Tuesday, January 2, 2018

Disagreements on Healthcare

Given some of the latest legislative events, I wonder what will happen to America's broken health care system.  Will we finally start to fix it in a bipartisan manner, or will we continue to see the bickering which has destabilized the system for many Americans?

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The reason I write this entry is a heated discussion I had the other day with my friend Joanie.  We come from very different ends of the spectrum, and have very different interpretations of the way the world works.  I see many people who need help, but are often too proud to accept that help. She sees anecdotal evidence of "Welfare Queens" who bum off the system. If one looks at the evidence, there may be a small number of people who abuse the system. But there is a large number of people who have to game the system so that they can collect the paltry benefits to which they are entitled.

Why is it that a system geared to help the needy has to be gamed in the first place?  In many areas of this country, a certain Calvinist explanation is accepted for why some people are poor and why others are prosperous. God delivers to those in this life to whom he will favor in the next. In short, it is your moral failure that keeps you from having a bountiful life. And if you aren't doing the right things to have this life, why should we help?  This attitude is unforgiving, and falsely assumes that the person in need caused his/her own predicament.

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When it comes to healthcare, Americans are blissfully ignorant of why it is dysfunctional for large portions of the population. Joanie is one of those who are ignorant, and to make it worse, was once a medical student outside the US.  (No US school would have her.)  So her biases would likely be strong from the very beginning of any conversation.

Let's start with some basic assumptions:
  1. The more the pool of insured reflects the community as a whole, the lower the cost of providing insurance to any one member will be.
  2. Cherry picking healthy people from the larger pool will increase the costs of insurance for those left in the pool.
  3. Employer paid health insurance separates part of the decision of buying healthcare from the person(s) who actually use that healthcare.
  4. Employer based insurance pools indirectly encourage employers to discriminate against employing people with high healthcare costs.
  5. People who are unemployed for any reason are excluded from employer pools (after COBRA expiration) and fall into an insurance pool which no longer reflects the community as a whole.
  6. Even when we have large community insurance pools which properly reflect the health of that community, young people will cost less to insure than older people.
  7. Governments do not adequately cover the cost of treating the uninsured in hospitals, thus forcing hospitals to recover these costs by overcharging other patients.
  8. Insurance companies use their power to prevent their insured from paying for the uninsured's medical care. This pushes prices up for those not covered by insurance.
  9. Poor people will often defer getting healthcare, as they often have other more immediate needs for the few dollars they have to spend.
  10. Poor people have often been uninsured and unable to pay their medical bills (when incurred), thus raising the price of healthcare for the rest of us.
You'll note that I have not itemized issues such as family coverage, transparent pricing, tort law, doctor's insurance costs and the quality/effectiveness of prescribed treatments.  Healthcare is a Gordian Knot of intertwined problems, and no amount of simplification can make it simple enough for the average person to understand. And when people can't understand enough of the problem to be comfortable with its nature, they get angry and push for simple solutions which only make problems worse. And that's where my conversation with Joanie comes in.

As I've stated before, I am a strong supporter of the ACA (Obamacare). It is a very flawed law which has gotten worse due to the GOP's desire to repeal the law without a well thought out replacement ready to go.  Recently, the repeal of the individual mandate has made things even worse, as it allows presumed healthy people to cherry pick themselves out of the community pool, and then be at risk for non payment when catastrophic care is needed. Couple this with the removal of insurance subsidies, with the bogus claim that it is a giveaway to the big insurance companies, and it is a miracle that Obamacare still survives. I guess that our previous president and the Democratic party expected these political problems when they enacted this law, and made sure that it could withstand GOP control of government for a few years.

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Joanie is understandably pissed off at our health care system.  She was unemployed for several years from the early 2010's to the middle of the decade - just before the benefits Obamacare took effect. She got both shoddy and expensive care from her doctors when she needed treatment for one ailment. She couldn't afford to be passed around from one doctor to another, couldn't afford to spend hundreds of dollars on 5 minute consults, and didn't see value for money spent when she had little money to spend on health care.  So she entered our discussion with a very different mindset regarding healthcare than I have.

My position regarding health insurance is that everyone must carry it, and that if a person is too poor to afford it, government should subsidize it.  This addresses issues #1, #7, #9, and #10 above.  I am not happy with employer paid healthcare, because of items #2, #3, #4, and #5 above.  However, I have no problems with employers if they were to subsidize my choices from insurance bought on a marketplace. Money is money, and if I got more of it in pay (direct or indirect), I should be the one saying how and where it is spent.  And I support the idea that there should be cost shifting from old to young when it comes to health insurance, as it helps compress the prices any individual will pay for healthcare throughout a lifetime of care.

When I mentioned healthcare to Joanie, she was very angry.  Phrases such as: kept coming from her mouth:

"People should get a job and get healthcare from there." 
"Why should I pay to subsidize deadbeats?" 
"I got shitty care. Why should I be required to pay for something I don't want?"

She could not see the larger picture, as she focused on how she was screwed by the system. And this is quite common among many people.  Joanie told her doctors that she was unemployed and that she couldn't afford expensive treatment. But living in Manhattan, any doctor she found there would likely perform lots of expensive tests, as they know they might be sued for any little mistake. The doctors likely focused on what was the right care to give her, and not what was the most affordable treatment that could be given to her.

Contrast this to what happened when I screwed up my right hand last New Year's Day.   I fell on my right hand, straining a few muscles.  When the hand still hurt after a couple of days, I finally went to see my doctor - who immediately ordered X-Rays to see if any bones were broken. When I eventually talked to him again, I found out that it was only a muscle strain, and it would take a long time to heal.  Joanie had 3 doctor visits and 1 MRI.  I had only 1 doctor visit and 1 X-Ray for similar problems. I paid much less for my care than she paid. No wonder why she is angry.

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Healthcare is expensive.  But in America, it is needlessly expensive.  Government is prohibited from negotiating drug prices, and as a result, we have the highest drug prices in the world. Marketplace distortions have affected American healthcare since the 1940's, and a large sector of America has been cherry picked out of what would be a large community market for healthcare insurance. Government has subsidized excessively expensive drug therapy for ailments such as cancer.  This sounds good.  But when there is no lifetime expense limit on healthcare, insurance prices only can go up. I may sound heartless here, but I'd like to limit the amount of research being done that results in high cost treatments for many diseases.  Yes, more people will die. Yet, it would leave more money available to treat those ailments we already know how to cure or manage.

What is the cost of a human life?  Insurance effectively demands that we answer that question. And in a democratic society, do we value each life equally? Or, do we value lives depending on how much wealth a person has?  To answer this question, we can not ask this about healthcare alone, but we must ask this about how much any life is worth to a society. The Bible says that there will always be poor. But does society have to treat poverty as a moral evil instead of an economic misfortune?

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