To argue, as so many are apt to do, over the latest edition of the Repeal and Replace law is pointless at this stage. The Senate has yet to deal with it, and the pointlessly rushed House bill takes a bad law, Obamacare, and makes it far worse. How it will end up remains a sufficiently long way off as to make it a pointless discussion at this time. It’s bad policy.
But one aspect, coverage of pre-existing conditions, is at the core of the debate over whatever eventually is enacted, and it’s game on for the battle over the saddest stories designed to persuade the nation that people who suffer from pre-existing conditions can’t be left out. There are two thrusts to this argument*, the first being that everyone has or will have a pre-existing condition at some point, the purpose of which is to make this an issue that touches each of our lives so that we see the personal benefit in supporting coverage.
The second is that those who suffer pre-existing conditions aren’t bad people, didn’t do something to deserve it such that their problems are unworthy of our concern and the basic appeal to emotion, the sad stories of those who will be hurt. And indeed, the stories can be very sad.
When my child was first diagnosed, I struggled with uncharacteristic rage. I felt as if other families were enclosed in a smug bubble, spared the understanding that misfortune can be random and inexplicable. Over the years, I have learned that anger was sadly misplaced. I have watched tragedy touch too many. Schadenfreude is no remedy.
I would not wish what my family has endured on anyone, even the legislators who voted to take away the protection that gave us such relief. I don’t really care about theory, about which is the more efficient way to rein in costs, or to give families the most choices. To me, preserving the principle that people should not be punished for a fate they could not control seems fundamental.
Is this about insurance coverage? Nah. This is about medical treatment. This is an important distinction that gets lost when the argument is over law. Nobody (except insurance company execs and their families) cares whether insurance companies make a handsome profit off premiums. We care about whether we can afford and obtain necessary medical care.
Insurance is about risk. The system survives on the healthy paying their money into the pool so the unhealthy can get medical treatment. If the only people on insurance are the ones who already know they need significant medical treatment, then it’s not insurance at all. There’s no risk involved. They need medical care, which has to be paid for, which needs money.
If an insurance company is paying out an average of $100,000 per person insured, it has to take in that amount plus its costs and profit. If the only people paying into the pool are those who know, in advance, that they’re going to need care that will cost this amount, then their premium will have to cover it. That, of course, is impossible since they don’t make that much, don’t have that much, can’t afford that much. So the system collapses.
It’s not humanity. It’s not hate. It’s just numbers. One of the most unfortunate aspects of any public policy discussion that involves math is that people hate math.
But the flip side of the discussion is that something has to be done with people who need health care, but can’t afford it. The options are treat them anyway or let them die (or suffer, as the case may be). Assuming, arguendo, that letting people die for lack of money to pay for treatment isn’t an option, whether because we are a good and humane nation that won’t stand idly by while people suffer or because we don’t like stepping over the dead bodies of children on the sidewalk, then they need to be treated. There is a secondary question about how much treatment they should get, how expensive, heroic, experimental, but we don’t reach the details until after we’ve addressed the basic issue. Do we let them die or not?
So who pays for these people who suffer conditions that demand treatment? We do, either way. The healthy pay for the unhealthy.** The question is whether we pay for them through insurance premiums, because the healthy don’t want to take the risk of being naked should a health catastrophe strike, and so pony up premiums year after year, far in excess of their occasional stop in at Doc in a Box, just to be covered.
Chances are high they won’t use the services those premiums buy, and so the money paid will be available to cover the health care expenses of the unhealthy, for whom there is no risk. Their need is definite.
It really leaves only one grand question, provided you’re not of the “let ’em die” persuasion. Should the pool of money to pay for the treatment of those in need be comprised of a subset of healthy people who are unwilling to take the risk of catastrophic injury or illness and decide to get health care and pay premiums? But if this pool of healthy premium payers isn’t large enough to pay in enough money for the insurer to pay out to cover its full panoply of costs, then it collapses. It’s just math.
Or, the government can run the system itself, take in money from everyone in the form of taxes and cover the cost of treatment of those who need it. And, if it’s so inclined, dictate to hospitals and pharma how much it’s going to pay them for their kindness. It will be a good deal for some. Less so for others. But none of us will have to step over the bodies of dead babies in the streets on our way to work.
Much as the government may suck at most of what it touches, no other distribution of risk makes any sense unless you are fine with letting people die for not being able to pay for medical treatment. And if you are, then what are you doing here?
*Obviously, this discussion is very basic and fails to address a multitude of issues, details, etc. It’s a blog post. Get a grip. The reason for this post is that too many people fail to connect the dots between money in and out, and that the question of coverage of pre-existing conditions isn’t about hating those free-riding people who are sick and suck all the money out of your pockets (and if that’s your concern, you’re really gonna hate insurance companies), but whether they get treated or die.
**Health insurance as part of an employee compensation package may feel completely different, but isn’t. It’s just another form of compensation. If your employer didn’t provide health insurance, they could pay you more in salary. But instead, you get a benefit, as if it’s a free add-on, in lieu of salary. See how that works?
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I’m going to hell for posting this pic.
Save me a seat close to the fire.
The fact that there are people who, if not treated, will die quickly, is undeniable. However, the other fact that gets left out of this discussion nationwide is that the vast majority of medical treatment goes to improve quality of life, not length of life. The vast majority of doctor visits are to obtain medication to alleviate symptoms that would go away on their own if untreated (even if there would be a little more suffering along the way). The vast majority of elective surgeries are also to improve quality of life. The vast majority of dental care is a quality of life issue. Once you recognize that most medical treatments (and spending) currently are for quality of life, you then have to grapple with why they should be paid for with other people’s money. Rich people get better food, better houses, better cars, better clothes, etc. That is why people are motivated to make more money; it improves their quality of life. Why should quality-of-life medical care be any different?
Granted, if you don’t want to have some committee deciding which health care is “essential” and which is “luxury”, then you have to pretty much roll it all up together and accept the fact that in medical care, some people will have their quality of life subsidized by some other people. Not that there is anything wrong with that, there are plenty of areas where this is happens anyway (see, e.g., your local library, county park, state park, national park, etc.). But certainly, there are reasonable arguments to be made either way.
I might have hoped that you would grasp that this fell into the gap that I purposefully, and expressly, left out of the discussion. My hopes are now dashed by your lack of self-control. Whether it’s a “vast majority” may be in issue, and what differentiates quality of life treatment (botox or rhinoplastry isn’t the equivalent of a cleft palate or Fragile X syndrome) is that secondary issue. Once we get past the basic question, we can get to what constitutes medical necessity and what’s fun and games. First things first.
Maybe it is my lack of intelligence, not my lack of self-control. It is unconscionable that you make me feel bad about that. You should think deeply about what a violent person you are, and self-flagellate.
Regardless, “first things first” begs the question. The number of people who would argue that medically-necessary-for-life procedures should be withheld from those who cannot pay is negligible. Even the most fervent conservatives, at the end of the day, grant that people should get care in an emergency, even if they cannot pay. They just feel that those people should lose all the material wealth they have, however meager their current existence already is.
That I’m a horrible person is a given. As for what the most fervent conservatives think, you seem to know their private thoughts awfully well. Did you take a survey? There is a parallel here to law. People complain that they can’t afford lawyers all the time, when the truth is that they can, but they just don’t want to spend their money on them as they would rather keep their money and spend it on more pleasant things. Does that make them indigent or cheap? Does that entitle them to a free lawyer, at public expense, so they can keep their savings intact?
The difference is that people don’t buy legal insurance, so it doesn’t come on the radar until they need a lawyer. But for those who do, much like those with pre-existing conditions, should it be an entitlement so that they can get the benefit without any burden to them while putting the burden on others? The analogy is less than perfect, but it ultimately comes down to who, as a matter of policy, should foot the bill.
God would approve of a thorough post from a CDL about the current state of machinations within the legal insurance racket as it currently exists in the marketplace.
Especially seeing as how it has become a reasonable common perk in many compensation packages, these days, particularly at certain striations of salaried serfdom.
P.S. Selling legal insurance policies would be great way to pay for the bus tour fuel, no? Heck, just, thinking about all upside potential in the years to come makes me want to go out and get circumcised.
About my inferences on the thoughts of fervent conservatives: for the sake of brevity, I simplified slightly (it’s a blog comment, get a grip), but it is true that I infer that from a few decades of voting behavior rather than reading their minds. I have yet to see anyone vote for a policy that would let grandma die on the street outside the hospital door, but I have seen votes that would allow policies that allow the cost of that care to be formally billed directly to grandma regardless of her circumstances.
Please realize that I am not criticizing here. This is one area where I do not know enough to have a very informed opinion, and therefore choose not to have one. I think that having an informed opinion requires quantitative knowledge about costs and benefits that I do not have.
Your parallel to the law is apt, and probably more apt than even you mention. I have legal insurance; it is called liability insurance and my insurance company will pay for my representation if I am sued. Granted, I do not have legal insurance that will cover me in case I am accused of a crime. So, some services are covered and some are not.
I am a little perplexed by your question though. If I pay for coverage from an insurance company (legal or medical), then of course the burden of my expenses (should I have them) will fall upon all others who agreed to similar coverage from that insurance company. How could that be any different?
For a guy who doesn’t know enough to have an informed opinion, you sure use a lot of words.
While you may have coverage under your homeowners insurance for certain legal claims, it’s not legal insurance. You didn’t buy it because of this coverage, but because you own a home. It’s a throwaway benefit, so it’s not comparable to health insurance. My question had nothing to do with insurance, but with entitlements. It appears you’ve mixed the two together.
So let’s assume you’re arrested. Your HO policy doesn’t cover your legal fees. You have a home, savings and investment, but that was never meant to be give somebody like me for a purpose like your criminal defense, and you really don’t want to squander your life’s savings, your retirement, your kids’ inheritance, on me (and I don’t blame you for this, by the way). So, do you get a free lawyer or are you constrained to squander your savings to the point of indigence to see my smiling face standing next to you in court? Poor people get free lawyers, but you’re not poor. But you may very well be once your case is over, win, lose or draw. Which is it?
I don’t necessarily agree with a whole lot of what delurking is saying, But in Canada legal insurance certainly does exist. I pay for it specifically as part of liability insurance with my business, as a separate charge from the general liability insurance, and I have the distinct privilege of paying an extra $10 and change per month specifically to pay for up to 100k in legal defense in case of the “accusation of sexual assault”, since my work involves putting my hands on clients a lot. And yes, I checked before posting this, it includes criminal as well as civil defense.
And was there a point here relative to this post, or was this just a random Canadian observation?
You’re ignoring that so-called “quality-of-life” medical care is also “enables productive life” medical care. Is it better public policy to not spend the money on QOL medical care and allow people to suffer in misery and be unable to hold down a job, therefore necessitating other financial support such as SNAP, welfare, disability stipends that also come out of your proverbial tax dollars? Or is it better to pay for those QOL medical treatments that let people hold down paying jobs and support themselves and pay taxes?
I’ve been recently reading “The Healing of America” by T.R. Reid (2010) where he visits multiple countries and investigates how their health systems work. I know this is just a basic post that is lightly touching on the subject matter, so I won’t delve too deeply into things, but I think that part of the problem of the current situation is that insurance companies in the United States are no longer non-profit. The customers that insurance companies take care of are the stock owners. Patients are just the revenue source. The US insurance companies are following the maxim of maximizing shareholder value, which is at odds of maximizing consumer value. IMO, this has led to an American health care system that costs a lot and does not get a very good grades for how effective it actually cares for or solves health care issues. And, as you say, there are huge complexities that can’t be really explained or covered in just a blog post. It definitely will not be an easy problem to solve and we’re all going to have to ask the question about what exactly do we want to get out of health care and who gets to have health care. Anyway, have a great weekend sir.
There are many fingers in the health care pie that aren’t charitable. Insurance companies are huge pigs. So are hospitals. So is pharma. They’re businesses. That’s how businesses work. This isn’t a mystery.
> … no other distribution of risk makes any sense…
This is one of those things that are often presented as stark either/or. You have correctly presented the reality about dead babies in the street or not, but there’s another reality here, as well — rich people will always be able to get better medical care than poor people, and any system that doesn’t allow middle-class people to aspire to the better health care of the rich is as doomed as Hillary Clinton’s 1993 attempt at fixing the problem.
Many other countries have baseline care provided by the government, with optional insurance allowed (see, for example, BUPA); with the amount of money awash in our system, we should be able to do this or better. Letting children die in the streets is un-American, but so is not letting people privately contract with the doctor of their choice. We could have both good public and private health care, but due to politics as usual, in some cases we appear to have neither.
This is why we can’t have nice things.
Do we consider health care to be a public good (like roads, national defense, etc.) or a private benefit? We all pay for roads that most of us will never drive on (especially true in the case of I-80), but most people don’t complain or even think about that expense. But when it comes to paying for care of the sick and injured, suddenly using public funds becomes a major obstacle in the minds of some people. It’s an interesting disconnect in how people view this matter.
I suppose it’s a matter of what we historically consider a public good. We now accept compulsory education as a public good. If that was true for universal basic healthcare, we would be arguing about the fringes instead of the basics.
Don’t you have Medicare and Medicaid, which seem to be about 25% of the federal budget? The obstacle can’t be all that major. Perhaps the issue isn’t whether to pay for care of the sick and injured, but identifying who those sick and injured are, and how far the limited resources can cover them.
The mechanisms are in place already (though Medicare and ‘caid aren’t the same). Then there are the “death panels.” Good times.
I try to stay off I-80 as much as possible, but to say that most of us will never drive on it belies my lived experience. I think I am feeling triggered and marginalized.
Dear Papa SHG,
Thanks for this post. A person with cancer cannot wait for a sale for cancer treatment. They are forced into the market without any choice in the matter. This is why markets and healthcare do not mix. If the choice is bankruptcy or die, it isn’t controversial that most will choose financial ruin.
This is depressing. There’s no way out of the current system flushed with all that sweet sweet cash. It’ll have to get really bad before it gets better. Hopefully not though.
So the papa thing is ongoing? Great, because father’s day is coming up. My expectations are very high.
There are a great many things in life that will result in bankruptcy despite no wrongdoing. Cancer is one. A market crash is another. And then there’s the car accident that kills a parent, a sole breadwinner. Unfortunately, terrible things happen in life. They aren’t all crimes or wrongs, and they can’t all be fixed by laws, good intentions and sad tears. Life can be cruel, even before Trump.
You can be my mama instead and get a gift earlier. You’re more like my birth mama anyway. Your pick. Father’s day cards are funnier though.
There’s problems we can do something about and others we can’t. Healthcare can be made more efficient and people can have better outcomes. Everyone wins except the stakeholders – insurance companies and hospitals who just happen to be profiting immensely from the ACA. After you take over the ACLU can you start lobbying for healthcare reform? Make the donate button bigger maybe?
I’m patient. I can wait. And I do prefer funny cards. As for healthcare reform, as soon as I’m done with the ACLU and a few other loose ends, I’m on it. Get your mother a really nice gift for Mother’s Day. She’s suffered enough already.
“But the flip side of the discussion is that something has to be done with people who need health care, but can’t afford it. ”
I would respectfully suggest that a good first step might be to inquire as to why it’s so unaffordable. Round here, an MRI costs $3000 or so. There’s a chain of clinics in CA that does them for $350. They don’t get any subsidies, it’s just that that’s the cash price because they don’t get involved with insurance companies. They will give you a bill, that you can submit to your insurer yourself for reimbursement, but they apparently save enough on overhead that they can make a profit while charging 10% of the “market” rate (sneer quotes because there’s not really a market and there’s even less transparency).
Clearly, it would be facile to say that 90% of the cost of health care is non-productive overhead, on the basis of a single example. But it does seem likely that there is massive bloat in the system. Further, the players are incentivized to keep it that way – insurers make their money from investing premiums and which hospital manger wouldn’t prefer to be in charge of a multi-billion dollar enterprise, rather than a lowly multi-million one?
That an assistant manager at Dairy Queen might not have a spare $3000 to drop on an MRI seems plausible. That he might not be able to come up with $350 much less so.
Good of you to explain how medical care is expensive. Probably completely foreign to most Americans. But it’s also a different issue than discussed in this post, despite your orthogonal leap from a sentence fragment.
It’s probably because I used to be foreign. At the risk of getting “rabbit hole” yelled at me, I’ll just say that it wasn’t so much “how” as “why?”. Anybody who believes that those same perverse incentives don’t apply to single payer hasn’t spent the majority of their life under the tender mercies of the NHS.
There will always be a death panel. It all depends upon who you want on it. In a system with constraints, “no” is one of the answers. The interesting aspect of turning it over to the government is that political power can become one of the drivers. Most medical costs occur with older people* who also tend to donate more money, and are a very powerful voting block. Try getting on AARP’s shit list and see how well you do next election.
*CMS.gov has all of the data you could ever want about health care spending.
Definitely. And the oldies milk Medicare for all its worth. It fills the empty hours.