Tag: health care

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.

Precognition

how fucked up is our form of government when the passage of a bill rests on the author’s ability to craft perks for Alaska without specifically saying “Except for Alaska, which will get an extra fifty mill each year and the Department of Interior won’t accidentally lose all of their grant applications for the next three and a quarter years”?

Repeal and Replace

There’s a television show where a group of people go around to auctions and buy ‘stuff’ to resell. They’ll “bid up” the price to screw other people out of money (I expect this is a strategy to prevent competition for upcoming items?) but sometimes get stuck with a high price on something they didn’t actually want because the competition backs out of bidding prior to expectations. I’m worried the AHCA is the guy who overpaid for junk … it started out as a marketing ploy than actual legislation. Pass a repeal and go to their constituents with “*I* got this passed for you (vote for me again), but the bloody rest of the HR stopped your will from being enacted. We don’t have enough Reps, donate NOW and get more R’s in here. Oh, the cursed President said not to worry because he’ll veto the bill — donate NOW and vote for the R. Oh, wait, this didn’t pass the Senate – send money NOW so we can get a super-majority in 2018.

Except it passes the Senate and the incumbents have to live with the results of their legislation. And, yeah, this country has a policy where hospitals need to provide emergency care to anyone regardless of means (they can also bill the person a few hundred thousand dollars, slowly drain away that person’s assets, and file a lien against the estate). Which is great for a relatively health person who suffers a sudden calamity — car crash, fall down a mountain, etc. May not even be terrible for someone who experiences a heart attack. Town halls with Tea Partiers going on about abstract death panels are going to seem like nothing. Wait until the people slowly dying with access only to emergency interventions that extend their suffering start popping up in the town halls — no coverage for the cancer relapse, but you’ll stabilize me and send me home to suffer a few more weeks. People who realize that, sure, an insurance plan *is* available to someone who had a stroke a few years back but how does this state high risk pool with a 250k annual premium help ME? Seniors who lose their subsidies and can no longer afford heath care. People stuck in terrible work situations because losing coverage means the condition will become pre-existing.

Wait until women see premiums quadruple after having a child. My local rep couldn’t tell me if the insurance company would be disallowed from raising my premiums if I self-funded sterilization, provided a doctors note attesting to menopause, swapped over to female partners, or otherwise precluded future pregnancies … and he then he got all annoyed with my expectation that he would have read and, ya know, *understood* the full text of a bill for which he was voting. 

And Republicans will free insurance companies from ACA’s requirement to spend 80-85% of premiums on health services … so all of these sad stories will be coupled with record profits and stock buy-backs within the insurance sector.

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.