Tag: aca

My Area Of Expertise

Jimmy Kimmel had an interesting comment about his input into the healthcare debate:

“I never imagined I would get involved in something like this, this is not my area of expertise. My area of expertise is eating pizza, and that’s really about it. But we can’t let them do this to our children, our senior citizens, and our veterans, or to any of us.”

But let’s be honest here, there aren’t a lot of people whose area of expertise is the impact of public policy on health care. Kimmel does, however, have expertise in being a health care consumer dealing with a condition where there is no such thing as a rational actor: a parent trying to save their new baby.

Maybe Cassidy will claim he didn’t outright lie, as Kimmel asserts. But saying you have crafted a compassionate health care policy because a parent won’t have to watch their kid die for want of a life-saving surgery is disingenuous. Essentially any health care plan passes “the Kimmel test” unless it repeals the Emergency Medical and Treatment Labor Act (I believe the act scopes the ‘provide emergency care to anyone without considering ability to pay’ bit to facilities that accept Medicare, as it is the acceptance of Medicare funds that places the facility under federal purview … so the parent may need to go do a specific hospital, but they can find one). The hospital has to perform a medical screening, and they are not permitted to discharge the patient without stabilization (or the patient opting out of treatment, or if they are transferring to another facility better equipped to deal with the issue …. but I assume the accepting hospital assumes the same legal burden so the two end points are the condition is stabilized or the patient opts out of treatment.)

It’s an inefficient structure. My sister had a kidney stone. She could go into the hospital a few times a month in extreme pain, take up a doctor’s time, get doped up on some pain killer (which takes up even more of the doctor’s time because there are people who surf hospitals looking for Oxi), be handed a prescription she had no way of filling, and be on her way. Now if the stone ruptured something, surgical intervention may have been required to stabilize her ailment. But it didn’t, so they didn’t have to perform surgery to remove the kidney stone because the condition was stabilized by eliminating pain. It would have been cheaper to just remove the thing, but she couldn’t pay for that service.

Another facet of the long-standing federal law is that the hospital is not prevented from billing you for their services. If her kidney had ruptured and emergency surgery been required, she’d have been billed tens of thousands of dollars. If you don’t have anything to take, there’s a lien that sits on the record it expires. Or you have some assets and need to file bankruptcy to protect your car/home and clear the medical bills.

It’s not enough to say our health care system put a parent in the position of being unable to afford saving their kids life – it’s been that way since 1986. Our health care system shouldn’t make the parent bring their kid in every week to be stabilized until the situation becomes so dire that the underlying condition cannot be stabilized and actually needs to be resolved. Our health care system shouldn’t make a parent file bankruptcy to save their house and car from being liquidated to cover the lien from that hospital bill.

The Legislative Process

I am not sure what to make of the legislative process when there are Senators willing to vote for a bill if they get assurance from the House that said bill will not pass over there. That they would hold a vote on a significant piece of legislation without providing adequate time for Senators to read it. And I know exactly how much the opinion of constituents matter given the amount of time between the release of the bill and the vote.

Government by Threat

Trump is reportedly threatening Alaska, hoping to garner enough votes to pass something health-care related. No matter how bad the bill might be, no matter how it may impact *his* voters, no matter how much money it will end up costing everyone (great, I save 20$ in taxes but I’m spending 20k on insurance each year instead of 6k).

A president looking to influence legislative decisions is certainly not new, but I question the legality and ethics of this technique. What is the point of “checks and balances” if the party that implements the policy and uses the budget uses their responsibilities to force legislative direction? Or threatens to abdicate their responsibilities to the same end?

I’m reminded of every bad mafia don show ever made — that’s a really nice building you got there, be a shame if something happened to it. The president has become this caricature! That’s some really lucrative mining we’re planning to approve for your area. Be a shame if someone lost this approval form.

Goofiness aside, this (if true) is the most frightening report to come out of the nascent Trump presidency. Well, maybe not the most frightening. That dubious honor, thus far, goes to Michael Lewis’s nuclear threat piece in Vanity Fair. I have to categorize the potential for nuclear destruction due to administrative ineptitude and malfeasance as worse than the breakdown of the entire system of American governance. Despite coming in a close second to nuclear annihilation … why in the world is there not an investigation into Trump’s strong-arming of Alaska for votes?

24/7 Campaign

How can you be the president of the entire country if you cannot even be the president for the entire military?

The address Trump gave at the commissioning of the USS Gerald Ford may reflect the increasingly long campaign cycle or it may reflect his complete misunderstanding of government (not to mention a complete misunderstanding of how military health care works!). He encouraged (ordered? Not speaking to intent; but as the ostensible head of the military, it would behoove him to use more care in selecting what will be communicated to military personnel) those assembled to “call those senators to make sure you get health care”.

A generous interpretation would be that he isn’t letting an opportunity to push for his legislative agenda pass by – this will be televised, reported … but who stands up at a guy’s retirement party to laud himself and ignore the retiree? Or at a commencement to congratulate yourself … oh, wait. That’d be Trump too. A man seemingly incapable of participating in an event and not making it about himself. Even the generous interpretation is essentially “I’m too self-centered to let your thing be the highlight here”.

But beyond the optics of using the commissioning of a naval vessel as a campaign rally, the ACA does not have a whole lot to do with health care for the active duty military personnel to whom he was ostensibly speaking. TRICARE covers them. It qualifies as insurance under the ACA, so they’re set. Given Trump’s other outright nonsensical ramblings on health care, this in and of itself is telling. Enlisted persons have no more need to lobby for whatever ACA replacement is currently on the table than members of Congress. It’s not going to fuck up their coverage.

Worse, though, the military may report to the president like employees report to the CEO … but it isn’t like we changed out the military for a Republican one in January. They may fight to defend the country, but they are not obligated to support the legislative initiatives of the current administration. From his speech at the CIA Memorial Wall bemoaning how unfairly the press treats him — imagine a similar topic being delivered in front of the Vietnam Veterans Memorial Wall — to this most recent address, Trump seems ignorant of the fact there are liberal government employees and military staff. There are Libertarians. Red scare McCarthyism aside, there are probably socialists too. Point being — there were people in the audience who do not want either of the current Congressional health care plans to pass (given it’s approval rating, the majority of the crowd may even feel that way!) and how insulting is it that the speaker would co-opt what was meant to be a naval celebration to rally support for something to which you object?!

Logic

Trump wants to help some poor baby in England who has an incurable disorder and really no hope for recovery. Of course he doesn’t want to help people with mitochondrial DNA depletion syndrome by funding medical research. He doesn’t want to help Americans with any sort of disorder by ensuring they have affordable health insurance. Or, hell, a single payer system where they don’t need insurance to obtain rehabilitative medical treatments. The new American health care strategy  — develop SEO and social strategies to ensure your sad medical story gets a presidential view and thus you win medical care.

Or perhaps, profiteer that he is, Trump wants to help someone who has raised 1.7 mil come here and spend it. How much does he care about thousands of other terminal kids around the world who don’t have a couple mil to blow? Consistent with the new GOP health care plan: “make sure you have a load of cash on hand”.

I’ve long maintained that humans are not able to perform as rational actors in a free market when it comes to their health care. We may be limited by reality, but I suspect anyone who could come up with a billion dollars would be willing to spend a billion dollars to save their life. Looking at the fundraising for this kid, I realize we are not capable of performing as rational actors when it comes to other people’s healthcare either. A fact which reflects well on society, but makes any capitalistic form of medical care irrational.

More telling, he doesn’t want to subjugate his desires to expert opinion or reality. Sometimes modern medicine cannot do anything to save a person. Terribly sad fact, but still a fact. The question then becomes what measures should be taken to prolong an individual’s life. I have had older friends with DNR (do not resuscitate) orders – or more specific documented requests of what they would and would not like to be done to prolong their lives. How much money is it reasonable to spend allowing machines to breathe for someone who is effectively dead? How many people’s lives could be saved with 1.7 million dollars?! It’s these kinds of questions that make health care policy “hard”, but they need to be answered in a way that is consistent with legal frameworks and funding. Especially funding — if we value life so dearly, then we are willing to pay millions of dollars to stave off physical death for those with no hope of recovery. This means either taxes, insurance premiums, or both. Or we draw a line somewhere. And, yeah, it sucks when your loved one is on the other side of the line. But it sucks that your loved one has no hope of recovery too. There’s anger and the bastards refusing to pay for this treatment are an easy target. If we could only sustain his body for a few more decades as medical science advances …

Then agree to pay more for insurance when you are younger to balance out the pricing for older and sicker people. Or agree to cede more of your earnings for taxes that will fund all available medical care for the duration of any sick person’s artificially prolonged life. Both providing infinite care and not paying for it is not an option given the freedoms we have in this country.

Coverage does not equal access

Coverage does not equal access — this political quip used to argue against the ACA is indeed true. Not sure why the answer is not that *no* coverage pretty well ensures no access.

It was a little silly to say that no one would need to change plans or doctors with the new law. Each new annual enrollment period at work, we have different plans and, yeah, I have to change plans even though I liked the one five years ago that had WAY lower deductables, lower out of pocket expenses, and lower cost to purchase. It isn’t available. I remember my mom changing doctors a number of times in the 80’s because her doctor no longer accepted whatever insurance she had at the time. Why one would claim the ACA would change facts that have been true as long as insurance has been about is beyond me. But the claim was made, so it’s a point of criticism for the law.

I guess the implication is that the AHCA will provide both coverage and access. I’ve read the bill … and not heard anyone explain how the changes even provide coverage let alone access. I guess if fewer people can afford coverage, the lucky ones who can don’t compete for appointments anymore. But that’s hardly a selling point for a bill — a bit like saying we’ve increased selection at the grocery store by making sure 18% of your neighbors can no longer afford food.

There’s a balance in the ACA that I don’t really like. But I *understand* that if we are going with the insurance model of health care and don’t want insurance companies to refuse to cover pre-existing conditions, we’ve got to ensure they’ve got customers who aren’t sick. In this light, the proposed changes to the AHCA allowing states make up their own list of essential services makes a bad bill even worse. I’d be able to have “continuing” coverage (and thus not be someone who could be charged a surcharge from an insurance company) by buying the cheapest policy available that covers only sprained left wrists. Then when I *actually* get sick, buy a good insurance policy that covers actual medical care.

Health Care Re-Reform

I am rather shocked that Congressional Republicans did not have an ACA replacement written and ready to go on day 1, but it’s here now. Scott and I were discussing the proposed changes, and he was all for making older pay more to allow younger people to pay less. Because, fairness.

That’s viewing insurance premiums in yearly increments instead of over an entire lifetime. ACA isn’t making younger people pay more for other older people. It is making younger people pay more so they can pay less as they age. The electric company has a level billing option often utilized by people on a fixed income. Instead of having a 150$ bill in winter and summer with 50$ bills in spring and autumn, you have a 100$ bill each month. If viewed as just April’s bill, yeah 100$ is high. But it isn’t like your extra 50$ is going to someone else’s electrical consumption. It’s paying for electricity that you are going to use for AC in August or heat in February.

Young people don’t get screwed in the deal, really. Over an average lifetime, they are going to pay about the same amount. It’s just level billed throughout their entire life. The only way you really get screwed in the ACA system is non-medical early death (a drawn out medical problem, covered by insurance, may well offset insurance premium prepayments). Spend fifteen years paying middle aged kinda healthy person premiums in your youth and then die in a plane crash … never attaining the offsetting bonus of not paying old people premiums. But, seriously, if you die in a plane crash and the biggest downer is the money you’ve essentially wasted on pre-paying health insurance … get some priorities!

Sure, current old people got a steal (same as the first social security payments — the recipient hadn’t spent decades paying into the fund). Old people paid young healthy people premiums forty years ago. They paid middle age kinda healthy people premiums twenty years ago. And maybe they paid a couple of old people premiums before ACA became law. But they’re not looking at paying twenty years of old people premiums. They get 10-20 more years of middle age kinda healthy people premiums. Middle age people get an advantage too — they paid their twenty years of cheap young healthy person premiums and have forty years of middle age kinda healthy people premiums.

 

Health Care Is Complicated

Aside from the silliness of declaring the whole health care thing just harder than people think — which doesn’t give much credence to people, a lot of public discourse on healthcare tries to avoid sounding insensitive. But the challenge of health care is cost. Not routine costs – even if you do not believe preventative care can reduce long term expenditures, I think we can all agree that a couple of hundred dollars a year is nothing compared to the cost of chemo, or pills taken daily for decades. Arguing about preventative care is like trying to discuss the budget without addressing military spending or entitlements. Lot of people do it, but they’re by design unable to make significant impact.

The big question in the health care debate is how much money should be spend on keeping any one individual alive? I have a friend who had a premature baby (two, actually, but the first time she worked at a med school and basically had unlimited free services through the med school). She incurred neigh a quarter million dollars in bills during the difficult pregnancy. The baby – before he was a year old – had incurred more than a quarter mill himself. Now this was before the ACA removed lifetime insurance caps, and most plans had a million dollar limit. For someone accustomed to dealing with annual physicals and the occasional course of antibiotics, a million dollars seems beyond generous. For a nine month old kid who has already used up a quarter of his lifetime limit? Not so much.

From a purely economic health care perspective, the kid should have died. Even from a general economic perspective, it is statistically unlikely that any individual will contribute millions of dollars of excess value to society (i.e. my work may contribute to society, but I also extract from society). Yeah, there’s the black swan guy who invents computers or cures cancer. Or the whole chaos theory a guy who ran a traffic light and ran over someone’s grandmother prompted a young student to choose a medical degree. The med student identifies a cure for cancer … but would he have even entered into medicine if not for the car accident? But there’s no way to assign a value to an individual’s life before it is over.

Are we OK with letting someone’s premature child die? Are we OK with telling cancer patients that they either come up with a couple hundred grand or they an languish away at home?

And if we are not OK with heartlessness in the pursuit of fiscally rational decisions, how is anything other than universal public funded health care acceptable? Health care isn’t difficult, convincing people that their own values dictate public health care … well, that’s nearly impossible.

Maintaining the role of private insurance in healthcare is hard — in an area where it is impossible to act as a rational decision maker, capitalism in health care is difficult enough to manage. Adding a couple of layers of administrative costs makes it much worse. Having two companies looking to profit makes it much worse. Spending somebody else’s money isn’t a way to make customers cost conscious. Having a system that does not encourage price shopping — often times makes it impossible to price shop — is not a way to drive efficiency or reduce costs. Company paid insurance hid the true cost of private health care insurance … until recently when companies realized they could greatly restrict wage increases because they are paying so much more for health insurance. How many employees actually sat down and calculated if they would have been better off with a real raise than 0$ and whatever the premium increase was. You can see how much your employer spends on health care — I doubt that amount has gone up 1% of your salary in the past year, and a 1% annual raise isn’t spectacular.