Tag: healthcare

The lonely consumer

One of the trends which troubles me a little in the U.S. health care debate is the push to foist “choice” on us. Giving individuals “choice” seems to be the new panacea for health care, as if we didn’t already have some choices – here in the land of the “free market.” If only individual consumers had more choice over the way their health care dollars are spent, or so the argument goes, the more prices for health care would come under control, and the better care we would receive. On the surface it seems reasonable enough. After all, who doesn’t like having the freedom to make their own decisions.

Here’s my problem with it (there are actually several – bear with me). Having more health care choices tends to be a much better deal for healthy people; especially considering the choices suggested in the U.S. (less expensive policies with higher deductibles, health savings accounts, etc). If you are someone with no health problems, which health insurance plan are you more likely to purchase? Are you more likely to choose an expensive health insurance plan with little or no deductibles and inexpensive co-pays, or a cheaper plan with high deductibles which covers a percentage of catastrophic care only? I’ll wager that 99 percent of the time you’re going to go with the cheaper plan – the cheapest perhaps being private contributions to a health savings account (HSA). The catch here is it defeats or undermines the best feature of health care systems: risk sharing. Most healthy people don’t plan to be sick. It’s a surprise. Human nature tends to make us believe we’re invulnerable, until we suddenly find out were not. We inadvertently underestimate the amount of coverage we need (there are aren’t many reliable ways to predict how sick we’ll be, or when), making the allure of an HSA particularly strong. In the mean time, healthy people would be putting less money into the system, thereby making it harder to cover the people who really need it – and possibly leaving more (unexpectedly) sick people with woefully inadequate coverage, despite a few grand saved in a meager HSA. Consider that people already find out their coverage is insufficient, when it’s too late – without this choice of stripped down plans and HSAs. I fear this is a prescription for disaster.

This wouldn’t be a problem if “choice” (re: independent consumers, unleashed from the the constraints put on them by their insurance companies, and spending their own dollars saved in HSAs) by itself led to significantly lower prices; but I have my doubts. In certain large economic systems, unorganized individuals tend to have less choice (perhaps the same amount at best), not more. The trend in health care, like many large industries, is to consolidate. As an individual health care consumer, you’re not necessarily negotiating price with a local provider, you’re “negotiating” with the local branch of a health care corporation. If there are few companies operating in your area (or if you’re in a rural area and there’s just one) how much leverage do you have as a single consumer? Where I live (a relatively large market for health care – they used to call it “God’s waiting room”), if I need blood work done I can go to Quest Labs in Palm Harbor, Quest Labs in Clearwater, Quest Labs in Tampa, Quest Labs in Pasco, LabCorp in Palm Harbor, LabCorp in Clearwater, etc. That may look like a lot of choices to some, but it really isn’t. It’s easy to say you’re for choice. It sounds good, it’s easy to say… and it means nothing. The tricky part is identifying what those choices really are, and where the pitfalls lie. Unless we’re going to force corporations that are responsible for providing a chunk of our care (or the care that’s most expensive anyway: labs, hospitals, etc) to un-consolidate, I see no practical difference between “free market” care and government care, so far as choices are concerned.

The other factor in the price we pay is demand. As much as we’d like to make analogies to other industries, getting health care isn’t like purchasing other goods on the open market. It’s very nature leads to much higher demand. If I’m a diabetic who needs insulin, I need insulin. Its not like going to the grocery store and deciding to pass on the broccoli because green beans are on sale. If the price isn’t right on a new television I can wait for a better price with few consequences. If I wait for health care, it could kill me. I’m no expert (my last class in economics was in high school, and it wasn’t my favorite subject then), but it seems to me that the current climate of low supply (or even sufficient supply, with few real choices – because of “free market consolidation) and high (inherent) demand leads to high or relatively fixed prices… regardless.

If consumer choice is the way to control prices, then a system held up as a model for consumer choice should be less expensive. The Swiss system has been such a system. And it seems they do spend less… only 11.5 percent of their GDP, compared to 15-16 percent in the U.S. However, I’ve also read that total cost in proportion to GDP is rising faster in Switzerland than in most other countries (above average, as reported by the WHO; although I don’t know how fast it’s increasing compared to the U.S.).

Let me be clear that I mean no offense to the Swiss. The purpose of this entry is not to attack or put down the Swiss health care system. The U.S. would do well to have a universal system as good as the Swiss, considering what we’ve got now. But let’s be clear, the Swiss system isn’t exactly the model of “free” market health care that it seems to be made out to be. From what I’ve read the Swiss system relies heavily on significant government regulation and price controls. Can you honestly say a system that (in part) relies on price controls is really realizing lower costs because of choice or competition?

This doesn’t have much to do with the rest of this entry, but just for fun… try arguing for price controls with a conservative politician in the U.S. Talk about good times!

Interestingly, I’ve heard the Swiss system compared to “Clinton Care,” or “Hillary Care” (the more popular name since she started running for president), which of course was the doomed Clinton universal health care proposal from the early 90’s.

Now isn’t that rich? A health care system that was characterized as a disaster in waiting, fraught with government meddling and depicted in scary TV ads suggesting you won’t be able to see your doctor any more… is now held out as a model for consumer choice in the world (second to the U.S., of course). I don’t know wether to laugh or cry.

Note: It’s probably pretty easy to rip into this entry, filled as it must be with rambling and hasty comments which undermine previous points. I my defense, I can only say that I’m happily medicated today. At least the steroids seem to be doing their thing :-)

Mom

It’s been a while since I’ve written anything about my mother, but it hasn’t been because nothing’s happening. I just don’t know what to say, or if I want to say it. That makes it sound kind of bad, but it isn’t; not really anyway.

The second sudden recovery came and went, but it was encouraging in that she didn’t lapse back quite as far as she had been. They haven’t needed to send her back to the hospital for fluids or medication, so that’s been good. However, they did have the Baker Act hearing for the involuntary six month commitment, which was ordered last week. The good news is she won’t be sent off across the state to one of the state institutions. She’ll get to stay where she is, close to home.

And there’s even more good news. My father found a way to pay for her care: Medicaid. It seems that there is a way to get long term care for your spouse. You just have to get a lawyer, and let him or her get creative with your assets.

But isn’t that really the American dream, to have the means to have your own attorney on retainer?

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Universal health care and democracy

From the book Sick, by Jonathan Cohn:

To its critics on the political right, universal health care is an imposition on liberty that weakens individual initiative. But this is the classic bait-and-switch of modern conservatism – to make us forget that in a democracy, the government is merely an expression of our will and resources as a community. Universal health care is really about finding collective strength in our individual vulnerabilities – about helping a family member, a neighbor, or a fellow citizen because, next time, any one of us could be the person who needs help. It isn’t about them. It is about us.

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Here I go again – lets talk about health care

Twice in two days! That’s how many times someone said (to me) some variation of: “don’t people who live in countries with universal health care have almost half of their pay taken in taxes, to pay for their health care?”

If this was just one person who said it twice, or even one person who was relaying it from someone else, then I wouldn’t be writing this post. But no… I heard it from two people who didn’t know each other, were not involved in the same conversation, and would have no idea what the other said.

Naturally, I’m going to take it out on you, the (mostly) innocent.

I’m going to throw out some statistics and I’m going to tell you why I think they’re important. The conclusions I make from these statistics may be total crap, but I’m counting on you to let me know (I promise I don’t bite). Some of these stats will be referenced, and some will not. Those that are not come from several sources which, unfortunately, I can’t readily recall or locate. However, almost all of them are covered in a book: Sick, by Jonathan Cohn.

First of all, I can’t argue what kind of taxes (or how much) are taken out of people’s paychecks in other countries; I just don’t know. However, even if they do pay more in taxes, I don’t think it tells the whole story – not by a long shot. Most of our health care cost is not attributable to health insurance premiums deducted directly from our paychecks (by a wide margin). Health insurance premiums for families in the United States (and by that I mean total insurance premiums) averages $11,480 per year, or $956.67 per month. I don’t know about you, but that’s not what shows up on my pay-stub every month. I’ll bet it doesn’t show up on your’s either. In fact, the average amount that people pay directly is $2973 per year, or $247.75 per month. Employers pay the difference, but they don’t do this out of the goodness of their heart. It’s part of their total cost of employing someone, and it’s part of the reason that some private contractors (or consultants) are “paid more” for doing the same job that a salaried person might… because the employer isn’t spending a chunk on benefits. If your employer could pay you more money if they didn’t pay for those benefits – then in essence, you’re paying for it. You know what else? We pay taxes too. Federal Income Tax ranges somewhere between 10 and 30 percent, with payroll taxes (Social Security and Medicare taxes) adding up to another 7.65 percent. Then, depending on which state you live in, you may pay an additional percentage of your paycheck for state tax withholding.

Ah, but $900 – $1000 per month in health insurance premiums, Federal Withholding, payroll taxes, and state income taxes don’t add up to half my paycheck. (Remember, I don’t know what they pay in taxes in other places.) Well… what we pay for insurance premiums doesn’t add up to our total health care expenses either. Consider that the U.S. spends A LOT more per capita on health care than ANY other country. If I recall, the next closest country spends something like 65-75 percent (per capita) of what we do, with many countries spending even less (and they all have universal care). Now you may be thinking to yourself, we’re a wealthier country… if we’ve got more money, we’re probably going to spend more money on things… because we can. Well, I think there’s a way to control for wealth… look at what countries pay for health care as a percentage of GDP.

In the U.S., we spend about 15% of our GDP on health care.
figure-1.jpg
http://www.frbsf.org/publications/economics/letter/2005/el2005-10.html (figure 1)

Compare that with Germany (less than 12 percent), France (around 10 percent), Japan or the UK (both around 8 percent).
figure-2.jpg
http://www.frbsf.org/publications/economics/letter/2005/el2005-10.html (figure 2)

Forget about how much people in other countries pay in taxes. You’re looking at apples and oranges. Any way you slice it, we’re paying more in the U.S. for health care (per person) than any other country… period.

Some of you will argue that you get what you pay for, and we’re paying a lot… for superior care. Well, I’m afraid I’ve got to burst that bubble too. By most measures of quality… infant mortality, life expectancy, diagnosis rates, and how long we live after being diagnosed, our care is not superior. In fact, there are some measures which suggests it lags behind other countries with universal coverage. (There are other measures for quality of care, which are complicated, and supposedly are more independent of quality of life issues. They’re explained better in that book I mentioned.) I’ve heard some conservatives in the media say that prostate cancer has a much better diagnosis and prognosis record in the U.S. than in other countries (with universal care), suggesting this is proof of the superiority of our care. This is both true and misleading. While the statistic is accurate, it’s misleading because the same CAN NOT be said for almost EVERY other type of cancer.

Someone suggested to me that the U.S. already has universal health care. Anyone who’s on death’s doorstep is guaranteed care. Due to death or bankruptcy, many of these people don’t pay for this care. But make no mistake, someone pays for it (and it ain’t your employer, out of the goodness of their heart). I think it’s pretty safe to say that if you pay for insurance and your own care, you’re paying for it – just too late to do any good. Many will claim that people have to wait longer for non-emergency procedures in countries with universal care. First of all, I’m not sure that’s true of all universal health care systems; but let’s assume it is, for argument’s sake. Imagine the uninsured person with diabetes who can’t afford their medication, and loses their sight, an appendage or two, suffers all kinds of associated health problems, and dies prematurely. Or, imagine the uninsured adult that doesn’t have that lump checked out, in part because they’re in denial (worrying about the financial ruin that would follow a cancer diagnosis), and subsequently dies a painful, horrible and avoidable death. Imagine all of the illnesses people suffer, and in some cases die from, because they don’t have insurance. Wouldn’t eliminating these things be a fair trade for longer waiting times for non-emergency procedures?

As I see it, we pay more for the care we get, we don’t get more for the money, and some people don’t get any care at all (until they die, or are near death).

Is this really the best way to provide health care? Is this really the best way to spend the vast sums of money we already spend?

Health insurance and mental health

One of the supposed hallmarks of the U.S. system of providing health care is choice. “Don’t let the socialist boogeyman come and force you to see a doctor trained in Guatemala!” You may not realize it, but that’s pretty funny (not the bit about Guatemala… the part about choice). Well, it doesn’t quite rise to the level of expelling fluids through your head’s secondary and tertiary access points, but it’s still funny.

Come on, ask me why it’s funny. You know you want to. You think you may know, but your dying to know if your right (yes, I’m nothing if not a little presumptuous).

My mother is on the verge of being sent back to the (medical) hospital again. She’s gone back to not eating, drinking, or taking her meds. One of the nurses says she’ll probably have to go back (possibly as soon as tonight or tomorrow). In the mean time, they’ve scheduled a hearing (again) to decide on long term commitment at one of the state psychiatric hospitals. A couple of the possible facilities (there are three where she might be sent) are the same place they send people who are unfit to stand trial (for all sorts of things). My dad asked the social worker if there were any choices.

“No, not if you don’t have insurance coverage.”

See, that’s when you were supposed to laugh. By U.S. standards, my father is not wealthy, but he’s well above average (in terms of salary). He’s highly paid, highly trained, and employed by a large company with loads of lucrative defense and aerospace contracts (among other things). If anyone was going to have good health insurance (besides a government worker), you’d think it was him – and it always seemed like he did – until now. My mother was in the hospital for just under two months earlier this year, in a locked-down psych ward… and that ate up all the benefits for the year. There’s no more coverage left until next February.

So here’s the choices, under the U.S. system of health care:
1. Accept a commitment to the state mental hospital.
2. Sell the house, cash in the retirement savings, borrow from the kids, sell some organs on the black market, and go to a private hospital.

I hate to be down on a state run operation, but experience tells me that facilities in this country which are operated for the benefit of those who can’t pay are rarely top notch, and have the reputation of being substandard. After all, politicians get elected in this country for cutting back on welfare, not for maintaining the status quo (or – gasp – expanding it).

I could be wrong. I pray I’m wrong. I fear I’m not.

You gotta love those choices.

Acceding to my wife’s demands

First of all, I’d like to give myself a great big pat on the back for spelling “acceding” correctly on the first try. I have it on good authority that if there’s a gene responsible for good spelling, the Kauffman family doesn’t have it.

So what is this demand and why am I acceding to it? You wouldn’t know it from this site, but my wife has a lot to say about what I write. I tell her she should post comments, and she tells me she’s not going to communicate with me through no stinking blog. Sheesh!

Lately, my wife – critic extraordinaire – has been on me for something without political flavor. I asked her why, and she says she hears me talk about it all the time, she doesn’t need to read it too. Fair enough. Although it’s not my primary goal with this thing, I suppose I can throw an entertaining bone (forgive me for my presumptuousness) to someone who makes up a large percentage of my regular readership.

Yesterday Cheryl took our eldest for an overdue eye exam (I may not be able to spell, but I have no need for regular pilgrimages to the local lens-crafter – HA! TAKE THAT!). Any hoo, Cheryl and Beth both got the windows to their soul properly measured and analyzed, and Beth was distressed to learn that her eyes were once again a little worse. The lenscrafter tried to explain to her that it was normal for folks’ eyesight to get a little worse over time, and that her eyes were following the typical pattern. Beth (who does have the Kauffman gene for anxiety) was having none of it. As is Beth’s way, she laid her own brand of shock an awe on the lenscrafter, in the form of a saturation bombing of questions. “Why are my eyes getting worse?” “Will they always get worse?” “How bad will they get?” “Will I go blind?” “How long do I have before I need to wear glasses all the time?” “Will I be able to were contacts?” “Do they hurt?”

The Lenscrafter showed exemplary patience, but with Beth there’s always a question that breaks down the barriers of sanity. On this day, it came shortly after Beth shared her fear that she would not be able to fly into space if her eyesight got too bad.

“If I get Lasik will I still be able to be an astronaut?”

“Honey, they don’t do Lasik on children. You can worry about that when you’re an adult.”

This person obviously doesn’t know Beth.

Cheryl is my wife and she approved this message.

Who are you calling a socialist?

It occurs to me that even private health insurance represents a kind of “socialized” medicine. If I may be so bold, I’d like to tell you what I think of private insurance: the bastard child of socialism and capitalism. The idea behind insurance is to pool resources with a larger group, so that individual members are better able to cope financially with misfortune, minimizing individual risk. Insurance companies are just the mechanism to facilitate this relationship… siphoning off money for shareholder profits. When you think about it, this community sharing of risk is a pretty socialist idea. So, when you get right down to it, you’re supporting a kind of “socialized” medicine if you’re a proponent of the insurance model of providing health care. Real capitalists would only support a straight fee for service model… only opening your checkbook when you purchase the care itself (none of this paying insurance premiums crap).

Real Americans pull themselves up by their own bootstraps, they don’t need the village to help them up.

Intellectual consistency

Who am I to call for consistency of thought? I can’t keep my mind on the straight and arrow for a day, let alone a lifetime of policy decisions. Still, I got a kick out of a line I read in an article this weekend (I can’t for the life of me remember which one). The author of the piece said that conservatives against “socialized medicine” didn’t understand that we already have it… for old people (Medicare) and government employees… such as Republican Congressmen and Senators.

If conservative opponents of “socialized” medicine believe in private insurance so strongly, maybe they should put their health where their mouth is.

Broken

Earlier this week my mother was hospitalized involuntarily under the provisions of a Florida Law known as the “Baker Act.” When the legal requirement for the hospital to hold her expired, and they determined that her benefits (through her health insurance) had been used up, she was shipped out to the first facility that would take her. It was an assisted living facility, which primarily deals with elderly adults who can – to some degree – care for themselves. My mother could not, but what choice did we have? The hospital staff advised us they called the non-profit, inpatient facility that is familiar to me because of my wife’s work in the criminal justice system, but they turned her down, allegedly because of her age (too old).

She was at the assisted living facility less than two days before my dad got the call this morning – the one where my mother was destroying property – the one that resulted in the police being called – the one that resulted in my mother sitting in the back seat of a police cruiser, handcuffed.

When my father arrived on the scene the police waived him over to let him know where they were taking her. The hospital – the place where all of this started earlier in the week – would not take her back, based on the health insurance situation. I’m not sure what was the deciding factor, but the non-profit that turned her down two days ago took her (perhaps due to a contract with the sheriff’s office for Baker Act cases?).

This episode rises to a level of obscenity that defies description. It is accepted as unquestioned truth that no American goes without necessary health care, even if he or she has no insurance. “No one dies on the hospital doorstep,” or so the saying goes. The trouble with our system is the lengths one must go before the care is given. In this case it took the destruction of private property, (essentially) an arrest by the local police, and an involuntary commitment under the least ideal circumstances.

Is this really how we want to take care of ourselves? Health care reform is low on many people’s list of priorities. The reason? Even though an estimated 40 million don’t have health insurance… approximately 260 million do. Of those that do have insurance, most of them (at any given point in time) are in relatively good health, and have no need to test the limits of their coverage.

In the mean time there is a silent, growing minority who are being failed by our health care system. The poor, the chronically ill, and the self employed are the most obvious victims of our system… the ones who can’t afford private coverage. What’s truly insidious about our system is that even those with coverage… and pretty good coverage, by most objective standards, are at risk. My mother’s coverage was pretty good, in that it has covered mental health at all (even when there weren’t laws mandating it). Still, she had to be put in FUCKING HAND CUFFS before we could get her placed in an appropriate inpatient, mental health facility. HAND CUFFS! This for a person who was too squeamish to kill bugs when I was growing up… for someone who didn’t believe in corporal punishment (for her kids)… for someone who didn’t have a violent bone in her body.

What is wrong with us as a society, that we would deny our own people basic care? Think of all the things government pays for… subsidies to grow four times as much corn as we can eat, and fuck all knows what else. I am sick with disappointment in my own country, with my own people. You may not have made my mother sick, but you put the cuffs on her. You gave my father an ulcer. You broke that furniture at the assisted living facility. You broke my heart, you stole my hope, and you took what remained of my mother’s sanity.

YOU can vote.

YOU are the “people,” in a country governed by “the people.”

YOU ultimately decide who gets health care, and who does not.

YOU have failed my mother.

YOU have failed me.

YOU may have ultimately failed yourself.

YOUR decision makes me sick with despair.

What a difference a day makes

Today’s events will be a boon to bank accounts, but it’s unclear wether medical outcomes will benefit or suffer. Yesterday, phone interviews with assisted living facilities produced the conclusion that my mother needed more care than they could provide. Today, with the Baker Act placement ending and my mother’s insurance coverage exhausted, the hospital has decided that an assisted living facility is ideal.

You know what I’m thinking? As it happens, I’m trying to do as little thinking as possible right now. It’s my defense mechanism du jour.