E-Neuf small thinking! Our health care problems are monumental and our approach to reform, as put forth in the Affordable Care Act, is banal and not up to the task. THe ACA is going to lead us to a future where businesses will drop defined benefit coverage and replace it with defined contribution coverage. Millions upon millions of American workers will find illness or injury means financial ruin. Who knew the modern cure for illness includes personal bankruptcy.

The only way out of this mess is to put the promotion of HEALTH itself as the centerpiece of health care. But how are we going to move away from a sick care system that supports an American medical-industrial complex far more adept at creating wealth than health?

One way forward is to blend insurance with health savings accounts. The trick is maintaining principles of shared risk and solidarity common to all equitable health-care financing mechanismsOne way forward is to blend real insurance with health savings accounts. The trick is maintaining principles of shared risk and solidarity common to all equitable health-care financing mechanisms. When I say real insurance I mean policies that are risk protection mechanisms, not means of purchasing everyday health care services.

Remember, the right supports health savings accounts based on the belief the accounts boost individual responsibility. The left can’s stand HSAs because they believe they will destroy comprehensive coverage. The reality, as is usually the case, is somewhere between these two poles, in that fertile ground where new ideas have a chance to take hold.

We can combine HSA type accounts and coverage in such a way that all Americans will will be covered and no one gets a free pass. How? First require all  non-disabled persons below age 65  to buy a federally defined health benefit policy and to open a new type of health savings account.

Provide low-income Americans with income-based subsidies to assist in buying coverage. Insurers would sell the policies to individuals and pre-existing condition exclusions will be banned. The policies should have maximum deductibles of $2,500 to $3,500 per year for families and $1,000 for individuals.

These HSAs would be individually or family owned and fully portable over a working lifetime. At death, HSA funds could be transferred into someone else’s HSA on a tax-free basis; other bequests would be subject to a tax. HSA account owners would be allowed to contribute additional funds, on a pre-tax basis, up to $2,000 per year. Unspent account balances would roll over each year and earn untaxed interest, much in the way IRAs do now. At retirement, funds could be used to pay non-Medicare-covered retiree medical expenses.

The key is that each policy would be required to include, above and beyond the required  benefit, coverage for a yearly health exam. This  exam would generate a “health report card” with recommendations on individual health improvement, including better management of chronic disease. The goal is to provide individually relevant health information that will be acted upon.

These new style HSAs will be financed by employers, who will be required to deposit $3,000 to $5,000 per year in an employee’s HSA, but would no longer purchase employee coverage. The self-employed would make the employer contribution, just like social security.

The HSA funds would be used to pay for health-care expenses such as doctor and dental visits, routine tests and prescription drugs. The health coverage policy would cover risk by paying for large, unanticipated medical expenses. 

To protect persons form the ongoing expense of chronic illness, additional subsidies in the form of publicly funded health vouchers would be deposited into the HSAs of persons with certain serious chronic conditions. The vouchers would help individuals with high chronic care costs pay the additional medical expenses resulting from their illnesses. 

HSAs would be individually or family owned and fully portable over a working lifetime. At death, HSA funds could be transferred into someone else’s HSA on a tax-free basis; other bequests would be subject to a tax. HSA account owners could contribute additional funds, on a pre-tax basis, up to $2,000 per year. Unspent account balances would roll over each year and earn untaxed interest, much in the way IRAs do now. At retirement, funds could be used to pay non-Medicare-covered retiree medical expenses.

Are there weaknesses in this approach? Absolutely, and they are significant. But the ACA’s health-care financing approach is not going to cure all that ails America’s health-care system. We have to start moving towards substantive reform that places the acquisition and maintenance of good health above all else.

It’s everyone’s responsibility to demand our leaders in health care, politics and business start the serious conversations needed to get America’s health system out of the critical-care unit, past rehab and into a functional future.