Monday, May 8, 2017

Some thoughts on healthcare

I am rethinking how I am going to talk about healthcare with people.  I think that it is important that we fight what is, essentially, a repeal of the ACA, but recognize that the ACA is a woefully imperfect bill.  I think we need to force the discourse to move in a different direction and be careful about how we do it.

One thing that is dangerous is debating pieces of Trumpcare - although we can point some of it out.  I'd really rather have us just start talking very differently about our entire healthcare system.  Take the debate where we want it to go rather than being on the defensive.  

To me, the real question--and it is a moral question--is, should profit-making motives have anything to do with healthcare?  Do we really want a system of healthcare that is designed to generate profit for corporations?

The reason that we have governments is that there are times in which "the market" is the wrong instrument for social organization.  There are many reasons why this might be the case.  Sometimes they are social "goods" that are just never going to make a profit, but that we recognize as contributing to society in important ways, so want to support them.  Sometimes it is because if the services were run like a business, it would be dangerous for society - imagine if the military was not a government entity, but was loyal to companies and shareholders - we would be back in the days of warring petite fiefdoms.  I believe that healthcare is one of these instances in which the market is just the absolute wrong instrument for healthcare.  The goal of healthcare is to prevent illness, heal the sick and the injured, ease the suffering of the dying, and to help the members of the society thrive.  As such, there needs to be enough money in the system to fairly compensate all those who work in healthcare, to ensure that facilities are top notch, and to encourage continued research and development into new treatments, but they should not be about profit.  And I'm going to point out that I know A LOT of people who work in the medical professions, and not a one of them got into healthcare with profit as their main motive.  They got into healthcare because they wanted to serve humanity as healers....because they care about people.

The ACA was an attempt to move the needle, but it was a compromise, and not a very good one.  What we really need is to get medical care free of the insurance companies by moving to single payer - to Medicare for all.  This would cut way down on the administrative burden.  A huge amount of the business that doctor's offices have to deal with is trying to get claims paid.  Medicare for all would dramatically simplify that.  With all the population in the pool - it would balance out the younger and healthier balancing the older and sicker.  Rather than returning to the horror-show of pre-existing conditions exclusions, Medicare for all would eliminate the terrible risks to people who have employer paid insurance if they lose or change jobs.  The government could negotiate for actually reasonable drug prices.  We could kill the UCR tables where every bill I ever get from a doctor says things like "Hospital services, amount charged $39,541.60, Allowed amount $4,466.50, Amount paid, $4,466.50."  (This was from my surgery).  So, what this says to me is that my surgery costs around $4500, but in order to get that amount, they jacked up the price by almost $35,000 and if I didn't have insurance...I'd be paying almost $40,000 for the surgery I just had...which means I wouldn't be having that surgery because I don't have $40,000.  I mean, who does?  What reality are we living in?  I guess I'd just continue to go through life with sinus troubles and not being able to breathe.  I suspect that if we had single payer, they could negotiate what they are going to pay and there would be no more of this crazy math.  And before anyone says, "But wait! SOCIALIZED MEDICINE!!!"  That is a red-herring.  Nobody says in hysterical tones, "SOCIALIZED STOPLIGHTS!!!"  There are things that it makes more sense if they are run through the government rather than the market.  Medical care is one of them.

So now, I want to wind the clock back to before the ACA and talk about what I DO NOT want to go back to...and what I believe Trumpcare could re-create.

Obviously, there were a lot of uninsured people who would go to emergency rooms for everything because they didn't have care and you can't get turned away from an emergency room.  We will have a lot of people who will lose their insurance.  But, at the moment, I'm going to speak from the position of someone who works as a manager in an organization that has employer-provided healthcare because I want to point out several ways that tying employment to healthcare makes NO SENSE.

Without laws making it illegal to exclude pre-existing conditions, depending on how large and aggressive your company is in negotiations, you may or may not have a plan that has pre-existing conditions exclusions.  Now, this doesn't necessarily keep you from getting "care," it just means that the plan is not going to cover conditions that you had prior to being covered by that plan.  So, let's say you are in the job and you have something that you are concerned might be serious or chronic.  If you knew that no matter what you would be covered, you would go get the diagnostic tests as soon as you were worried about it...possibly catching a situation early, when it is easier to treat.  But instead, you think..."well...I may want to change jobs in a couple of years and if it is something chronic, then if I switched insurers, they might not cover me and I think in the long-run, I'm not likely to be at this job in ten years.  Maybe I should just wait and see if it goes away."

This kind of thinking is really common.  It keeps people from getting checked out when things can often be dealt with more safely and cheaply and then they finally end up in the doctor's office when it is really bad and much more expensive to treat.  This is one of the reasons why our healthcare costs were so ungodly high.

Another scenario goes like this.  You know you have a chronic condition that needs to be managed and that if you left your job, would be uncovered.  Maybe you need a drug that costs $200 a month for the rest of your life, a liver test that costs $1500 annually, and if anything ever went wrong with it, it could be quite expensive.  You hate your job and you feel trapped, but you don't dare leave.  On the other hand, you are a good twenty years from retirement.  Every day, you get up, feeling trapped and resentful.  You carry that into the workplace where you are angry, ready to take offense, frustrated in general and are a morale dark hole.  You are totally toxic in your workplace, but are not going anywhere.  You do your job well enough to not get fired, but negatively affect everyone around you.  Another variant is that instead of being angry, you are a hyper-anxious mess about the possibility of getting fired and losing your coverage...which is also a seriously negative hit on productivity and morale.  These were really common and are devastatingly bad to an organization.

Maybe you have an entrepreneurial spirit and would really like to try starting your own business.  Or you are an artist and can support yourself, living frugally, on your art and a part-time job.  Except you can't, because you can't get health insurance that would actually cover anything at a price you can afford.  So, instead, you never strike out and, instead, stay at a full-time job that does not allow you to take a chance on your innovation.  Is this good for our country?  I don't think so.

Finally, you have employer-related insurance for your children.  You have a teen that is showing some signs of a potentially chronic condition.  They are going to be off your coverage you wait on seeking a diagnosis and medical care in the hope that they can make it until they get a job that they will then be tied to?  Do you get them the care and then hope that they will be able to get into a job that is both large enough and has been able to negotiate strongly enough that they don't have pre-existing conditions exclusions...but what if they don't?  What do you do?  If it's a mental illness, you only have until they are eighteen where you can force them to get help, but then you set them up to be potentially without care the rest of their lives.  Yay.  This totally sucks and there is no good conclusion without pre-existing conditions being illegal.

We need, we absolutely need, the requirement that companies must cover pre-existing conditions and that those with pre-existing conditions should not be isolated into their own "high risk" pool.  What will happen if they are isolated is that they will be given an "opportunity" to buy health insurance that will be so cost prohibitive that no one who is not wealthy will be able to afford it.  That isn't "access" to health care.  That is a "bare opportunity."

Again, I think we need to step back and ask ourselves why we have for-profit health insurance companies.  Unlike, say, fire insurance - health problems happen to all of us.  It is part of the human condition.  There isn't anyone who is not going to get sick, get hurt, get old, and eventually die.  So, it isn't like the statistical odds of various forms of accident or fire insurance where you are paying a bit into the kitty on the off-chance that you are the one who will need it...but you may never.  You WILL need healthcare.  You will probably need health care at some point this year.  You SHOULD probably at least get screenings for something so that you can stay healthy.  Insurance is not the way to deal with this.

The clear solution is Medicare for All.


Maggie said...

I agree with your analysis, entirely. And I suspect that some folks are unaware of parts of the relevant history. Here are a few:

Employer-paid health insurance began as a way for employers to reduce the payroll taxes they paid while still offering 'competitive' compensation. Instead of paying you (in made-up numbers, take them as examples) $4000 more per year and letting you buy your own health insurance, they negotiated with Blue Cross (at first the only provider) to pay $1500 per year for the same coverage you could buy on the open market for $4000 ... and take that cost as a tax deduction for the business, not pay the payroll tax on even that $1500, and also keep your income tax lower. Looked like a win-win-win for all concerned, right?

Except that what no one mentioned out loud (where employees could hear it) is that this would also reduce employee turnover by tying you to your big-company job. Because in those days little companies couldn't negotiate any such thing.

Or how about the fact that the early health insurance policies only covered surgeries and other big-ticket items, but left well-baby visits and other preventive care for you to pay by yourself? This seemed a good idea at the time, but turned out to encourage people on tight budgets to skip preventive care and hope for the best, knowing that if they got "really sick" the insurance company would pay for it. And mostly not thinking about the possibility that some preventable illnesses might prove to be unfixable.

So then, as a culture, we 'fixed' that problem by having some insurance plans pay for more and more preventive care ... and then we started judging doctors by how many of their patients conform to measurable norms for things like blood pressure, blood sugar, weight etc. Which we now know has resulted in some doctors and hospitals being penalized for taking care of people with significant illnesses or injuries or intractable conditions.

The more we try to tinker with the system, the worse it gets. Time for single-payer.

Congress won't do that until they can find a way to salvage the jobs of the CEOs and other corporate executives at the big insurance companies. Maybe we should be finding significant, useful work for those folks to do.

Susanna said...

Very good analysis. I've been self-employed for most of my working life, so for many years I paid for what insurance I could afford, usually through a group. This was major medical only, which is to say it covered almost nothing. When my monthly premiums went from $272 to $643 (it was 17 years ago and I still remember those numbers), it was a no-brainer: I dropped it. I was uninsured till Romneycare was implemented in Massachusetts. Whew. I went from Romneycare to Obamacare (the bureaucratic hassle was immense), then last June I turned 65 and went on Medicare. Huge sticker shock! I'm now paying about 2 1/2 times what I was paying under the ACA for roughly the same coverage. The problem is that the subsidies under the ACA go up to about 400% of federal poverty level, but with Medicare you have to be close to FPL to qualify for anything. That needs fixing. Dentistry needs to be included. But single-payer is the only way to go. I hope the Trumpcare travesty will persuade more people of that.