The Reischl Model 

A Public Utilities Commission for people who go to doctors, take medicine, get sick, i.e., everyone

In his spare time, Professor Uwe Reischl is helping bring telemedicine to the remote Peruvian highlands. He's also aiding the Brazilian government in its effort to regulate ergonomics in furniture. He knows the hottest chick on campus at the State University of Minas Gerais in southern Brazil and designed the cockpit in her experimental super fuel-efficient car.

He built a comfort-measuring mannequin in his garage, and the Croatians want to get their hands on it.

Still, Reischl complains that he's no Uwe Reinhardt.

Uwe Reinhardt, the James Madison Professor of Political Economy at Princeton University, is the guy you hear on National Public Radio anytime they do a health care reform story. He's on government panels and the editorial boards of prestigious medical journals, and he blogs about health economics for The New York Times.

Reischl is just a professor of health sciences at Boise State with a radical idea for health care reform in Idaho. Reischl suggests treating insurance companies like we treat the power or gas company—as a public utility.

click to enlarge Boise State professor Uwe Reischl. - LAURIE PEARMAN

"The reason that it's novel is because there's nothing new," he said. "It has all of the components in there that have made America great."

If Uwe Reinhardt were to blog about Uwe Reischl's idea, it could inspire multiple blue-ribbon panels and send a buzz through statehouses up and down the Eastern Seaboard.

But Reischl had to settle for a cup of coffee with Boise Weekly. And we were more interested in the lady racecar drivers at Minas Gerais, where Reischl is spending his first sabbatical from Boise State.

"Brazil always wins the design prize," Reischl said, even when its 180-mile-per-gallon car breaks down on the track.

Brazil already has a basic state health care system. Idaho does not.

But, according to Reischl, Idaho's Public Utilities Commission has the tools at hand to make health care more affordable, coverage more predictable and insurance available to more Idahoans.

And there is no need to confront Idaho politicians with the specter of socialized medicine, nor to wait for federal edicts.

The handful of folks around Boise concerned with health care reform have a name for his idea. They call it the Reischl Model, and as a hybrid of single payer and free market approaches to reform, it has opened up a new front in health care reform discussions here.

It could accomplish many of the goals of health care reformers and remain politically feasible in Idaho.

"We do support the notion of single payer, one risk pool, in this country," said Bob Vestal, a member of Idaho Health Care for All and a prominent Boise clinical pharmacologist. "However, it's not clear when that's going to happen, and we have noticed that many states are adopting or working on programs to improve health care access and coverage around the country."

Reischl has presented his idea to a handful of groups in Boise and to the Seventh International Conference on Health Economics, Management and Policy in Athens, Greece, last year.

He calls his concept an Idaho solution to a national problem: "My model is a business model."

What brought Idaho and the majority of states to the point of massive government intrusion into the electric, gas, water and telecommunications industries in the first place?

"If there's limits to choice and limits to competition, what is the threshold that society would say, 'wait a minute, maybe we need to have a regulated industry?'" asks Jan Beecher, director of Michigan State University's Institute of Public Utilities.

The giant power conglomerates of the 1920s, which quickly became regional monopolies, were more efficient, could produce cheaper power through economies of scale and could carry power to places that smaller operators were not willing to go.

But they were monopolies and naturally began to abuse their power, so states offered them a deal: keep your monopoly but submit to government oversight and public scrutiny. Thus the public utilities commissions were born.

Utility regulators and many economists consider monopolistic behavior, in all its efficient glory, to be a free market failure.

"If indeed the market is failing, then we need to design good regulation to step in," said Beecher. "It's not acceptable to have an unregulated monopoly."

Idaho's PUC began in 1913 and today regulates all investor-owned electric, gas and water companies and has some oversight authority of telecommunications, railroad crossings and pipeline safety.

So a company like Idaho Power, which has a near-monopoly in Southern Idaho, must come before the three PUC commissioners whenever it wants to change its rates and make a thorough case for the change.

But Idaho Power is still a publicly traded company, a subsidiary of Idacorp, which brought in $98.4 million in profit in 2008—profits allowed by the state-appointed regulators.

In January, the PUC authorized a $20.87 million increase in revenue for Idaho Power; the company wanted $66.6 million. Commissioners questioned the company's plans for major construction projects in a down economy and scrutinized bonuses and reimbursements for meals and cell phone charges.

During the case, the PUC also recommended that Idaho Power focus more on energy efficiency and find ways to help struggling customers pay their bills. Third party organizations—from activist groups to Micron Technology Inc.—as well as the public have a chance to testify on the rate increase as well.

Uwe (pronounced oo-vay) Reischl, 63, appears professorial, even among the morning rush of academics at Boise's downtown Java. He speaks in a mild German accent, littered with American slang and enthusiasm for his many diverse academic projects. He has an M.D. and a Ph.D. in public health. But he also served as president of a patent company in Florida before coming to Boise State seven years ago.

Three years ago, it was a group of sharp business students at Boise State who got Reischl thinking about the power of the PUC. He began teaching a health economics class made up of free-market minded business students and socially-minded health students.

click to enlarge Uwe Reischl and his flow chart, illustrating the Health Insurance Public Utility Corporation model. - LAURIE PEARMAN
  • Laurie Pearman
  • Uwe Reischl and his flow chart, illustrating the Health Insurance Public Utility Corporation model.

The business students challenged him to re-read Adam Smith: "Oh crap, Uwe, you're not an economist," they told him.

So the class got into the basics of capitalism and health care, and Reischl found a new way to explain that medicine deserves some special market considerations above and beyond strict free enterprise.

Health care transactions pose two exceptions to free-market principles, Reischl said. First, in a free market, it is assumed that consumers are as informed about their purchases as they want to be. But patients are rarely fully informed about their health purchases. They do not have enough medical training to make informed decisions and are reliant on medical professionals for those decisions.

Second, health care decisions are not necessarily rational. When you are making decisions about your own life or death, assuming you are conscious, or for the life of a child or a spouse, you cannot possibly make a rational economic choice.

But another choice—whether to buy insurance in the first place—could be made much simpler under Reischl's proposal.

"No reasonable person would refuse health insurance if it were affordable," he said.

So, back to Beecher's question: At what point does government legitimately step in and regulate a market?

Most Idahoans have accepted such interference in the gas and electric sectors. In 2005 the Idaho Legislature deregulated telephone service—Qwest was the state's main phone provider—in the wake of competition from cell phone carriers.

President Barack Obama called for reforming federal regulation of the banking industry in his recent address to the nation, though the type of oversight he spoke of presumably does not rise to the level of control that Idaho has over public utilities.

But Reischl appears to be the first person to suggest placing the health insurance industry under a public utility model.

"I have never heard of a utility regulatory commission in any of the 51 jurisdictions or in any other nation ... taking on the responsibility of regulation of providers of health care or health care insurance," said Scott Hempling, executive director of the National Regulatory Research Institute.

Hempling said adding health insurance to the jurisdiction of Idaho's PUC would require an entirely new field of expertise for the commission and its staff. And insurance is already regulated in Idaho by the Department of Insurance.

But Idaho is a "file and use" state, meaning the insurance companies get the benefit of the doubt on rate hikes. They must file rate books with the Department of Insurance and the rates are reviewed to ensure compliance with Idaho laws, but the department does not have the quasi-judicial role that the PUC has over power companies.

"Our mission is to regulate the insurance industry in Idaho," said Bill Deal, director of the Idaho Department of Insurance and a former insurance agent and state legislator. "I don't know that the PUC can do it any better than the Department of Insurance."

Doing it better assumes that there is a problem, which Deal acknowledges. He recalls the bill for a CAT scan that his wife recently received: $1,600 for an 11-minute procedure.

"Those are the problems that I see with health care," Deal said. "That we have no way of really knowing what that escalation of costs is."

Deal does not blame doctors (they just give us what we want: lifesaving procedures), insurers (they have to recoup those costs) or technology (again, saving our lives). But he does not have an answer for escalating costs or growing ranks of the uninsured either.

"I am one that believes that a single governmental plan isn't going to save money," Deal said.

Reischl's plan changes the discussion. It would create a single plan, basically a single payer for the state, but it would not be a government plan anymore than Idaho Power is a government agency. While many put health care into the same category as driving or owning a home—a privilege—Reischl and a large number of Americans, possibly including the new president, view it as a fundamental national priority, if not a right.

Like electricity, water and even schools, Reischl argues that health care is fundamental to the economic stability of the nation. Like the utilities, it should be uniform, widely accessible and priced fairly.

"Insurance ought to be considered a critical public service," Reischl said.

But that does not mean government needs to provide it. Just as Idaho Power provides electricity, private companies like Blue Cross of Idaho, Regence BlueShield of Idaho and Primary Health already offer insurance in Idaho. Their success depends on the accuracy of their risk model, which is their business model, which necessitates off-the-charts premium increases.

"They're not evil," Reischl said. "They're just doing what any other business would."

Giving the PUC authority over health insurers would change the insurance business model in a way that Reischl argues would be beneficial to the companies and customers.

Under the model, the state would give one private insurer the right to a monopoly in the Idaho health insurance market. Reischl calls it geographical exclusivity rather than monopoly, and allows that a conglomerate of insurers or perhaps even two or three across the state could qualify (different power companies serve northern and southern Idaho).

Reischl estimates that the new health insurance company would be able to instantly lower its premiums 30 to 50 percent based on its larger risk pool of, perhaps, a million healthy adults.

The company would also be able to make long-term contracts with doctors and hospitals, assume a more stable customer base and ease the billing process for medical providers.

There would be costs, too: an entire layer of insurance marketers, hucksters and agents would be eliminated, and insurance firms that were not selected by the PUC would either go out of business or would have to convert to offer supplemental insurance for coverage not offered by the public utility.

And, perhaps the biggest hurdle, the insurance industry lobby, would not be happy. At a recent Idaho House of Representatives Business Committee meeting, at least five insurance industry lobbyists nodded in agreement as two bills passed—to allow 25-year-olds to stay on their parents' plans and to allow external reviews of coverage decisions.

One of the lobbyists, Elwood Kleaver, president of the Idaho Association of Health Plans and CEO of Primary Health, said he had heard of Reischl, but dismissed the PUC model as just another attempt at nationalizing health care. He said larger pools may be attractive, but that the state setting payment rates for doctors would drive them out of the medical field or out of the country.

Like in Canada and England.

He said state regulation would sap all of the "creativity" out of the insurance market.

Deal, who sat with Kleaver at the committee hearing, also associated PUC regulation with universal coverage plans like Massachusetts has implemented, relying on taxpayer funding. The Massachusetts program is, predictably, over budget.

"We all want it to work, but how are we going to find the dollars?"

The Idaho PUC does not get any taxpayer money from Idaho's general fund. Its staff is funded by the utilities it regulates, which are fully funded by ratepayers. If it were to assume responsibility for health insurance as well, this private sector funding model would remain in place.

Reischl argues that a public utility health insurer could even peel off some customers from Medicaid, if rates were to come under control. In another turn of phrase designed to appeal to Idaho's extreme fiscal conservatism, Reischl posits that affordable and regulated health insurance could get government out of the health care market altogether.

Reischl also suggests that his model would empower more creativity in health coverage. For example, the PUC could use its rate-setting power to boost payments to primary care physicians—which nearly everyone in Idaho agrees are in high demand—and steer young doctors away from over-saturated specialties.

All of this Economics 101 still begs the question: Have the health insurance industry and associated health care sectors reached the point of market failure in Idaho?

"There is a clear conflict between short-term financial interests on the part of the current health insurance industry and the long-term needs of a community," Reischl writes in a three-page description of his PUC model.

This week, Reischl is making a pit stop in Boise, en route from Croatia back to his post in Brazil. It took him a year to arrange his fellowship at Minas Gerais. While it was not a great year for the economy, in Reischl's view, it has provided a new climate favoring transparency in certain sectors.

"We have seen that lack of transparency has perhaps contributed to the recession, to the collapse of the economy," Reischl said.

To Reischl, the transparency that the PUC would provide over insurance coverage is its prime selling point: "Now we have seen the banking industry has done things that were unimaginable before, and so now people are saying, 'gee, maybe we should have more transparency, maybe the public should be able to see what the hell is going on.'"

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