Medicare

My spouse becomes eligible for Medicare this year so we've been paying attention.  We've had to pay attention to insurance for a number of years as I have a genetic condition that causes a chronic disease.  It has been under control for me since 1987 but that is irrelevant.  On the open market, I was not insurable at any price.  I had medical insurance available through our denomination but it was nearly $4K a month and was no longer affordable by my employer or my family.  The ACA saved us... me... literally. (This is not about the ACA and I see serious problems there which I have addressed before a number of times).  So paying attention to Medicare didn't feel unusual.

I noticed quickly that while some folk have complaints, few of them are the elderly folk on Medicare... and the complaints that population does have are no different than the general population dealing with any insurance company - costs, restricted access, complexity...  I do hear younger folk who say that Medicare is proof that the government can't run a healthcare insurance system.  They say it is nearly bankrupt and doesn't work anyway.

So, with those thoughts in mind, we went to a two hour seminar yesterday to get a basic understanding of Medicare presented by a non-profit that advocates for the elderly and helps them with issues around Medicare.  I came away with some impressions... Medicare is too complicated.  Negotiating part D and supplemental plans is difficult and clearly a lot to ask of some seniors.  $300-400 a month for a newly retired person in California for part B, a reasonable part D, and an F class supplemental plan is a lot of money, especially for someone on a fixed income... and it will only go up.  The "free market" alternative - Medicare Advantage - may work somewhere, but it requires a population density that we don't have where we live so the choices here are thinning rapidly (there are only three plans available in Santa Barbara county now and only one that covers the entire county) as the companies can't make the level of profits they desire.  Even where it might work, it still has the significant limitations commonly associated with HMO's.  The donut hole is scary for someone with a chronic condition but the way that the ACA is filling in the hole is at least a little heartening.

It seems that making Medicare a single payer system, eliminating the need for Part D and supplemental plans would go a long way to simplifying the system.  Both pieces feel to me like compromises made with the private sector so they can continue to get some portion of income from this group of high consumers of medical care.  We are worried about the realities of paying that much money a month for insurance after having employer provided insurance our entire lives but I am more than glad to know that I will at least have coverage.  I anticipate that at least one of my meds (which is stupidly expensive) may not be covered but that will be what it is.  I have 3+ more years until I become eligible and another year beyond that until retirement so some of those worries are meaningless.  A Republican president and congress could make the entire program go away.  A Democratic one of each might strengthen the programs... time will tell there.

Of course there are the big public policy questions that continue... Is healthcare a right that everyone should be provided regardless of their economic condition? For me as a theologian, what are the theological implications of that question?  How do we control costs while at the same time insuring good care?  And for me a central question, what role should the profit motive have in healthcare?  (I would argue none)

The Problem with the Insurance Argument

After the Supreme Court ruling, the question of health insurance has come back to the front with Democrats celebrating and Republicans vowing to repeal.   Democrats should not be celebrating and while the Republicans might be able to repeal the Affordable Care Act but they have no solution worth real discussion.

First off, the free market does not and can not work with regards to health care.  The consumer has no power to influence the market at all.  You can't shop for the lowest cost when you've just had a heart attack.  Add that there is often only one hospital nearby and the physician on duty is the physician on duty.  Most of us also have no control over what, if any, insurance is available to us and even less over what is covered by that policy.  Employers may shop for the lowest price on insurance but it is very seldom that they do so while comparing two identical products and the dissimilarities may not be obvious until the product is used and the patient discovers that a specific lab or physician is not covered by their insurance.  And the coverage is constantly changing so a physician covered one year may not be the next year.  Which services and providers are covered by a given policy rarely if ever have anything to do with quality of care.  Market forces simply do not work when it comes to health care so if we rely on them to control costs or quality, we will only see failure.

Second, there are some things that should not be sold for profit.  Health care is one.  In a for profit business, the business always has a primary responsibility to make money for the stock holders.  There is a legal responsibility to do that regardless of whether they are producing widgets, automobiles, or providing health insurance.  The first responsibility is not to the client, it is to the stock holder.  Obviously, in the free market, a better product is more likely to produce higher profits for the stock holder, but the primary job of any for profit company is not to produce widgets, automobiles, or sell health insurance... it is to make money for stock holders.  For health insurance companies, that means denying coverage.  If they can deny a procedure, they have made more money.  It is no surprise then that for profit insurance companies have employees whose job is to find ways to deny coverage to the patients and they get bonuses when they do so.  At least a panel of government agents making decisions around coverage would have the well being of the larger population as their primary concern. 

The bottom line is that the current system, even under Obamacare, cannot solve the problems we face and will remain the most expensive health care delivery system in the world while at the same time being far down the list in terms of almost all of the significant metrics for outcomes.  The good news is that there are models around the world that actually work.  All we need do is swallow our pride and embrace a model that delivers health care to all of our citizens at a more reasonable price.

Affordable Care Act

Today the SCOTUS ruled that Obamacare is constitutional.  I am not a lawyer and don't claim to understand whether or not it is a good ruling.  My gut says "yes," but that is an opinion without any real basis so take it with that degree of impact.

Whether or not the law is constitutional has nothing to do with whether or not it is a good law and there are those on the right and the left who are arguing that it is not a good law.  Those on the right say that the law interferes with the movement of the free market and impacts the freedom of individuals.  Those on the left argue that health insurance is too important to be subject to the whims of the free market and should never be a for-profit business and that this law will make the movement towards establishing a non-profit, single payer system more difficult to accomplish. 

I hoped for at least the option of a single payer system all along and in the best of all worlds, that is what Obamacare would have been.  I'm not sure how this law will impact that possibility.  There are those who argue that the constraints on the private insurance companies included in this law will drive them out of the health insurance business and push us towards single payer.  Others argue that this law just entrenches the for profit health insurance companies which will keep us from moving towards single payer.  Time will tell.

The Republicans will vote to repeal this law although, it isn't clear that they would do this if they really had the power to make it happen.  Being seen as responsible for removing the popular provisions of this law is not likely something they really would want and keeping the popular provisions without the individual mandate is not something the insurance companies are likely to be happy about...

Interesting times.

healthcare yet again

Last night I was searching for a radio station as I drove home and found a right wing talker, disparaging Obama's meeting with congress. A caller made a statement that I found completely true and critical for the discussion. He said, "If health care is a right, then it doesn't matter what it costs, we must make it available to everyone. If healthcare is not a right but a choice, then government should not be involved at all."

I think he is correct. If healthcare is not a right then we should do away with medicare, with public health insurance for children, with any government programs. Let the elderly who consume too much medical care to ever be able to afford any health insurance die. Let families provide for their children or let the children die. If it is not a right, government should not be involved. If it is a right, then the only discussions should be regarding how to pay, not whether we pay.

Having said that, it is important to realize that every industrialized nation in the world has decided that it is a right except the United States. Think of that... Every other industrialized nation has said it is a right.

I cannot understand how anyone, especially people who call themselves followers of Jesus can justify any other position. Healthcare is a right and it must be guaranteed as a part of the commons.

I have said before that there are a variety of ways to do this. My personal preference is for a truly socialized system like in Great Britain, but that is not the only option. Most of Europe uses private insurance that is highly regulated and given to all and the providers are likewise part of the private sector. Canada's system is not a national system but is province by province and is essentially socialized insurance while the medical providers are private businesses. Whatever option is chosen, I believe we must provide insurance for all and don't really care how we do it.