The Unhealthy Side of Capitalism

I have health insurance and I am grateful for it.  Like most Americans who have health insurance, mine is via my employer.  Like many people whose employer is a small non-profit, I pay a significant share of my benefits.  In my case, that's 40% of the premium.  To insure JT and me, I pay an amount that is a shade more than $550 a month; more than $6500 a year.  My employer adds another chunk of change, nearly $10,000 a year.  The total to ensure JT and I exceeds $16, 500 per year.  That's a significant amount of money, though I wouldn't consider going without health insurance.

Most years, the company who provides my insurance is making money.  It's a for-profit corporation and that's what for-profit corporations do: make money.  It's clear that most Americans actually forget that fact when they think about health insurance.  But it is important to remember that most health insurance companies are in the business of making money.  They collect a premium from their customers and place a bet that we won't get sick.  The customers pay that premium, hedging against the prospect of illness.  No one actually wants to be sick, of course, and we quickly lose sight of the basic nature of this arrangement.

I mention this because in the current hand-wringing about Obamacare and changing insurance plans, we've once again lost sight of the fact that in choosing an insurance-based for-profit model of healthcare, we've signed ourselves up for a very costly enterprise.  Obamacare's regulations require insurance companies to pay for a host of treatments, treatments that Americans want to be included in their healthcare: maternity care, birth control, vaccinations, regular check-ups, preventative measure tests like mammography and colonoscopies, and host more.  Those things are expensive.  Of course our rates will go up.  This is a significant burden for the people who pay for insurance: employers and employees.

If you work for the government or a large employer with a stash of cash, you likely pay a very modest share of your insurance premium.  For example, state employees in New Jersey typically pay less than 15% of the cost of their premiums, while their employer pays significantly more.  This is not unusual and it creates a challenging political climate.

I am frustrated by this increasingly unequal arrangement and would cheerfully support a single-payer system of government-managed hospitals and physician clinics.  It would be less costly, a fact born out by the current New York Times series about the cost of healthcare, "Paying Till it Hurts."  I've linked to the most recent article in the series here.  A single-payer system would also be accessible to every one of us and significantly better than the system we have today. 

Until then, I've received word that my insurance will cost at least 20% more next year.  My monthly outlay will therefore increase to $610 a month.  That's 610 dollars that will not go into the economy for other goods and services.  If I am lucky and we remain healthy, it will go into the coffers of a private corporation whose profits will pay stockholders.

It could be me, but that seems like an unhealthy arrangement.

Ten Other Things

Adam Serwer at Mother Jones has a terrific article with a listing of the big changes that will come about thanks to the Affordable Care Act.  Some of the reforms were immediately available, others will be fully adapted by 2014.  Individually, most of them are popular with Americans, though plenty of us still don't like Obamacare.  Liberals needs to start talking about these individual changes and explaining, over and over again that this is Obamacare.

Supremely Pleased

Yesterday, I got ready to write a post for today's Supreme Court ruling on the Affordable Care Act, and I sat before my computer with quiet fingers.  My heart hoped that the Court, the last institution of the federal government to enjoy the confidence of a majority of Americans, would do the right thing.  For me, the right thing was recognition of the constitutionality of the Affordable Care Act.  There were two paths to that conclusion and both looked good to me.  The first path meant recognition that Congress had the power to mandate the purchase of healthcare because of the commerce clause.  The second entailed affirmation that the Congressional power to tax is clearly constitutional and that the mandate wasn't a mandate so much as a fine (or tax) on those who fail to purchase healthcare coverage.  Either way, we get a lot closer to healthcare for everyone in this nation and that is a desirable goal, even if the logistics to get there are mighty confounding.

And yet, Justice Roberts has invariably been such a disappointment to me that I had little hope he would side with Justices Breyer, Ginsburg, Kagan, and Sotomayor.  Though I have great respect for Justice Kennedy, the usual swing vote on the Court, I was convinced that his long-established preference for state's rights would be essential in this case and not good news for ACA.  I had no expectation that the triumvirate of Justices Scalia, Alito, and Thomas would be the least bit helpful.  These men would've sided with the Confederacy on questions of state's rights.  They weren't about to affirm the ACA on any grounds.  So I had to pin my hopes on Roberts and by golly, that was nerve-wracking.

I did a lot of re-reading yesterday, including a good deal of the oral arguments from the case.  I recalled Justice Ginsburg's cryptic statement a few weeks ago, when she said that the pundits had no idea what the Court planned to do.  I took hope from that.   But I went to bed last night still confused.  This morning, as we came down to the wire, I tweeted what my gut told me: the Court would rule ACA constitutional.   Then I waited with my fingers and toes crossed.  Seconds after the opinion came down, I gave my dad a call.  He was watching CNN screw it up, so I got to tell him that ACA was upheld.  And we were both emotional, which pretty much says it all.

I was raised by the kind of good, old-fashioned liberals who believe that they have an obligation to make the world a better place.  In his dotage retirement, my dad spends a good deal of time working at the local senior center helping the elderly poor to get access to decent healthcare and the prescription drugs they need.  That's an expensive prospect in this nation, even with Medicare, and helping little old ladies find a way to live on $800 a month has turned my dad into a radical.  He's not voting for himself when he casts a ballot, he's voting for the poor, the underprivileged, the folks who have been let down by society.  He wants universal healthcare (so do I) and he hopes that ACA gets us on that road. 

Voting outside your own narrow interests is an important thing; the very definition of a just citizen.  Today, Justice Roberts recognized that.  And I am supremely thankful.

What He Said......

I had intended to write a post about the ridiculous Republican rhetoric that accompanied the passage of healthcare reform earlier last week.  But Paul Krugman's March 25 editorial in the New York Times really says it all.  So go read it and picture me nodding my head vigorously.

True that, Mr. Krugman.

Real Life Conversation with JT: Healthcare Policy Edition

The backstory: In keeping with his Sassafras Family origins, JT is prone to talking back to the television.  The other morning, he was watching a game show and talking back to the telly.

TV:  Blah, blah, blah, medicine for depression, blah, blah, blah....side effects may include bleeding.

JT:  A depression medicine with a side effect of bleeding?  I think that unexplained bleeding would make me even more depressed.  Fools.

Wisdom like this might be very useful in the on-going healthcare debate in Washington D.C. I will notify Congress at once.

My Healthcare Plan

Today, the Senate begins the process of reconciling the two healthcare reform bills that have moved through the committee process.  All told, there are five healthcare reform bills in Congress right now; the task ahead is to reconcile these proposals into one bill able to receive majority support in both the House and the Senate.  It's not going to be easy, but it is essential.  As we move into this critical stage, I'm asking my members of Congress to support a plan that includes the following reforms:

1.  Evidence-based care.  We need to end the current system whereby patients demand (and physicians provide) treatments and services that patients do not need.  Evidence based medical care, where physicians recommend and supervise health treatments that have a proven track-record of success, a track-record established by the rigorous collection of scientific data, must be the foundation of our healthcare system.

2.  Electronic record-keeping.  In the Obama stimulus plan, there was a good deal of money made available to hospitals and physicians prepared to adopt electronic record-keeping.  Good.  Better would be the adoption of open-source VA system because it would permit coordination between physicians and hospitals nation-wide. And it's much less expensive.  More facts about open-source record-keeping can be found here.

3.  Ending fee-for-service reimbursement of physicians.  Physicians get paid every time they perform a test.  That creates an incentive to order more tests.  I'm not suggesting that physicians order tests to make more money; I am suggesting that we shouldn't pay physicians on that basis.  I'd prefer a salary system like the ones used so successfully at places like the Cleveland Clinic and the Mayo Clinic.

4.  Compassionate and realistic end-of-life care.  If we set aside the crazy debate about death panels, the fact of the matter is that Americans are not very good at planning for the end of our lives.  We know it's inevitable and yet.......We must make a greater effort to understand what it is we want out of our final months of life and then lay out that plan with our families.  In my mind, this has nothing to do with the financial costs of medicine and everything to do with the emotional costs of life.  But the reality is that planning for the end of life may very well save people money, at least in terms of avoiding expensive, aggressive, and unnecessary treatment.  It will certainly provide us with peace of mind.

5.  An individual mandate accompanied by a sound public option.  My real preference is for a universal care, single-payer system.  But that is not going to happen in this round of reform.  The next-best-thing is an individual mandate and a public option plan.  An individual mandate will require every American to obtain healthcare insurance.  This will improve the pool of insurance recipients, ensuring that more young, healthy people are paying into the system.  Anyone should be able to buy into the public plan (a distinct help for small employers, who are currently drowning in health insurance costs) and it must be self-sufficient in terms of costs.  That will allow the public option to compete with private insurers on an even field.  At the same time, we must provide significant subsidies to assist low-income folks who will now be required to join the healthcare system.

I'm willing to start reforms incrementally, with the caveat that we immediately cover every child in this nation and that we move quickly to provide a reasonably-priced public-option to get uninsured people into the system at once.  My not-so-secret hope is that a public option plan would prove a success that would transition us into a universal care single-payer system.  Other reforms, like requiring evidence-based care and electronic record-keeping, could be used in a public option plan.  I am confident that they would quickly prove their worth as cost-cutting reforms.  The bottom line is that our current healthcare system isn't working.  We must try something new.  Now.