterally determining reimbursement rates that do not adequately reimburse some areas of health care. In the current system, providers can refuse Medicare patients because there are other sources of income. If there were only one system, it is natural to be concerned about having the profession crippled by misguided government policies. At times Medicare has also made heavy-handed threats of prosecution for fraud and huge fines when providers have made errors in following bureaucratic procedures. The Veterans Administration is known for bureaucratic inefficiency.

Balanced Choice is not this kind of government program. It protects providers from these abuses because it allows patients and providers to make choices. Providers are not locked into accepting the fee schedule and can use the Independent Option if the Copay Option reimbursements are insufficient. Balanced Choice would be required to distinguish between bureaucratic errors and fraudulent billing, and it would be prohibited from the heavy-handed threats of criminal prosecution that were used by Medicare. Balanced Choice is not a health care delivery organization; it is a payment system for independent providers of health care services.

Would Balanced Choice interfere with treatment decisions?
As providers, you are the best people to make treatment decisions, and Balanced Choice maintains your independence and central role in making health care decisions. You have the direct involvement with patients, and in Balanced Choice, you have the personal and professional responsibility for the quality of health care. Neither third party utilization reviewers nor bureaucratic guidelines can produce better decisions than yours. Balanced Choice supports your independent judgment and professional authority.

Balanced Choice allows treatment decisions to be made by the provider-patient team. It is not a system of managed care. In Balanced Choice, consumers are cost conscious. It is the provider’s role to guide patients in deciding when treatment is necessary, when it is optional, and how patients can safely reduce expenses.

Employer Question

How does Balanced Choice impact employers?
In Balanced Choice, employers are no longer responsible for health care. They no longer need to select or manage benefit packages and none of the employer’s staff or the employee’s working time is devoted to learning, understanding and managing insurance plans. Employers are freed also from the responsibility for paying for the health care portions of workers’ compensation and auto insurance. In other words, they no longer have responsibility for managing health care coverage.

Employers’ overall expenses for health care are lowered. Balanced Choice is partially funded by an employer’s contribution to a Balanced Choice Health Care Fund, but this would be $100 billion less than the overall annual amount employers already spend on health insurance. This financial contribution will not increase as health care costs increase. If more funds are needed for future health care, they will need to come from other revenue sources, not employers. Instead of being faced with rising health care costs and workers’ compensation costs, employers will obtain immediate relief and have a responsibility only for a predictable portion of their payroll.

Employers who have not been paying for health care will need to contribute to the Balanced Choice Health Care Fund. To prevent this from being a hardship, these employers will have their contributions to the Balanced Choice Health Care Fund added at less than the rate of annual inflation. Additionally, it will be easier to fill employer vacancies when the lack of health benefits is no longer an issue.

In addition to savings on the expense of providing employees health care, employers would obtain a savings from workers’ compensation insurance and automobile insurance. Because all health care would be covered in Balanced Choice, health related expenses in workers’ compensation and automobile insurance would not be necessary.

Once employers are freed of responsibilities for health care, they can do what they do best—focus on business. In addition to lowered direct costs, they will be relieved of all the time that management of health care has diverted from productivity. Balanced Choice will enhance the ability of American business to compete in the global marketplace.

General Questions

How would Balanced Choice be financed?
Balanced Choice proposes obtaining funding, as much as possible, from monies that are currently being spent on health care. State and federal funds that are currently allocated for health care would be transferred to Balanced Choice. Employers’ current contributions to health care insurance would be diverted to a Balanced Choice Health Care Fund in the new system, with an overall savings for employers of $100 billion annually. Likewise, employees’ contributions to health insurance would be replaced by contributions to the Balanced Choice Health Care Fund based on a percentage of their earnings. Balanced Choice: A Common Sense Cure for the U.S. Health Care Systems, Chapter 4, “An Outline for Financing Balanced Choice,” explains the financing proposal.

What is the Balanced Funding Mechanism?
In order to maintain quality of care and prevent underfunding of the Copay Option, the Balanced Funding Mechanism was designed to respond to market forces. The Balanced Choice Governing Board is required to set Copay Option fees and Independent Option reimbursement rates such that patients and providers choose the Copay Option for 60% of the services and voluntarily choose the Independent Option to cover 40% of the services. For more information see Balanced Funding Mechanism.

How would reimbursement rates be set for all medical services?
Currently, the Center for Medicaid and Medicare Services (CMS) already sets reimbursement rates for all medical procedures for Medicare patients. Under Balanced Choice, the Governing Board would assume responsibility for creating this reimbursement schedule and, in most cases, would begin by using the Medicare schedule as a base. Where reimbursement rates have been too low to attract quality providers, the Governing Board could make the necessary increases.

How would Balanced Choice save money?
Under the current system, or, more accurately, 17 different systems, health care is not provided in an efficient manner. Adopting Balanced Choice will result in one system designed to provide everyone with health care security in the most efficient manner possible. A conservative estimate of the administrative savings indicates that universal coverage could be obtained for less than is currently spent on health care in the U.S. Some of the savings would be made available to fund research that furthers the development of less expensive treatments. In addition, Balanced Choice encourages competition based on cost, which will lower future expenses.

As opposed to the short-term focus of our current funding, Balanced Choice Health Care financing provides cradle-to-grave coverage. This long term perspective provides proper incentives for preventive care, wellness programs, mental health and substance abuse treatment, in home care, medical home programs for complex illnesses, and other approaches that have short term expenses and long term savings 10, 20, 40 years down the road.

Will Americans accept another tax?
Many Americans are categorically opposed to taxes. However, market advocates, single payer advocates, conservatives, and liberals all propose using tax money to finance health care. It is widely accepted that some form of taxation is necessary to fix the health care systems.

The choice is between paying higher costs for health insurance in an insurance-driven health care system, or paying less, on the average, for a Balanced Choice system funded through taxation. Do Americans want lower taxes offset by higher insurance premiums in a system where they could lose their health care coverage any time their employment situation changes? It is likely that total cost and how well the system works is more important to most people than whether they pay their money to an insurance company or make contributions to a Balanced Choice health care fund.

A Balanced Choice contribution is not a tax that is used to support special interests or a segment of the population. It is a tax that will directly benefit all people and their family members each time that they need health care. The Social Security System is a similar government benefit, and it is generally supported. Likewise, Americans may accept a tax if it could provide an efficient health care security system for all. The voters should be given the choice.

Is Balanced Choice too good to be true?
It is not that Balanced Choice is too good to be true, but that the current insurance-driven and managed care system is so bad that there is plenty of money for a sensible system. After all, the U.S. has the most expensive system in the world, 46 million uninsured, and only mediocre outcomes compared to other industrialized countries. Balanced Choice would merely provide the quality, accessibility, and efficiency that the U.S. deserves considering how much is already being spent on health care.