14 Jul 2009
8 minute read
agk’s Library of Low Resource Medicine
Its been a while since I’ve written anything that could be considered weighty commentary, and as the economic situation is now positively baroque and far beyond my comprehension, let alone my capacity to explain in 4800 words or less, I will stick to a subject on which I can still hold my own in street-corner arguments with PIRG fundraisers with whom, as usual, I agree about 70%. I am, of course, discussing health care.
I think health care reform is dead in the water. The emergence of factions claiming that their flawed but beneficial (to them) alternatives are “better than nothing” requires that “nothing” enter the debate as a realistic option, and given the circumstances it may end up being the most comfortable, and hence most inevitable, law passed. With the exception of consumers, all of the players derive their income from health care costs and expenses, and therefore no-one is interested in giving up their share. Increasingly consumers are implicated as well, as the health industry becomes a lifeboat for laid-off workers in other fields and health-care-related bonds become the core investment of institutions and municipalities, so messed up as it is, the American health care system may end up being the ultimate (in both the “most exemplary” and “final” senses of the word) case of too-big-to-fail. Still, a post-mortem perhaps?
The problem isn’t that the crisis is too big- the problem is that there are too many crises, which contradict each other. I will try to run through them here.
First, there is the question of how insurance is run. When you ask people what the “health care crisis” means, you are likely to hear immediately about the number of uninsured Americans. Health care without some form of insurance is unlikely – costs are unpredictable and require an enormous amount of cash Right Now when they arise. In countries where single-payer systems (which I support here, though I recognize this would be something of a financial/employment tunguska event for all the reasons above in paragraph two) are the norm, large and sudden costs are paid out by governments who retain the capital and credit to fund them whenever they come up. Governments, in other words, function as insurance companies, and since they tend to be enormous and to have responsibility for a very large number of people, the chance of a sudden cluster of expenses overwhelming the reserves is very slight. In a private insurance system, insurers carry the funds, but being smaller than governments they also require their own insurance, and have to return a portion of their income to shareholders. In addition, insurers compete with each other for staff, which justifies paying their executives enormous bonuses. The involvement of shareholders and executives who derive direct income from profits leads to a pressure to reduce costs and increase revenue – charge more and pay less.
None of these problems go away if the government subsidizes insurance, either through tax deferrals, penalties against non-enrollment, or directly paying for citizens to have policies. The US Government is probably the single entity that least requires an intermediary company to handle the slow-income/sudden-cost problem in health care, and in fact it operates several successful health plans (Medicare, Medicaid, VA Medical, Tricare, and the famous US Government Employee Health Benefits program) without benefit of a private, for-profit intermediary. Given that no government employee is paid higher than the president ($400k compared to the $3.5m earned by the head of Blue Cross) and there are no profit-demanding shareholders in the government (well, except maybe foreign T-Bond investors – but remember how this isn’t about the economic crisis?) it seems logical that a single payer system might not be a terrible idea here. But this isn’t just about cost containment at the insurance level.
Instead, what we’re hearing is some expansion of the Massachusetts plan, where employers are penalized for not offering health benefits – and citizens are required to carry insurance at all times. This removes the null option of being uninsured, but other than criminalizing people who either can’t or won’t sign up its hard to see what that changes. After all, plenty of medical bankruptcies involve people who had insurance but couldn’t pay their bills. Furthermore, given that this guarantees a market for insurance providers, it seems it would tend to push for more expensive policies that offer less: when I first started reading Dykes to Watch Out For in the early nineties, the bookstore employees were furious that they suddenly had a $1000 deductible – I work in the health care industry and my deductible is $5000 or, if I max out, $416/mo. That’s on top of my premiums. Under a Massachusetts-style plan, that counts as a success.
Insurers have a list of demands as well, of course. They would love less regulation, more guaranteed customers, and higher premiums, as I hinted above, so that they could pay their shareholders and executives more and, oh yes, undercut the competition, but we already talked about that. Insurers also want to change the way people use health care in a way that benefits, duh, insurance companies.
I’m not going to talk about preventive care until later in the essay, by the way, but I’ll get to it.
Insurers are the ones pushing for increased “efficiencies” and reduction of “unnecessary tests” and “unecessary utilization.” Its debatable how much of our health-care dollar is “wasted” on such things as records retrieval, duplicate filing systems, and complicated referrals, but if the government is paying to fix these issues, you better believe Humana wants to see them fixed. I’m not going to stand up for inefficiency – the VA completely turned itself around with a rationalized records-and-continuity system – but I definitely don’t think that eliminating it will solve the health care crisis on its own. Also, what an insurer calls inefficiency, a doctor or a hospital might call “autonomy” or “patient advocacy” and as we’ll see in the next paragraph these have some value.
Insurers don’t just have it in for doctors, clinics and hospitals – they also have it in for consumers. My health plan includes a $100 charge – payable to my insurer – for any emergency room visit, justified or not. The heading on the page that explains it reads “Think Before You Act” and yes, we’ve gotten to aversive penalties. I remember when these “utilization” fees first started appearing, about six or seven years ago. Back then, an emergency room visit that did not (in the end) require hospital admission would be hit with a $75 penalty to discourage people from seeking their primary care in the ER. Doctors, always aware of insurance regulations, would try to game this for their patients – many serious emergencies can be handled without a long-term hospital admission, such as infections for which IV antibiotics can be given in the ER – by finding a way to “admit” borderline cases without incurring more than a $75 co-pay for their patients. Now that the admission criterion is gone (and punitive fees have been extended down to include urgent care, which was another billing trend for cost-conscious doctors) you have basically a guaranteed income stream for insurers. Because the ER is always open and will always serve you regardless of payment, people will always come in for problems that under other circumstances might be handled on an outpatient basis – but its difficult to see where in this country those “other circumstances” would obtain.
Insurers (and plenty of patients, come to think of it) are constantly harping on another problem as well – “unnecessary care.” Expect any insurance-backed health care reform to contain incentives here as well. Insurers think that doctors do too much screening for things that don’t show up very well in tests or aren’t statistically likely, and the only thing they like less is actual treatment for a condition which has not been conclusively proven by a test. If this sounds like a contradiction it is, and they hire rooms full of statisticians to find the precise line between the two “problems.” Most providers and patients who, after all, are much more interested in individual outcomes rather than aggregate ones, will tend to play conservatively on one side of the line or the other, and no matter which way they go either they, or after an expensive lawsuit the insurance company will pay more than the minimum statistically necessary to keep the most people disease-free. Insurers hate that (especially the lawsuits) and will probably want to see a unified protocol in place for when tests are warranted, which means doctors and hospitals will be limited to following a narrow treatment plan that doesn’t place individual patient improvement at its institutional center.
----------------------------------------------------- from HUCK FINN ON ESTRADIOL © . My friend Anne's old blog, available via http at tagonist.livejournal.com -----------------------------------------------------
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