Sunday, September 20, 2009

Health Care: Why It Will Still Suck After They "Fix" It

I admit I am getting annoyed. I tried to be patient with this process, but as the days and the weeks and the months tick by, it becomes more and more clear that 300 million Americans are about to get a giant Congressional rectal exam.

I'm not one to join the Teabaggers (and really, with a name like that, how can you take yourself seriously?), and I'm certainly not one to take my AR-15 to an angry town hall meeting. But I think I have read enough on the subject of the health care reform fiasco to realize that we're not going to get the change we've been promised. What we will get is a piece of crap legislation that protects the interests of Big Insurance and Big Pharma and does nothing to improve access to and the quality of our healthcare.

We know that what we have now isn't working. The oft-quoted figure is 47 million Americans are uninsured, and the truth is that millions more are underinsured. In this country, we provide more "care" at greater expense and at worse outcomes than any other industrialized nation. The insurance industry and Medicare have a whole lot of influence how physicians practice. Insurers and Medicare set reimbursement rates for procedures. Basic care has a low reimbursement rate. But the more tests and procedures a doctor orders, the higher the reimbursement. As a result, they often provide more, often unnecessary care. I don't blame doctors for trying to make a living. They go through years of study and rigorous training to practice medicine. But we've created a system that incentivizes quantity over quality.

In the endless, exceedingly tedious debate about healthcare, a few major items have been discussed.

1) A single-payer system. Often compared to Canada and the UK, opponents argue that it will "ration" healthcare. And send your grandparents to the death panel. Certainly those systems have their drawbacks. It is true that some people have long waits for treatment, though my understanding is that those are "nonemergency" cases. If you're having a heart attack, it's not like they send you to wait in line. I also just want to point out that WE ALREADY RATION HEALTHCARE IN THE U.S.. Every time an insurance company denies a claim or refuses to cover a test, treatment, or procedure, they are RATIONING. And if they deny someone a treatment that could or would be lifesaving, well, that sounds an awful lot like a death panel to me. A uniquely American single-payer system (with salaried doctors and coverage for everyone) could be made workable if anyone cared to try. But try getting that past the insurance companies who have bought off Congress. This option is completely off the table at the moment, maybe forevermore.

2) "Universal mandates." Everyone has to be covered, no ifs, ands, or buts. Employers must offer coverage to employees. Those who are unemployed or otherwise don't have coverage through an employer are required to buy into insurance cooperatives (see #3) and/or a government-run plan (see #4). Sure, sounds great in theory. But small businesses will be hard-pressed to provide insurance to their employees, even if there are cooperatives to buy into. And large businesses could choose to cut costs by scaling back their plans- and if employees opt-out, so be it, they'll save even more money. So there is no reason for companies to provide anything but a bare-bones plan with minimal coverage. Employees can choose the lousy plan their employer offers, or pay more to the government plan or a cooperative. Which means we'd be in no better position than we are now. Furthermore, without underwriting reform (see #5) to ensure that no one can be denied insurance or be required to pay astronomical premiums due to pre-existing conditions, requiring everyone to be covered could put a lot of strain on a lot of family budgets.

3) Insurance cooperatives. This is an idea with some potential, but also with some pitfalls. The basic idea is that doctors, hospitals, and businesses band together to offer services to members. The model would likely be Group Health of Seattle, which covers about half a million members. The benefit is that co-ops are non-profit and member-run, with the goal of keeping costs low. In theory, such co-ops would compete directly with private insurers and force insurers to lower their own prices. However, co-ops have a less than stellar history, and there is no guarantee that they would be successful in significantly reducing premium costs to members. (Just for kicks, I went to Group Health's site and got quotes based on my own family of 5... They don't have a plan that matches our current health insurance. The co-pays are higher, they all have some kind of deductible, and all have at least 10% coinsurance. The closest plan to ours is $888 a month, which is more than what we currently pay out of our pocket, but my husband's employer picks up part of the tab. My guess is that the total cost is fairly similar, but Group Health's plan covers less.)

4) Government-run plan, aka "the public option." Sort of a third alternative to Medicare and Medicaid. The government obviously has the negotiating power to keep costs low. But would it just be Medicrap? Hard to say. The insurance lobby has been crying like a bunch of little girls whose kitten died about this one. They complain that they couldn't compete with the government keeping prices low. Well, they could start by not paying gazillion-dollar salaries and bonuses to their company officers. There are questions to be answered about any public option, such as who would be eligible and what kind of financial assistance would be provided to those at lower income levels. But what once was a mainstay of Obama's call for reform has been all but ditched.

5) Medical underwriting reform. At present, insurance companies can refuse coverage to, or cancel coverage for, anyone with a "pre-existing condition" or a condition that becomes too expensive to treat. Depending on the insurance company, a pre-existing condition can be almost anything, from seasonal allergies to cancer, from a being beaten by one's spouse to a prior c-section.* And watch out if you get sick: Your insurance company may drop you like a hot potato. This denial of coverage definitely needs to change. In 2007, nearly 2/3 of all bankruptcies were due to medical bills- in 80% of those cases, the folks who filed had health insurance. (Himmelstein, D, E., et al, “Medical Bankruptcy in the United States, 2007: Results of a National Study, American Journal of Medicine, May 2009.)

6) Tort reform. Supposedly our legal climate forces doctors to practice defensive medicine. I say supposedly because it appears that doctors are acting more as a result of the fear of lawsuits than actual litigation. A new report in Business Week asserts that malpractice suits do not add appreciably to the costs of health care. According to the New York Times, frivolous lawsuits and huge jury awards are not burdening the system. Those who favor tort reform point to Texas as a successful model. While it's true that malpractice lawsuits, malpractice judgments, and liability insurance costs have all been lowered in Texas since the reforms were implemented (all good things), Texas still has some of the highest healthcare costs in the nation.

Will any meaningful change actually be made in this reform process? I somehow doubt it. The smoke and mirrors thrown at us so far fail to impress me. I don't pretend to have the answers myself, but I can clearly see that the House and the Senate have done nothing but kill trees with their 1000+ page bill. I am disappointed that Obama has taken a weak and waffling standpoint on the whole issue. He has backpedaled on the public option. And he didn't give any real direction to Congress- a group of folks who have probably the best health care plan in the country and therefore could care less about anything but the campaign contributions they get from Big Insurance and Big Pharma. The bottom line is that as long as healthcare has a profit motive, we will never see any meaningful improvement in costs or in quality. Since there doesn't seem to be any likelihood of making insurance companies non-profit entities, I'm betting that real reform is nothing but an illusion.

*The c-section issue is a double-whammy, because those women who can't get insurance due to a prior c-section also face hospital and physician policies "prohibiting" VBAC . Which means that many of those women will not only essentially be forced to undergo major surgery, but they'll also have to foot the entire bill, to the tune of $15,000 or more.

1 comment:

  1. There is no incentive for doctors or patients to question the choices they make in healthcare. Making the healthcare industry subject to anti-trust regulations might help but the only way that people are going to start making choices that effect the bottom line of how much healthcare costs is if they have to share in that cost.