Health Care: Pre-existing Conditions

Now that the convention is over and Mitt is the anointed Republican candidate, his story is starting to shift in an attempt to appeal to the masses.  While the rhetoric before the convention was REPEAL OBAMACARE,  now he is saying that parts of the law are good and should be kept.  One of the parts that he likes is not allowing insurance companies to deny coverage based on pre-existing conditions.

First, by admitting that insurance companies should be compelled by law to insure a certain class of people is an admission that the free market economy will NOT  deliver the best result for the people in all cases.  It is not in any insurance company's interest to insure someone known to be sick.

Second, given that insurance is to be provided, how is it to be paid for.  There are basically three scenarios.  1. You just add them to the pool of those already insured, in which case the cost of insurance goes up for everyone in order to cover the added expense of insuring people with known health issues. 2. You create "high risk pools" into which these people fall and for which insurance companies will provide coverage.  Unfortunately, insurance companies are "for-profit" entities and they must set the premiums at a level that, on average, will cover the expenses of the group of sick people plus administrative overhead  and profit.  To take a simple example, let's say the "high risk pool" consists of people with cancer, the treatment of which costs $50,000/year.  In order for the insurance company to survive, it must charge $50,000/year plus 15% for administration and profit.  Who can afford that.  3. You can spread the risk, and cost across all people  by insuring the healthy as well as the infirm.  This is how insurance works, the people who are fortunate enough to never need it are the ones who pay for the less fortunate.  This is exactly what the "individual mandate" in the affordable healthcare law is supposed to enable.

If you already have insurance and you really don't care if someone else does or not, I guess you're going to ignore this line of reasoning.  Just remember though: as we learned in 2008, most of us are one "economic downturn" away from being jobless or switching jobs.  When that happens, perhaps your current beloved insurance will no longer be available.  If you've got diabetes, you're screwed.

Of the 3 options above, the only one that seems reasonable is exactly what the Affordable Care Act is trying to do.  The biggest issue I have with it is that it keeps the "for-profit" insurance companies in the middle of the whole thing.  Get them out of the way and go for a Single Payer system and we'll be on our way to a modern, affordable health care system.

Contraception Coverage - ObamaCare

Through all the rhetoric, I think we've totally missed the point!!

I don't think anyone disagrees that everyone should have access to reasonably priced health insurance.

The first place we have a difference of opinion is in the definition of "everyone".  Some would include all US citizens as "everyone" while others would define "everyone" as those who had a job and could afford to pay for their own "affordable health insurance".  We'll leave that debate for another post.

Fundamentally, what the government is trying to do is establish the minimum standards for health insurance that is to be "affordable".  Of course, we can get affordable insurance via the unrestrained free market, but what will the level of coverage be?

Before the dreaded ObamaCare, if you didn't have a job that provided health insurance and you weren't poor enough to qualify for Medicaid, you were out of luck.  Either you couldn't afford the insurance premiums or you were denied coverage because of some pre-existing condition.  How do we get the free market system engaged to solve that problem?  Perhaps we allow insurance companies to compete across state lines?  However we do it, one thing is for sure: The free markets will produce a glut of insurance products that are definitely affordable, but only to the insurance issuing agency.  Coverage will be gerrymandered to minimize the payout/premium ratio.  That's how it works folks.  Corporations (including health care corporations) exist to make money.

What gets lost in the high-profile debate between the Government and the Catholic Church is that the Government is merely trying to establish a baseline for reasonable coverage that we want to get at a reasonable cost.  Yes, there are sticky situations such as the inclusion of contraception in the baseline, but the important issue is that the administration is attempting to establish a baseline at all.

Regardless of what you may think from the above, I fully support the repeal of ObamaCare.  But I support it for a completely different reason than the talking head Republicans who are delighting the President every time they make a public statement.  I support a repeal because I do not believe ObamaCare went far enough.  The free markets can deliver neither affordable health care nor affordable health insurance.  The objectives of free markets are at odds with the objectives of health care.  There needs to be some middle ground; managed and funded by a central agency that budgets what this country can afford to spend on health care.  Otherwise, we have health care for the rich and nothing for the not-so-rich.

If you know me you won't be surprised.  Let's all work toward a Single Payer system for universal, affordable healthcare for everyone.

Healthier Lifestyle Drives Healthcare Costs UP

Popular wisdom has it that if we live a healthier lifestyle, we'll keep the cost of healthcare down. I suggest that perhaps the opposite is true.

Not too many years ago, we got old, we got sick and we died. Sometimes we didn't even get old, we just got sick and died. We really didn't think much about a healthy lifestyle. We smoked, we watched a lot of TV, there were very few joggers. We rode a bicycle of we liked it, not to get any cardio benefit out of it. We ate trans fats and loaded up on cholesterol laden foods. We got cancer, heart failure or complications from diabetes. There wasn't much to be done except go home to die.

We now live longer than in the past for two main reasons: we live a healthier lifestyle and medical science has advanced to the point that they can now cure or slow down previously terminal diseases. While that is all well and good, it doesn't come free, and we have not yet figured out how to pay for our new-found health.

Our obsession with health leads to several costly things. The most glaring one is that, since we live longer, we are more likely to need nursing home care due to Alzheimer's, dementia or some other debilitating illness. Like it or not, no matter how healthy we are, our bodies eventually wear out. While there have been significant strides made in the area of prolonging life by lifestyle, medication,surgery and machines, there has been very little progress in dealing effectively with end of life issues. Collectively, we have not come to a realization that there is some point beyond which it is not worth keeping someone alive. As such, we spend enormous amounts of money on people who would choose death if it were an option.

Another costly effect of our healthy lifestyle is that we are no longer content to sit in front of the TV with our knee elevated when it is stiff and sore. We want to run, cycle, play golf and kayak. Not a problem, get a knee replacement, hip replacement, shoulder replacement.... or even two of each. These are not inexpensive procedures. I'll be the first one in line to get one as soon as I can no longer swing a golf club, but it should be recognized that these expensive procedures are part of the COST of a healthier lifestyle.

While it's somewhat related to the first issue, another costly result of living "healthier" and longer is that, in the long run, we need more medical care and medication. Again, like it or now, no matter how healthy we are, our bodies will wear out. We'll go to the doctor, we'll have surgery, we'll get medicine. First one pill, then two, then three. Some are necessary, like insulin for a diabetic. Others solve problems we didn't even know we had until we saw it on TV (didn't you always wonder why you were carrying around that beaker of green liquid?). The more different medicines we take, the more unpredictable are the interactions. Some mixed side effects lead to the prescription of yet another medicine.

So, if I don't smoke and get lots of exercise, I'm much less likely to get lung cancer and die when I'm 50. But, since I live past 50, I'll have a hip replacement, a knee replacement, a coronary bypass, treatment for prostate cancer, and extended physical therapy for a torn rotator cuff. I'll eventually be taking medicine for gout, overactive bladder, blood pressure, type 2 diabetes and arthritis. I start to forget things and wander off in the grocery store. Finally, my wife can no longer take care of me, so it's off to assisted care, then a full blown nursing home where, in my lucid moments over a period of 8 years, I wish my life could end.

Again, I do NOT mean to imply that smoking from age 16 and getting cancer and dying at age 50 is a preferred life scenario. What I am saying is that the healthy lifestyle and longer life leads to expenses that neither we as individuals nor the country as a whole were able to anticipate or plan for. So as we continue to invent new cures, prolong life and fill up our nursing homes, we will continue to cripple ourselves with unsustainable cost increases.

What to do? The first order of business should be to figure out a way by which a healthy person can define, unambiguously, the point beyond which he/she no longer wants to live. When that point is reached, a humane, legal and socially acceptable means to end life should be available. We've got to quit avoiding this issue and figure out a way to deal with it. I want that option for myself and I know many people who think the same way.

Second, maybe it's time to slow down the pace of medical advancement. Or, if we're going to continue, we've got to consider the results of that advancement in the context of what is affordable. OOPS, is that starting to sound like rationing? As much as I hate to use that emotion-laden word, we already do it and to manage our health care costs in the future, we've got to get it out in the open and have an honest dialog about how to do it. We can either ration the development of new technology (by constraining the available research dollars), or ration the use of the technology (say, by constraining the number of a given procedure to be performed each year). Alternatively, we can come up with some kind of single payer system where we, as a nation, decide how much we want to spend on health care, we tax the citizens and businesses to collect that much money and we budget the expenditures to achieve that cost. Of course there won't be enough for EVERYONE to get ANY procedure at ANY time they want it. Of course, there will be abuse. Of course, the rich will be able to buy services outside the system. Those are issues to be addressed, not issues that invalidate a single payer system.

It's easy to bash "big pharma" or "greedy insurance companies", but they are only part of the problem. Our culture is another big part of the problem. We've got to think seriously about how our current expectations for health care are not affordable and part of solving that problem should be managing those expectations.

Health Care Cost

When are we going to start separating the cost of Health Care from the cost of Health Insurance. Certainly then are connected, but the media doesn't seem to treat the two any differently.

The cost of Health Care should simply be the cost to provide any given procedure or service, regardless of who pays for it. With nearly zero inflation over the past couple years, the cost of Health Care should not have gone up.

The cost of Health Insurance is, of course, be a horse of a different color. If the insurance pool of which you are a member has seen an increase in the claims associated with a certain type of procedure, the cost of insurance will probably rise so the insurance company can continue to make a profit.

So, why has the cost of Health Care risen in the last couple years? Or has it? Has the cost of Health CARE risen, or has the cost of Health INSURANCE risen? Certainly the second. I'm not sure about the first. And, regarding the second; what are the real underlying causes of the increase?

Health Insurance Fable

Once upon a time, there was an insurance company named Profit Insurance. The Profit Insurance company sent it's marketing people across the land to determine the best price to charge for health insurance. The marketing results were that the best price for insurance was $100.

Management sent the the database trolls to the dungeon to work out a strategy for achieving the $100 price point. After examining years of health cost data, the trolls determined that they could sell insurance for $100, and still make a profit, if they did not sell it to people who were already sick. The managers liked the plan and made it so. Many people bought this insurance, but even though it was inexpensive, many young healthy people decided not to buy it. Profit Insurance managed expenses by artful claim denial and returned generous profits to the stockholders.

Now it turns out that in the same kingdom, there was a socially responsible insurance company that did not think it was nice to exclude people from having insurance just because they were sick. This benevolent insurance company decided to sell insurance to anyone who wanted it. Unfortunately, the trolls of the database told them they would have to charge $120 for this insurance policy. The management decided that the good hearted people of the land would surely be willing to pay $20 more to enable anyone to get insurance. Management put the Benevolent Insurance on the market.

People who were excluded from Profit Insurance because of existing illness flocked to Benevolent Insurance. Unfortunately (for Benevolent), existing Profit Insurance customers were not willing to pay $20 more for Benevolent Insurance, nor were the people who opted out of Profit Insurance willing to buy Benevolent Insurance. With only sick people in it's insurance pool, Benevolent Insurance was unable to survive at $120 and they went out of business.

The moral is that if you are in the insurance business and you want to maximize profits, it is best to limit your clients to the youngest, most healthy people you can find and deny as many claims as possible.

If, however, you want everyone to have the opportunity to buy affordable health insurance, you need to spread the risk across the entire population so that the young and/or healthy (while they are young and /or healthy) pay the majority of the costs of the old and/or infirm (until they become the old and/or infirm).

Single Payer/Medicare For All..... the only way to achieve reasonably priced coverage for all. If you bring in everyone, including the young and/or healthy who previously opted out; and eliminate the wasteful administrative duplication across the private insurance companies, everyone can be covered for the $100 (or less) policy.

Health Care I

Most of the people I know have health insurance.... and pretty good health insurance at that. While they might grumble about the cost, they are getting pretty decent coverage for the cost (assuming they don't consider how much their employer is contributing). Unfortunately, not a one of them sees the train wreck on the way. Insurance is really pretty simple; everyone puts money in the pot and those who need it take it out. If you don't need it (e.g. you're healthy) you're paying for peace of mind, nothing more.

Unfortunately, we've lost sight of that fundamental principle. In the name of providing "choice", we've allowed younger, healthy people to go uninsured, or buy insurance policies with minimal coverage. Without these people in the pool, the rates for those in the "not so healthy" category have soared. This, in turn, causes even more people to be unable (or unwilling) to pay the cost of health insurance, which shrinks the pool even more and tips the bias even more toward people who need to use the insurance rather than just pay for it.

How does it all end? Why does this need to be so difficult. Let's put EVERYONE in the insurance pool and have ONE insurance company that negotiates rates. We'll decide how much of the budget we want to spend on health care and we'll tax everyone appropriately. It works people. Don't listen to the hype. It really does work. No, it's not perfect. But if we don't do it, we're headed for a cliff. And oh, by the way... in case it matters to anyone, the 30+ million people that currently don't have health insurance will be covered. No, this isn't welfare. Most of these 30 million are hard working people who simply can't afford or qualify to get insurance. Don't forget, we already cover the poor with Medicaid.

I really think the half-assed compromise politically motivated non-legislation being floated around Washington needs to be killed. We really do need to start over, BUT, we need to start by resurrecting H.R. 676 and get everyone behind a Medicare-for-All, single payer system. If you agree, please write your congressman. If you don't.... think it over again. You're not feeling the pinch nearly as much as you're going to in the not so distant future. You may soon be one of the ones on the outside looking in.