Disentangling Healthcare Debates

With the passing of Ted Kennedy, it seems only appropriate to discuss health care today.

I watched Jim Moran's town hall meeting with Howard Dean last night and it is certainly true that not everyone on the political spectrum is interested in actual debate. It is also true that when your interlocutor is disinterested in rational engagement, bringing cogent arguments to the table is not like bringing a knife to a gun fight, but more like bringing a rubber chicken to gun fight. That being said, it is still valuable to be clear about the several different questions that are being confused and conflated.

When we talk about health care, we are actually talking about three different things that give rise to seven different issues.

1) Who pays.

A major part of the debate over health care has nothing to do with health care, but with health insurance, with who gets the bill. Our health insurance system arose accidentally in a manner that was not well thought out. We get our health insurance through work because in the aftermath of the crash of '29, when inflation was destroying our economy, there were wage controls put in place to try to keep prices down. As a result employers could not give monetary wages and so they sought to attract workers with better non-financial compensation, with fringe benefits and these included health insurance from for profit insurance companies. So now health insurance comes through employers. This has caused two big ol' problems.

1a) The uninsured.

Health insurance would be universal, that is, cover everyone, if we all had jobs that came with health insurance. But we don't. The unemployed, those with part-time or temporary jobs, and those who work full time for places like WalMart do not have health insurance. This is a problem because someone has to pay for their care and they cannot afford to. In addition, we know that these tend to be folks in populations who are more likely to have more regular and severe problems. There is an undeniable link between social class and public health. Additionally, because they do not have access to regular check-ups or family physicians, problems that could be spotted early and fixed easily and cheaply tend to be ignored until they can no longer be, get treated in emergency rooms when they are more severe, more debilitating, and more expensive. This means their care costs more, results in decreased productivity, and increased human suffering. No other industrialized nation has this problem.

We should be much more embarrassed than we are by it, but Reaganesque hatred of those lower on the social ladder has allowed us to turn up our nose at anything that would help those Americans who need help and we use the smokescreen of the word "rationing" to create the same hysteria we find around affirmative action. If we help the uninsured it will mean that good, hardworking white regular Americans won't get the medical care they've grown used to and thereby deserve. Of course, this is false, but facts are stubborn things.

1b) The uninsurable.

Insurance companies exist not to help Americans get the best health care possible, but to make a profit. They do this by collecting premiums, paying out overhead, paying claims, taking the money that is left and investing it to collect the dividends. As a result, they love people who pay in and who have no or few bills to pay. They hate those who have large bills. They employ actuaries who have seen that people who have been sick before are more likely to get sick again, especially in the same sort of way. So, what they've done is make up rules whereby if you have been sick before or may have been sick before, they can refuse to pay for any further sickness that is or might be connected. If you have a pre-existing condition, insurance companies see that they will likely make less money off of you and thereby will refuse to cover you or will only do so for things not connected with your pre-existing condition. in other words, they will let you pay in, but not take out for what you will most likely need it. The whole scam works just like a crooked casino, only one with really powerful lobbyists.

1c) The formerly insured.

But the crooked casino example goes farther. You have someone who is winning...a lot. What will happen even if the winning is legitimate? They will be escorted from the casino by large burly men with sports coats and earpieces. Same thing here only instead of bouncers, there is what is called rescission. There are employees of the health insurance companies who look for or look to manufacture reasons to disqualify their policy holders from receiving their benefits or removing them entirely from their roles. The health insurance companies sat in front of a Congressional panel, admitted that they do this, that they pay bonuses to employees who successfully keep the corporation of having to fulfill their end of the bargain by leaving their customers to go bankrupt. They told Congress that not only do they do it, but they had no intention of stopping.

But it's ok, they said, because it really only affects .5% of policy holders. That does sound small...until you run the numbers. As Taunter points out, though, this is not a random occurrence. When you realize that most of us don't make use of our insurance in a given year and look at the percentage that make significant use, the odds of having the rug pulled out from under you for being inconvenient to the bottom line of your insurer approaches one half. In other words, they are happy to take your payments, but the minute you really, really, really need what you paid for, they'll flip a coin to see if you get it. It's the American version of Russian roulette, only the Russians give better odds.

1d) the underinsured.

More than sixty percent of bankruptcies in this country derive from a medical emergency. Most of those people were insured. We pay and we pay and we pay and we still get screwed often because of nothing we did. You do everything right, something unfortunate pops up and even though you thought like any rational person that you had all the i's dotted and t's crossed, the system leaves you in a place where you are not only suffering physically, your entire family is devastated financially.

1e) the complexity of paying

With health insurance companies controlling the purse strings they do everything they can not only to avoid paying, but to delay payment. Since they make their money investing the overage, if they can put off paying, they make more money. So, the dark labyrinth of codes and forms are put in place. This means that every doctor now has to hire staff for the sole purpose of battling insurers to get paid for their services. This means they have a higher overhead and therefore we have to pay yet more for health care. Additionally, much of the hassle gets passed along to us in the form of rejected claims that require hours on the phone with generally unhelpful representatives trying to baffle us with arcane details that we surely know nothing about. A version of the auto mechanics swindle where the asymmetric knowledge leads to an disadvantage for the consumer that can be exploited.

2) How much we pay.

In addition to where the payment comes from, there is also the problem of how much we are paying. We pay much more than any other country for a lower standard of care. Why? There are a number of factors here. The American lifestyle and diet makes it more likely we will not be healthy. Financial incentives are there on the part of providers to do more when less would be fine or better. Other countries have panels of experts that look at the relative effectiveness of treatments and which are more likely to succeed. We, on the other hand, do not and have major drug companies with highly paid sales wings taking doctors on junkets. We, as a population, have a fascination with the newest, the latest, thinking it always to be better even if it can be shown not to be. We feel cheated if we haven't done everything, tried everything, even if there is good medical reason to believe that the additional very costly procedures offer nothing by way of actual health benefit.

Further, one third of all spending is on end of life care. It turns out that when you ask people what they would actually want at the end of their life, it isn't what they get. What they want turns out to be much cheaper, but grieving family or reimbursed physicians worried about lawsuits will opt for more care even when it isn't warranted. It would be a good idea, one would think, to have people who understand what often happens at the end of life to talk to folks so that people can write down their actual wishes in terms of care. This increases personal freedom and decreases costs. But, if you were dishonest you could whip people up about government run death panels and say that such compassionate thoughtfulness is morally equivalent to Nazism.

Finally, much of the treatment comes in the form of drugs. Pharmaceutical companies have made sure that we do not use our collective bargaining power in our dealings with them. Big players and make better deals, but because of the lobbying power they have, the government has agreed to allow them to continue to fleece us lest their campaign dollars go to folks on the other side of the aisle.

3) What we pay for.

None of this is actually about the care we receive. The move to managed care has meant fifteen minute visits with someone who is no longer the family physician who knows and cares about you. When you look at major markers in terms of time waiting before getting seen, medical outcomes, and patient satisfaction, we lag far behind other industrialized nations. Our for-profit health care system is the equivalent of new Coke.

So, what we are dealing with now in terms of the public option is only something that affects 1, not 2 or 3. It is not about care, but about payment for care. This would be a government run non-for-profit insurer who could keep the for-profit companies honest. But it would leave them on the playing field to use all the advantages conservatives say that the private sector affords them. This is different, not the same, contrary to, a horse of a different color with respect to a single payer system like that proposed by Representative Wiener. On that model, insurance companies go away and everyone ends up on the equivalent of Medicare. That seems to work well for those countries who are ranked above us in terms of care provided and yet who spend much less than we do to get it. But we trot out the phrase "socialized medicine" to scare people away -- Sure, that might be a better mousetrap, but don't you see that the packaging is RED.

There are several very distinct conversations that need to occur. Yet none are actually happening. When we try to have any of them, they all get conflated and outright lies get violently shouted. All the while Americans suffer. Maybe the passing of Senator Kennedy will allow us a breather in which to begin to discuss these things sensibly. But I'm not holding my breath -- after all, it might be considered a pre-existing condition should anything unfortunate occur.