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Wednesday, July 29, 2009

Health, Health Care, Reform, Objections, and One Independent Bookseller's Response

A friend e-mailed me an article entitled “5 Freedoms You’d Lose in Health Care Reform.” Let’s go down the list one item at a time.

Freedom to choose what's in your plan. Well, I don’t have a plan. Don’t have health insurance. Can’t afford it. Have looked at various plans, and there is not one for me. I have been priced out of the market by companies who offer expensive plans and people who can afford them. “Good” health insurance pays the medical costs of a middle-aged person who has a slight dizzy spell, is put through thousands of dollars’ worth of tests, finally told there’s nothing wrong and she should “get up more slowly” in the morning. A lot of people make a living because of such coverage, but it drives the cost of health insurance sky-high, leaving a lot of us behind.

Freedom to be rewarded for healthy living, or pay your real costs. Another freedom I do not currently have. When I go to the doctor, I am charged the full, i.e., highest, amount listed for my visit and/or procedure. If I have to buy drugs, again I am charged the highest price. This is because I do not have health insurance. Luckily, I am very healthy; I am not, however, rewarded for healthy living. Friends and relatives with insurance get price breaks not only because insurance pays—their insurance company pays less than I am charged, because the companies are big and can bargain for better prices. Those of us who can’t afford insurance pay more than big insurance companies have to pay to cover their paying clients. A friend picking up a prescription forked over her one-dollar co-pay and asked, out of curiosity, what the “real cost” of the prescription was, and the pharmacist answered coldly, “That’s none of your business. You’re not paying it.” I might have been charged $80 for the same drug. How much did my friend’s insurance company pay for her prescription? Twenty dollars? Less? It’s none of her business and none of my business, according to the insurance companies and pharmacists. The doctors, I can tell you, have no clue. Read on.

Not long ago, a doctor thought I should, to be on the “safe side” (though he was pretty sure his diagnosis was correct), have a battery of expensive tests. I asked how much the tests would cost. He didn’t know. He asked one of his employees to call the place that gave the tests. The people there didn’t know, either, how much the tests would cost. “Our billing company takes care of that.” Americans are asked to be “responsible,” behaviorally and financially, for their own health care and then asked, if they do not have health insurance, to hand over blank checks to providers. This is a freedom?

Freedom to choose high-deductible coverage. This sounds good. I wish I’d ever been able to find it. Oh, we’ve looked into the question and have been offered a high-deductible plan, but there is a very high ceiling to the cost of such a plan, so that you can choose lower coverage, but you’re still paying the same as if you had higher coverage. You can bring the cost down to the third floor, but you sure can’t get it to the bargain basement. Bargains in high-deductible coverage are either a myth, or everyone claiming to offer them has ruled me out. Why? Because I’m self-employed? I don’t know, but I got tired of lengthy investigations that never once turned up a reasonable result.

Freedom to keep your existing plan. Again, I don’t have a plan. Once I had a plan, a very good one. University employees have been spoiled in this regard for a long time, but those days are numbered, whatever changes the government does or doesn’t make. One state decided to stop making employer contributions to retirement plans, since employees received a substantial tax reduction from the federal government. That’s retirement, not health insurance, but the writing is on the wall. How many people do you know who stayed in jobs solely for the health insurance—and then got laid off or had their benefits reduced or stripped when their hours were cut back or who got all the way to retirement only to find the benefits they had worked for had evaporated or came down with a serious illness and found their policy cancelled? Without government intervention, you have the freedom to keep your existing plan just as long as the company can provide it to you at great profit to itself and no longer.

Freedom to choose your doctors. This has been the panic cry as long as I can remember. At least Shawn Tully is honest enough to admit that HMOs curtailed the freedom in the same way a government plan would need to do. But guess what—private insurance plans do the same! If doctors don’t “participate” in the plan you have, you can be seen by them only on an emergency basis. You cannot, for example, choose a surgeon to operate on you and have your insurance pay that surgeon if that surgeon is not a participant in the insurance plan. There are probably a lot of people who don’t know this, as we did not until David was in the hospital in Florida this past winter. My freedom to choose a doctor is curtailed by my ability to pay, but that is always seen as okay by financial freedom hawks, so why is it any bigger problem that someone with insurance might want to choose a doctor whose fees would not be covered by that insurance? You want someone else? Pay for someone else! Oh, suddenly the shoe is on the other foot?

Someone else asked me earlier this summer, "Do you work out?" I don't go to a gym. What I do is go out in field and woods with my dog, and that (along with a grateful attitude) is my health insurance policy, insofar as I have one. Sarah and I went for a good hike this morning--fresh air, sunshine, refreshing breeze, lots of interesting things to see (and, for her, smell) in the woods--good exercise for both of us, refreshing body and soul. No insurance company is going to reward me for this. My getting out in the woods with my dog is its own reward, in the moment. I don't have to worry that it might not pay off in the future, after I've sacrificed my whole life to have it in place.


Deborah said...

An opinion piece in the WSJ today provides one British physician's response to the question of the 'right' to healthcare. I found the piece interesting in the ongoing discussion of U.S. universal access to healthcare providers.

Gerry said...


Last Friday a friend was going on about the health care debate. "I lived under socialism. I know what it's like. I don't want socialized medicine!" she ranted. So she's purchased a private insurance plan, right? Wrong. She has Medicare, single-payer, taxpayer-funded health care.

I'm not old enough for Medicare, so I pay for my health care myself. And when I do, I pay the provider more than Medicare pays for the same treatment or drug. My physician considers cost benefits when we're discussing options, but it is difficult to obtain price quotes. What other good or service do we buy without knowing what it costs???

On the other side of the equation, providers often don't know what--or if--they'll be paid. Medical billing is an arcane trade indeed, and insurers invest considerable effort finding ways to deny claims.

The system is broken. It is only a matter of time before the whole thing collapses of its own weight. We'd best be about designing something workable before that happens.

P. J. Grath said...

Among first-world countries, only the U.K. has government-provided health care. Other first-world countries, including Canada and France, have government health insurance programs. The British physician in the article Deborah referenced is arguing against the U.K. system. That system is not one the U.S. is considering. Also, he is arguing a very narrow philosophical point, i.e., whether or not there is a "right" to health care. His position is that there is not.

We don't need to argue this philosophical point. In describing my own case, I am not whining that someone else should be footing my medical bills. I don't think it's too much to ask, however, that routine medical care be available at reasonable rates and that those rates be obtainable before treatment is undertaken. I also don't see why I should pay triple what an insurance company pays. Yes, Gerry, they've invested a lot--and they're getting a good return on their investment. I'm not asking for a share of their profits.

I had another point, but it's late, I just got interrupted, and I can't remember what else I wanted to say. Darkness has fallen! To bed!

dmarks said...

Thinking about the plan, the part I like least is the "mandate" idea, which forces people who don't have a plan to choose one. Or else they pay a fine.

I am not sure of the status of it now, or if it is even part of the plan at this point. I hope it is never in the plan.

P.J. said: "Well, I don’t have a plan. Don’t have health insurance. Can’t afford it."

I think this might be the situation for many, even after reform, and I don't think that people should be punished if, even then, they choose "don't have a plan".

Good thoughtful discussion here.

Gerry said...

Um, "Amen" was directed at your post. I was writing my comment while Deborah's was on its way to the list and hadn't seen it. Still haven't read the WSJ article. Maybe later.

When I said I pay for my own health care, that's exactly what I meant. Not health insurance, for I have none. Health care. And I, too, pay more than what insurers - including Medicare - pay for the same procedures and drugs.

My point was that insurance companies' investments in Ways to Say No are one of the items that drives up the cost of health care, and that the utterly insane billing system is another.

Sorry if I was unclear. But then the whole subject is unclear, isn't it?

Deborah said...

Pamela, your friend who encountered the rude (and inaccurate) person when purchasing her medicine should have responded that yes, it is her business to know what the drug would cost without her insurance. It is our right to know - that is a law. Many people now call pharmacies to find out what the prescription will cost them and before making the choice to buy the drug and/or which pharmacy to use. I am very interested in reading what exactly is passed when/if something is passed.
Gerry, I knew your amen was to Pamela's post! I'd place my own amen there also.

billiecat said...

To all of your excellent points, I'd like to add this one.

One of the scare tactics going around is the claim that health care reform will lead to rationing. Well, we already have that. Health care right now is rationed on the the basis of money and employment status.

Of course, that's not a rational system for deciding how to apportion health care, so I guess we should call it "irrationed."

I frankly haven't seen anything suggested that qualifies as "rationing" in my mind, instead I see plans to bring "rationality" to healthcare, that is, evaluating treatments and medicines based on effectiveness and not on profit level. More generics, less spiffy new drugs that cost twice as much and are no better than a sugar pill.

Any reform worthy of the name must cover more people and bring costs down. Unfortunately, there are entrenched special interests that don't want a fair, rational system - they make too much money on the insanity we have now.

P. J. Grath said...

One of the most eye-opening things I’ve read this summer on health care in the U.S. was an article in the New Yorker magazine, which unfortunately I cannot find in our house. (I either loaned it to someone, or it got recycled, accidentally, with other magazines and papers.) Health care costs were compared across the country, and wide disparities were found. Treatment for the same illness or procedure or whatever might cost anywhere up to three times the minimum cost found, depending on where in the country the treatment was pursued. The author (? I think it was the person who wrote the article and not a “study,” but I’d need to re-read the piece to be sure) wondered what accounted for the differences. Could it be age of population? Income level? Health of the population? The quality of care provided? All of these were compared and found not to account for the price differences. The only element linked to geography that could be found to correlate with health care costs was—and this may sound vague—the nature of the local medical culture. In other words, in places where medical personnel were dedicated to practicing the best medicine, working together as teams to diagnose and treat, etc. (Mayo Clinic being the prime example), costs were reasonable. Not necessarily low, you understand, because some treatments are expensive. But in other regions, where medicine was practiced with an eye to the highest possible profit margin, the “same” care (not really the same, as there were unnecessary tests and referrals and nowhere near the level of team consultation) might easily cost three times as much.

The real question is not whether or not health care is a “right” but whether or not health care should be provided on the same basis as luxury items like diamonds and SUVs. It is not only the uninsured who are paying ridiculous prices. (It just hurts us more!) The rich and the insurance companies are also being milked.

I cannot recommend this New Yorker article highly enough and will be grateful to the reader who can find it for the rest of us and provide a citation.

Deborah, is it really true that pharmacists have to tell you what a drug would cost if you didn’t have insurance? Very interesting.

dmarks, I wonder how people who can't afford a plan could be forced to buy into one. Squeeze blood from a turnip?

Deborah said...

When I purchase a medicine the receipt shows not only what I paid but what I would have paid, at that pharmacy, if I did not have insurance (it's shown as savings). Yes, pharmacists and those who work in a pharmacy, have to disclose cost. Also, if you have a prescription but don't have insurance you can take the script to the pharmacy and request a partial amount - 30 of 100 pills for example. There are instances when someone knows they won't need 100 pills - so why pay for 100? - but will use 30.

P. J. Grath said...

Deborah, I passed your comments on pharmacy information along to the friend who told me the original story. Thank you for the information.

billiecat said...

I think you're referring to "The Cost Conundrum" by Atul Gawande, found online at:

P. J. Grath said...

Thank you, thank you, Billiecat! Indeed that is the article. Please read it, everyone, as it brings a dimension to the whole discussion that is most often ignored completely in narrow debates.