Accepting Realities
March 14th, 2007A short history of health care.
Slate column sort of reviewing New Republic editor Jonathan Cohn’s book Sick: The Untold Story of America’s Health Care Crisis—and the People Who Pay the Price that is refreshingly honest about the state of healthcare in the United States.
“The problems inherent in the U.S. system of health care are literally killing people.”
and:
“The overall trend—the gift of an increasingly market-driven health-care system—is to undermine the very idea that the cost of illness should be spread out among the general population, healthy and unhealthy alike. In this sense, the private health-care market is too efficient. Assigning health care costs to sick people is what the market wants to do.”
The notion that we should pay our own way in healthcare has been expressed in alarming ways on this site and on others linking here.
“I don’t want to pay for anybody else’s choices or illness” is a common U.S. notion. Until we get back to a non-profit, non-market driven insurance concept or something that doesn’t deny care to those that need it, those of us who “don’t want to pay for Ms. Jones cancer” or “don’t want to pay for somebody’s bad choices” are in a state of denial about the very nature of insurance. If you want the status quo, which will be less and less coverage even under an employer subsidized plan, you are still paying for those things. Maybe you won’t pay for my choices, but you are paying for choices of those in your plan. Look in the next cubicle or two. You are paying for their choices and their illnesses.
It is clearly time for a new way of talking and thinking about healthcare in the United States. This column on Slate is a good start. o
March 14th, 2007 at 10:11 am
How appropriate that you should post this today- I just found out that my insurance company is denying me any more physical therapy sessions. Apparently, being pregnant and having 4 herniated disks in your back is not a good enough excuse for physical therapy.
March 14th, 2007 at 11:32 am
Speaking as a man who is well-covered under two employer policies (and thankful for it), I have this to say:
The medical system in the USA is well and truly screwed up. The people who theoretically would be able to pay for more than co-pays (like me and my family), don’t pay squat and the people who can’t afford even basic care, have to pay more.
Am I saying I want that to change and I’ll pay more in taxes? Yeah, pretty much. (Yes, I’m a bleeding heart liberal). The health care system in the US is flawed and inherently unfair.
I know having a HUGE government program for universal health care isn’t a real winner for politicians or the electorate, but we already have one that could be expanded: It’s called Medicare/Medicaid and a zillion senior citizens depend on it. Yes, it has problems and people complain about it, but it does work.
I’d probably vote any candidate for prez. who had a sane health care initiative. It’s that important an issue in this country.
March 14th, 2007 at 11:42 am
I, for one, would rather not have to pay more taxes than we already do. Tobyjoe and I get slammed every year by both NYC and Federal (NYC has some of the highest, if not the highest, taxes in the country). I’m good there.
The thing that gets me is how much the Bush Administration has dumped into our defense budget. Isn’t it around $481 billion range for next year? That’s criminally insane. It’s not that I want our soldiers to not get the funding they need, but holy crap, considering he lied to get us there, it’s really disheartening at this point.
Can some bastard come along and lie us into the need for a 481 billion Health Care Defense Budget?
So, no more taxes for me. We’re all well and good and fucked here in New York. Instead, may I suggest they use the money we’re already giving them a little more wisely?
March 14th, 2007 at 11:44 am
Oh, and I, too, consider myself a liberal. Just not sure we can spare much more of our income without suffering some major consequences. We do alright now. I won’t complain. But if it gets worse, we’re in for some trouble.
March 14th, 2007 at 11:47 am
I know all too well how life can change in the blink of an eye.
When our daughter was diagnosed with Type 1 diabetes at only 18 months you would have thought that the insurance company would do what is right for a toddlers health. They could not have acted more indifferent to her needs and care.
We requested an insulin pump for her because it’s the best method to keep her glucose levels as steady as possible. There have been endless studies that demonstrate the sooner someone is on a pump, the better their diabetes is kept in check. I was faced with months of calls and letters only to be told each time that the answer was no. In the end I suggested that they issue the pump because I’ve proven the need and could demonstrate clinical studies to prove it was in her best interest. Their other option was to deal with a lawsuit. The pump was approved 3 weeks later.
The best part of the story is that the pump has a street value of about 6k - 9k dollars but one trip to the hospital to deal with hypoglycemia or hyperglycemia would cost about 5k and those trips can be common for toddlers who manage their diabetes with shots. It makes business sense for them to issue as many pumps as possible.
In the end, we were able to get what we needed for her and have it covered by insurance but we’re certainly more tenacious that most people would have been. I’m sure others have not been as fortunate and suffer because they don’t feel they have any options.
When you’re sick and need help, the last thing you should have to do is fight with an insurance company.
March 14th, 2007 at 11:51 am
In response to the comments abouit taxes…. I’ve always said we need to elect practical people who are good shoppers. I’m fine with paying higher taxes if I see that the money is being spent in an appropriate manner.
March 14th, 2007 at 12:08 pm
Thanks for posting this, though it does make me a little bummed. Several months ago I was singled out at a staff meeting when our new health care coverage costs were unveiled; “With everything that Katherine went through last year, it really hurt us in renewing coverage…” I kid you not. I’ve been looking for a new job ever since.
And I’m supporting Edwards thus far for ‘08. His ideas on health care aren’t perfect, but the best ideas I’ve heard from any of the candidates.
March 14th, 2007 at 12:15 pm
Katherine, I think you might have yourself a lawsuit there if you’re the type to sue.
March 14th, 2007 at 1:05 pm
I won’t list all the details, but suing wouldn’t be worth it under my circumstances. Besides, as the director of marketing, I would hate to have to do the PR spin for a suit I was bringing against the company. Heh!
The rather funny context of it all was that the last issue I had was a broken tailbone, which took 3 months to diagnose and 2 months to successfully treat. So just when I thought that the “pain in my ass” was gone, it came back in glorious metaphor.
March 14th, 2007 at 1:56 pm
I’m currently reading Hillary Clinton’s “Living History” and she discusses health care in America quite a bit, including the fact that many senators she spoke to didn’t know the difference between Medicare and Medicaid.
Don’t get me wrong…Canada has its own health care issues, most definitely, such as wait times and lack of primary health care physicians in many areas. But hearing about the plight of Americans on this issue is heartbreaking.
March 14th, 2007 at 2:32 pm
MangoFalls…
You have experienced what almost everyone who has to deal with any insurance company has found:
They are not on your side. They on *their* side (read: the shareholders)
As a matter of fact, in many cases the *only* way you can get their attention is by being adversarial, (i.e., hiring a lawyer or having a lawyer send a threatening letter). Insurance companies almost always universally suck.
I hope your daughter is doing well.
March 14th, 2007 at 7:04 pm
I really think that we’ve let health care get away from us. We treat insurance like it is supposed to pay for everything.
Why is that? Insurance is supposed to be there for when things really go bad, cancer, etc. Why do we think insurance should pick up the tab for our yearly physical? To many people give their insurance card to the front desk and never really examine how much things cost. This is like expecting your insurance company to pick up the cost of oil changes on your car.
Most of that cost isn’t about the doctor, it’s about the paperwork of filing all those insurance papers, and documenting the heck out of what exactly happened lest someone be sued.
I’ve moved to a health savings account plan, not one through my employer, one for just me and my family. I run the savings account, I pay the bills, and I shop for the insurance. I’m not doing this because it’s a tax free way of having a savings account. I do it this way because it keeps me in touch with exactly how much things cost. When the doctor charges me $200 buck for a visit where my kid was only in the examine room for half an hour, I have a discussion with them. It’s absolutely silly what this stuff costs and more people need to pay attention.
March 14th, 2007 at 9:23 pm
Increasing taxes isn’t the answer. Our government already spends money like Longshoremen on a day pass..adding fuel to that fire isn’t the answer. The smartest thing would be to remove the middleman that adds nothing but costs to healthcare (ambulance chasers).
March 15th, 2007 at 4:50 am
I wish Timothy Noah would opt for one of the following choices: (a) stop writing about health care or (b) take the time to learn something about his subject matter. There are so many errors in this piece that one hardly knows where to begin rebutting them.
For example, his first big “reality” clearly demonstrates that he is hopelessly out of touch with the basic facts of American health care. His assertion (often repeated in the various mass media) that health care is “inaccessible” for those without health insurance is sheer nonsense.
EMTALA assures that no one is turned away from a hospital ER for lack of money. It is also nonsense the “47 million Americans” without health insurance can’t get it. Two-thirds of these folks have annual incomes above $50K or are eligible for some sort of government assistance.
March 15th, 2007 at 8:04 am
EMTALA has undergone a series of legal challenges. If I have access to information, I can push my local ER to give me care. But it will not be the best care, nor will it be given under the best circumstances.
The fact that mothers need to sue to get help for their newborns is a huge indicator that there are major problems with the system. I have to have a lawyer to get healthcare in the U.S.? Are you kidding me?
One example can be seen here.
March 15th, 2007 at 9:10 am
David,
You’ve obviously always been covered under an employer’s health care policy or you would have a better understanding of how hard it is to get health insurance on your own.
My husband and I have a small farm business and we have only major medical coverage with a very large deductible– the kind where you have to have something catastrophic happen before insurance pays for even part of it. It’s all we can afford, and every year the premiums go up. I don’t know how much longer we can afford to pay a monthly premium that’s as high as if we were purchasing a Lamborghini.
The war in Iraq and health care are the two issues that I will use to decide who to vote for in 2008.
March 15th, 2007 at 10:43 am
The uninsured need no special information or expertise to access care in the ER. In fact, it is a standard policy of virtually all hospitals (including the four in which I have worked) to treat such patients before bothering them about insurance or money.
This notion that hospitals turn away patients because they can’t pay is a myth. The reality is that the average hospital in this country writes off between 5% and 10% of gross revenues to indigent, charity, and other uninsured care.
March 15th, 2007 at 10:59 am
But David, certainly you’ll admit that ER care for chronic conditions is not optimal or desired. If I have a chronic problem with my child, ER care is going to be costly to everybody involved.
The reality you seem to ignore is that millions of people don’t have health insurance, don’t know their options and are terrified to discuss other options than for profit insurance that is dwindling in its coverage.
While it’s noble that hospitals don’t turn people away, it’s not a solution to the bigger problems facing healthcare in the U.S. and the world.
Would you disagree with Noah’s notion that people are dying because of systemic problems from within the current U.S. healthcare system?
March 15th, 2007 at 12:37 pm
My main point is that many of Noah’s assertions simply don’t square with the facts, and that his characteristic reliance on hyperbole and mythology tends to vitiate the quality of the health care debate.
Which brings me to his “people are dying” statement. All health care systems have issues that cause unnecessary pain and (occasionally) death, including the vaunted Canadian system.
So, Noah’s insinuation that such issues are unique to our system is either ignorant or irresponsible, probably both.
March 15th, 2007 at 1:30 pm
McKinsey Global Institute recently published a comprehensive report on why health care costs what it does and some suggestions for reform on both the demand and supply side. You need to register to read the full report, but it is free and even better, interesting.
http://www.mckinsey.com/mgi/rp/healthcare/accounting_cost_healthcare.asp
March 15th, 2007 at 2:24 pm
PTC, thanks for that link. I’m reading it now.
March 19th, 2007 at 12:53 pm
There is a difference between risk sharing and subsidy. I don’t mind paying for someone who is paying premiums in a risk pool with me — they would do the same for me if our positions were reversed. (Assuming we are similar risks and making similar payments, or that our payments are adjusted for the differences in risk.)
Do I want to pay for someone who isn’t paying premiums, or isn’t paying a proper amount? No, I don’t, really. I’ll do it for someone who _cannot_ pay for themselves, but I certainly don’t want to do it for someone who could afford the premium.
The big trouble with our current system is that it is so convoluted and full of bad incentives that price signals can’t get through and admin costs are enormous. Take that stuff out, expose the real costs, give people real flexibility to seek out the coverage they want, and we’ll find that the vast majority of people can take care of themselves just fine. Then we can work out the rest.
Unfortunately, most of the calls for “reform” are really calls for income transfers. Yeah, I’m against that.
March 19th, 2007 at 1:03 pm
Nobody, I believe that you’ve described, partially, a universal system. That McKinsey document basically echoes the ABC News/Peter Jennings special on healthcare in America special from awhile back.
Your statement about admin costs being high matches the McKinsey findings (which I agree with also).
The McKinsey report also had some interesting findings regarding physician motivations and new technology adoption.
I agree with most of what you have written. When I talk about reform, I’m really thinking along the lines of a complete system overhaul, which changes the motivations of all parties. ER care isn’t optimal for those who can’t afford a primary physician. Nor are employer subsidized plans.
At some point, employers are going to bail on employees. And that is when the real shit is going to hit the fan.
March 21st, 2007 at 8:54 am
I spent a good portion of the early 90’s working for two software companies that provided medical and dental billing software. In one company, I wrote the user documentation and provided support for the part of the system which supported HMO billing. I have a special hatred for HMO-style healthcare insurance now and refuse to even consider it as an option.
The biggest problem I see is that the insurance company has inserted itself between the doctor and patient, subverting what should be a very intimate relationship. It really doesn’t matter to me at this point how the insurance company put itself there. All parties involved are complicit in this. The end result has been a complete destruction of expectations. When you go to see your doctor for an office visit, you pay a $15 or $20 copay, which under fee for service would probably run $80 to $100 bucks. The doctor may try to charge this amount minus the copay you’ve paid to the insurance company, but he won’t get that because of the Usual and Customary Fee schedule set up by your insurance company. He might get 80% of what he billed.
Further, if you get really sick and require a lot of tests and ongoing treatment, the insurance company will put a cap on the amount it will pay out or just flat out refuse to pay. Thus, you don’t get the treatment you need.
Universal healthcare will NOT fix those and all of the other problems discussed here. All that will do is move healthcare from a privately rationed system to a publicly rationed system and make a system that is out of whack totally disfunctional.
What I’d like to see is a removal of the insurance company from the doctor-patient relationship, where you pay fee for service for routine office visits and minor health issues and you have catastrophic health insurance for anything major like cancer treatment or major surgery. Further, this insurance would NOT be provided by employers as a benefit, you would get it, or not, on your own for as long as you wanted to pay for it, regardless of how many jobs you have.
I’d like to see tax-free MSAs exppanded to allow people to sock away money for their out of pocket health expenses not covered by catastrophic health insurance. They exist now in some form, but the restrictions that exist now such as ‘use it or lose it’ from year to year need to be removed in favor of some sort of cap on how much can be in an MSA, say 10K or 20K.
In this way, you have an incentive to see your doctor only when you really need to see him, when you’re sick or when it’s time for the yearly physical and you can expense the cost via your MSA.
March 21st, 2007 at 10:36 am
Roger,
Thanks for your comment. It’s this kind of thinking and discussion that needs to be pushed to the fore.
What you describe is what my family has. The only problem is the cost for catastrophic is so high because we’ve been denied insurance. But for almost all of our health care costs, we pay out of pocket. It’s not as much as I had thought it would be. Worse are the monthly premiums.
Medical Savings Accounts (MSAs) or Health Savings Accounts (HSAs) are emerging, but I agree that they aren’t common or the incentives to participate are low.