Anecdotes from The American Healthcare Front

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Teacher at exit ramp looking for a kidney donation

I have some issues with my ears periodically, and over the past week, it felt like one was developing a minor infection. It felt full a lot and started to become painful. I knew that I was going to need to give it some medical attention. I thought about going to my primary care team at Emory, formerly Harken Health. In the Harken days, primary care appointments were included in your insurance and you could schedule to go by any time. They also managed patient load so providers would have time to develop relationships, and they partnered with health coaches that could deal with the para-medical stuff so the medical pros could focus on things requiring their specific skill set. Now that Harken’s gone, Emory still has great staff, but works like a regular doctor’s office – scheduling visits always takes a few days, visits are shorter, and the health coaches, where they exist, are swamped and can’t give the individual attention my Harken coach gave.

The ER was out of the question, that’s a minimum of $2K spend and a distraction from people who need truly urgent, serious care. (Don’t believe me? Stop by an ER and try it for yourself. A friend of mine had stress-related chest pain due to the amount he was working and how little pay he was receiving to cope with the other stressors in his life and got slapped with a $5K bill.)

Urgent care is probably the best option, but that was going to run me a bit as well. Not too much, maybe a hundred or so. But of course I already pay several hundred a month for insurance, so that’s frustrating that my insurance is really more “hit by a bus” insurance than health care.

I ended up repurposing some antibiotic ointment I had for a recent eye injury that unequivocally required a doctor’s visit (that I’m sure I’ll get a hearty bill for soon), and it worked. I’ll keep at it for a few days to make sure it’s good.

Now, I have the means to get decent health care, even if it’s not convenient and a little pricey. What are people who have no flexibility in their schedule doing? What do you do when taking a half-day off work means you may be eating ramen next week, or nothing, because you’ll be fired “at-will”? And what happens when you face a real challenge that’s out of your control, like the teacher above who needs a kidney to live? If he can find the kidney, he will probably have decent health care as a state employee, but what if he didn’t have great insurance? Who would pay for that?

Those who support interdependent community do ourselves a disservice by allowing Medicaid for all, or any of the other public options, to be portrayed as an altruistically valuable but optional program, a gift to the neediest among us. It’s not a matter of kindness and convenience, without which life would be a little less pleasant but still bearable. People are choosing between medical bills and house payments, between medical bills and food. And it doesn’t take a significant condition or a bad decision.

We in the middle class especially make the mistake of thinking that we are where we are because of good decisions. The rich are lucky, sure, accidents of birth, right place, right time, but not us. We scrimp and save. We plan. We forego instant gratification for the long term, and look at our lives as a result. If we can do it, anyone can.

The truth is, we make the same bad decisions as the poor all the time. We buy a car that’s a hundred a month more than we should be paying. We spring for that dessert, or that hotel upgrade, or that extra night out on the town. TheĀ only difference is that we are not on the line between sustainable and unsustainable, and have a bigger cushion to absorb those mistakes. If you are making just enough to live on, springing for dessert could make you miss a payment. Missing a payment causes you to hit fees that push up your effective interest rate into triple digits. And the spiral begins.

I listened to a couple on NPR a couple of years ago that ran a food truck in Wisconsin. They were struggling, as the spouse with a corporate job had lost it, and lost their benefits along with it. When asked how they would deal with the cost of health care as they aged, they shrugged (with indecision rather than indifference) and finally stated that their children would take care of it.

I don’t believe this couple was intentionally so selfish as to burden their children with such a responsibility. But the language of American self-sufficiency has backed us into a corner. We cannot conceive of a world where a public good is actually, well, good. However, we readily imagine that a giant corporation motivated by profit will take care of our needs as well as our consumer desires. We respond with a sort of Stockholm Syndrome, where anyone on the wrong side of a law that protects the right to profit without regard to human cost deserves nothing, deserves to be cast aside. We are the worthy ones, because we currently have what appears like favor, but instead is simply utility to a soulless, unfeeling set of economic machinery.

As usual, any critique of the current order by an American must be met with “but I’m not talking about socialism!” So let’s get that out of the way. Public goods controlled by elected or especially appointed authorities who are not accountable to the people is just authoritarianism. This is what we saw in every single country that we love to hold up as inevitable outcomes of socialism. So no, I’m not talking about turning America into a giant commune or turning everything over to the government, certainly not while we have an apathetic republic that won’t hold its elected officials accountable in any consistent way. I’m also not talking about eliminating inequality. Human nature is to be rewarded in a proportion to effort, and any system that doesn’t allow that will eventually be overthrown by one that does.

But why do we think that this relentless pursuit of profit is the best of all possible worlds? We generate money printing machines that consume the landscape and crush the spirits of the people, and aggregate more and more for the machine’s makers. More importantly, we have created a mythology around poverty that causes us to see it more as damnation from a god that has refused your feeble sacrifice, while wealth is a blessing and a reward from a god that respects your hard work. This mythology is why we have the IRS losing money to chase small debts while corporations that evade billions in taxes are ignored. It’s why we won’t pay for Medicaid for All and are trying to dismantle food programs, quality public education, and other portions of the safety net, even though evidence keeps coming back that these investments are cheaper than the alternative.

Where the Christians have it right is that this is a heart issue. America loved the social safety net when it primarily benefited white men in the New Deal era. When the program was expanded to benefit more Americans through the Great Society, subsequent administrations quickly set to work dismantling them. Beyond the cost savings many properly implemented programs could bring, we have to ask ourselves what intangible cost our individual lack of accountability to our community brings. Are we safer when everyone is on their own financially? Are we less stressed when everyone has to work long days in cold environments? Are we happier when our neighbor cannot be counted on to care for us if we’re in need? Are we freer when every gift we give has conditions?

Who is my neighbor? And what is my obligation to them?

United Healthcare Pulls Out of Georgia – Thoughts on Health Care

United Healthcare is pulling out of the federal exchange in Georgia for 2017. You’ll see headlines about how this means Obamacare is on its last legs, or showing how overbearing progressive policies are bad for consumers. Healthinsurance.org has an article about the Georgia exchanges that has a bit more perspective. I would like to point out a few things about what this actually means in my opinion.

First, Georgia doesn’t have an exchange of its own. It opted to use the federal exchange provided for the states that refused to accept them. What’s more, Georgia actively created laws to prevent the creation of state-run marketplaces and make it harder for navigators to help people get coverage. In Georgia, a navigator must pass the same exam as insurance agents in order to be able to give advice to potential subscribers.

Second, according to this article, United Healthcare had less than 1K individual subscribers in Georgia, with most of their subscribers being in group plans. As such, it strikes me as disingenuous of United to paint their problem as being a gross profitability issue caused by ACA policy when in fact it probably was simply inconvenient for them to operate on such a small scale in the state. It is worth noting that their subsidiary Harken Health has signed up over 30,000 members in Atlanta and Chicago and will continue to remain on the exchanges. (Disclosure: I am subscribed to Harken and so far have been moderately satisfied with the insurance part and ecstatic about the primary and preventative care part).

Georgia has also opted out of Medicaid expansion, passing on billions in federal funding that would have created lucrative medical jobs and leaving nearly 300,000 Georgians earning too much to qualify for federal Medicaid, but too little to afford unsubsidized premiums. The principled stand is supposed to be that the program will ultimately cost Georgia too much money, but the data so far has not pointed to that. Instead, Georgia has opted to send federal tax dollars from their residents to provide health care to people in other states that did accept Medicaid expansion.

I find it interesting that the same politicians that favor deregulation and competition turn a blind eye to the mergers of the largest health care companies and pass red tape legislation to make it harder for an existing federal program to be successful. I have also not yet seen a credible alternative to ACA presented that would address the pre-ACA issues insurance companies had with refusing to pay for care and rapidly escalating premiums. What, then, is really motivating such staunch resistance to the simple question of how to get more people health insurance?

There’s an increasingly libertarian bent to arguments I hear from my conservative friends about the way things should be. The government is always bad at everything, and wants to take away your freedom at the point of a gun. Private companies have your best interests at heart because they’ll be motivated by a desire for profit and good reputation, and efficient markets will sweep away those that cannot provide the quality of service required for both. It is the responsibility of individuals to make optimal choices and protect themselves at all times, and the market can hold companies responsible for business done in bad faith.

This vision of how the world should work is attractive, especially if you believe that you are extraordinary. As much as I find libertarian ideals attractive, I find that when they hit the ground, there are some issues. Markets are great at what they do, but markets require open information. The American health care system is profoundly lacking in that, with dozens of prices for every item and procedure used, depending on who is ordering it and how it will be paid for. Try asking a provider how much anything costs. They couldn’t tell you if they wanted to, but most will answer, “I have no idea”.

Beyond the fact that the health care market is currently opaque, the myth of halcyon days of quality care before ACA took effect is false. Insurers were free to deny coverage to people due to diagnoses, culling the expensive cases and keeping the cheap ones, and there was no provider of last resort in most places. I was personally affected by this and had loved ones go without coverage for years until ACA took effect. I also paid for my own insurance out of pocket as an individual from 2003 to today, and I watched prices climb even faster than people complain about today. When the first ACA provisions took effect, my premium was cut by more than 50%.

At a deeper level, non-aggression and altruism are not natural human states, though it can be cultivated and encouraged in culture. I don’t think that removal of regulations automatically leads to Mad Max. However, given how companies try to take advantage of individuals as much as they can now even in the face of regulation and protection, I don’t see how removing regulations and protections would lead to less fraud. I also don’t believe that I’m so good at discernment and so popular or good at marketing that I could determine fraud, stop patronizing a business, and get enough others to do the same to shut a bad business down. Even if I dodge the bullet, someone else gets hit.

A more libertarian framework could work if people got serious about introducing competition enhancing measures along with the measures to unfetter corporations from regulations and limitations. We could use modern technology and new data aggregation and processing techniques to distribute more information in real time, keep everything visible and above board, keep private businesses a bit more honest. Frankly though, I’m busy enough trying to manage everything else in my life, and I don’t want to have to become an expert in health care administration and analysis just to go have my cough seen about.

Conservative politicians talk a libertarian game but are only interested in freeing corporations’ hands, assuming that in their benevolent interest in profit, they’ll do what’s best for consumers, and let the benefits trickle or rain down from the top. Until we can couple that with digestible, accessible information, and a media more interested in corruption than sensation, the net effect of deregulation will be continued massive profits for an oligopoly of companies and worse outcomes for consumers.