From HX Refactored in Boston in June 2017, this – “Jeopardy Meets The Price Is Right, Healthcare Edition”
HXR 2017: Casey Quinlan: Jeopardy + The Price Is Right: Health Care Mashup Edition
healthcare economics
Make America Sick Again!
The Insane Clown Car Posse (hat tip to my buddy Robb Fulks for that lovely turn of phrase) that’s currently at the helm of the ship of state here in the good old USA has started to give us a peek at their plans for US healthcare. The phrase “shit show” seems to have been invented just so it could be used to describe the excrescence that’s emerging, inch by fetid inch, under the banner of the AHCA, full title “American Health Care Act.” [Personally, I call it “the new National Eugenics Plan,” since the savings the legislation’s backers crow about are clearly gained from sick folks just dyin’ quicker.]
Maybe we could tag it as GOTCHA, “Government Out To Cut Healthcare Access?” Asking for a friend.
“Make America Sick Again!” seems to be the sales pitch here. After the gnashing of teeth, rending of garments, and fisticuffs that marked the passage of the Affordable Care Act in 2010, the ACA haters – we’ll call them “the entire Republican Party, and all who sail in it” – spent the rest of Obama’s Presidency voting to repeal the law, while doing very little else.
What the ACA, or “Obamacare,” accomplished was to finally put the theory of universal healthcare access on the table for Americans, who had spent the 20th century watching pretty much every other developed nation on the planet create either single payer (a la Britain’s NHS) or insurance-based universal access (in Germany and Switzerland) healthcare delivery systems for their folks.
I say “theory of universal access” because, like all Congressionally-ground sausage, it’s a mix of top cuts of awesome (10 Essential Benefits! Tax Subsidies on Premiums!) with awful offal from the abattoir floor (too much power concentrated in the hands of AHIP, ridiculously narrow networks, uneven Medicaid expansion). But it was a start, after every President since FDR trying, and failing, to get any kind of national healthcare access plan in place.
After trying to throw Obamacare from the train, on a loop, lather/rinse/repeat, for years, once Cheeto Voldemort (I refuse to say, or type, his name – work with me here, people) took up occupancy at 1600 Pennsylvania Ave., the ACA-haters wasted no time in getting their “repeal and replace” dance of the seven veils started. They need at least seven veils to hide this mess, but they’re starting to run out of cloth.
Here are the Greatest Hits (to humanity, and human life) brought to us so far by GOTCHA-care:
- Instead of getting direct tax subsidies to help pay health insurance premiums – currently, individuals earning less than $47,520, or families of four earning less than $97,200, are eligible for those subsidies – people who need to buy health coverage for themselves and their families will get a following-year tax credit for their coverage. Which sounds great, until you realize that, say, you’re a 58 year old human living in central Virginia who’s a freelancer, making $40,000 per year. You’ll have to shell out around $600 per month (annual total = $7,200) for your individual Silver plan, or $1,000 per month ($12,000 annually) for your family of four’s Silver plan, and then get a munificent … $3,000 per year. The tax subsidies under the ACA, for the same coverages: $3,200 for the individual plan, $10,000 for the family of four.
- The myth of “choice.” All the messaging coming out of the push for the American Health Care Act is about “giving Americans choices about their care.” What those choices reveal themselves to be are:
- “Go naked” – no individual mandate to buy insurance coverage. Combined with the hockey stick trajectory of health insurance premiums over the last 30 years, this is an actual “choice” that many people, including me, were forced into before the Affordable Care Act.
- “Buy a plan you can afford.” – this is code for “buy a craptastic plan that covers nothing.” I know people who had plans like this before the ACA. The ones who got sick after buying these plans are no longer alive if they didn’t survive long enough to get on an ACA plan.
- “Buy a plan that covers you pretty well, and then live in your car.” With a maximum tax credit of $4,000, for people over 60 years old, those who qualify for AARP membership will find themselves pretty broke-ass if they buy a plan with any kind of comprehensive coverage. Which is why the AARP is flaming Congress over this proposed “replacement.”
- After improving access to healthcare (before the ACA, 18% of Americans – 47 million people – were uninsured; that number as of January 1, 2017 was down to 11%, 36 million), and starting to see incremental signs of overall public health improvement, the Clown Car now seems to think that throwing 24 million people off the insurance rolls by 2026 is a great idea, while bloviating about a $337 billion deficit reduction. Which sounds great, until you realize that the US spends upwards of $3.35 trillion-with-a-T on healthcare annually, of which up to $1 trillion is estimated to be waste. That’s $1 trillion PER YEAR, making the overspend between now and 2026 close to $10 trillion dollars. That figure makes a $337 billion deficit reduction over ten years look like a bar tab.
The people who put Cheeto Voldemort in office are the biggest losers here, which just proves that low information voters can wind up the punchline in a joke they *thought* they were in on. Our 45th President’s broad promises to “cover everybody” at “lower cost” is laughable in the face of the numbers out of the CBO, and the language in the AHCA itself.
As I said at the outset, this is a shit show. People’s lives are on the line, but the jerktastic folks defending this mess are outright lying about its impact on working class and middle class Americans. My own Congressional (un)representative, Dave Brat, answered my question about rural hospitals and uncompensated care at his Town Hall in February 2017 by pointing at the community clinics that hospitals are setting up to help people who can’t access care … THESE ARE PROGRAMS MADE POSSIBLE, AND PAID FOR, BY THE AFFORDABLE CARE ACT.
Sorry, was I shouting? <deep breath>
Tom Price, the “healthcare is a privilege, not a right” orthopedic sawbones now at the top of the US Dept. of Health and Human Services, outright lied on “Meet the Press” on Sunday, March 12, when he said “nobody will be worse off financially” under the American Health Care Act.
He prevaricated again, at a CNN Town Hall on Wednesday, March 15, when colon cancer survivor Brian Kline asked him point blank, “Why do you want to take away my Medicaid expansion?” Price said, “The fact of the matter is we don’t. We don’t want to take care away from anybody. What we want to make certain, though, is that every single American has access to the kind of coverage and care that they want for themselves.”
Price is fronting that myth of “choice” I mentioned above. They’re lying, they’re ginning up one of the biggest tax bonanzas for the already-wealthy in modern history, while simultaneously reducing access to care for the average American Joe and Jane.
Oh, and if you’re reading this, and thinking, “HAH! You losers, I have coverage through work!” … don’t. Employer sponsored insurance – which I have been saying needs to get clubbed on the head and buried in the woods for a while now – is on the bubble, too, since the Republican plan eliminates a key penalty on employers who don’t offer their employees health coverage.
The American Cancer Society hates this thing. The American College of Physicians hates this thing. Consumers Union *really* hates this thing.
We’ve got to get the insane clowns out of their car before they grind us under that car’s wheels. Time to start taking up some figurative weapons, folks. If the pen – or the keyboard – is mightier than the sword, start swinging that QWERTY blade at your Congressional representatives, now.
Your life is on the line.
Really.
Medical Monopoly: Medicine has a major image problem
When you hear the word “monopoly,” does it fill you with a warm and fuzzy feeling? (Unless you’re Hasbro, you really should say no, unless you’re a cyborg.)
Healthcare is a monopoly. We can’t DIY cancer treatment, or surgically repair a broken hip for ourselves, so we have to go to the medical-industrial complex to regain our health if we wander into the weeds, health-wise. We also have deep difficulty accessing pricing information. I’ve talked about that here and in even more depth on the Cancer for Christmas blog over the last few years. Maybe not a monopoly in the financial-reg sense of the word, but it sure is mighty like a game of Monopoly.
This “chaos behind a veil of secrecy” (all credit for that phrase belongs to healthcare economist Uwe Reinhart) has created the impression in healthcare customers that there’s no way to tell what something will cost before you buy it. You checks the box and takes yer chances. No Get Out of the Hospital Free cards. No pass-the-admissions-counter-collect-$200 option. That’s a rotten way to run a railroad (one of the original monopoly industries in US history), and an even worse way to run a hospital.
Dan Munro wrote about this, and the star-chamber cabal that actually sets the prices in healthcare, the RUC, on Forbes.com yesterday. I’ve talked about the RUC myself. And the search for price transparency, which seemed such an outlier activity just a couple of years ago, is now popping up in the Well blog on the New York Times site, as well as on Reuters. The Reuters piece has the addition bonus of quotes from my buddy Jeanne Pinder, founder of ClearHealthCosts.com. (Yesterday was a big day in medical price transparency.)
This is the central reason I registered the hashtag #howmuchisthat with Symplur, the healthcare hashtag registry. We all have to start demanding that prices be visible, and that the RUC stop cabal-ing around with our lives and our wallets. As more and more people are finding themselves with high-deductible health insurance, asking how much things cost before you make a healthcare decision will become the norm. If a healthcare provider can’t answer that question, s/he will find that s/he’s seeing the patient panel sinking fast, along with practice revenue.
Get with it, medicine. Remake your image, and your brand, to be clear as glass and user-friendly. Outcome metrics along with pricing would be really nice, too.
A Modest Proposal (on Health Insurance Reform)
~ Casey Quinlan © 2010 [originally posted on the now-defunct Disruptive Women in Health Care blog, posted here for posterity.]
I will admit to a bias on the subject of health insurance, and healthcare reform: I’m one of the millions of America’s uninsured. I’m female, over 50 (I told you, now I’ll have to kill you), and I was diagnosed with cancer in December of 2007.
The first of those facts – being female – is the biggest dinger of the three when it comes to health insurance premiums. The reasoning there: women use more health services, starting in their teens and 20s and continuing through menopause. The second – my age – could signal a better rate, since women typically tail off in their use of healthcare in their mid-50s. However, the third fact – cancer within the last 10 years – gets me insurance coverage quotes of $2,000 per month, with a deductible between at $3,000 to $6,000 a year.
For the math-challenged, that’s between $27,000 and $30,000 out of my pocket per year before insurance covers Dollar One. Since that amounts to much of my annual pre-tax income in each of the two years since Cancer Year – 2008 was the last year I had health insurance coverage – I’ve remained on the uninsured list. And developed some fierce opinions about the future of healthcare and health insurance in the US.
The Patient Protection and Affordable Care Act, a/k/a “health care reform,” passed earlier this year includes some help for my situation…in 2014. Meanwhile, I’m managing to get the oral chemo meds I’ll be taking until 2013 (which cost $500 a month) with the help of a community clinic. And I’m keeping my fingers crossed that I stay as healthy as I was before the cancer diagnosis, and as I have been since I finished radiation treatment in 2008.
That’s my current health insurance policy: crossed fingers.
There are two things that I think have to happen to bring about meaningful change in the healthcare cost/payment/insurance conundrum, for me and everyone else:
- Tort reform*
- Severing health insurance from employment
I realize that the tort bar, the health insurance industry, and pretty much everybody with a job-related health benefits package will take out a hit on me for making those suggestions. But the system has fallen, it can’t get up, and until major changes – not the chipping-away-at-the-edges approach of the current iteration of “health care reform” – are made in both the US legal system and how health insurance is marketed and sold, meaningful change doesn’t have a prayer.
How would tort reform help? Defensive medicine – practicing medicine with one eye over your shoulder looking for lawyers – adds as much as $45.6Billion-with-a-b annually to US spending on healthcare, according to a Harvard study published in September. That may seem like a drop in the bucket when the total annual spend on healthcare in this country is $2.3Trillion-with-a-t, but those dollars are all coming out of our pockets one way or another. Whether it’s in higher health insurance premiums, deductibles, fee increases to help providers cover those who can’t pay, fee increases to help defray the costs of malpractice insurance, or tax dollars for Medicaid and Medicare, we pay for it.
Reducing the dollar impact of medical liability would start to address some of those costs. Tort reform would give providers a defined worst-case scenario for liability, and would reduce the sue-the-bastards incentive for patients (and their lawyers) who don’t get the outcome they want from treatment. There are no guarantees in medicine, other than that there are no guarantees in medicine. Patients who are harmed by doctors that are unfit to practice wouldn’t be left without recourse, but the dollar amount of settlements would be capped.
Now, on to my really controversial suggestion: severing the link between health insurance and employment. Employer-paid health insurance benefits weren’t common in the US until World War II, when stiff wage controls made defense plants and other employers get creative to attract and keep good employees. They came up with offering to pay for workers’ health insurance. Thus was employer-sponsored group health insurance born, and the individual health insurance market stamped with an expiration date.
If you’re selling something, wouldn’t you rather package and sell it to as large a group as possible? Insurers, helped along by federal labor laws, have had a great revenue model: sell to large employers, keeping their annual premium-per-employee at an acceptable level because of the size of the risk pool. Cherry-pick the individual market, and put a high price tag on coverage for individuals who look like they might get sick – like women.
I’m actually quite pleased with one of the provisions in the health care reform bill fines employers with 50 or more employees $2,000 for each worker if they don’t provide health benefits. Why? Because the largest US employers – Walmart 1,000,000+ US employees, Verizon 200,000+, UPS 350,000+ in the US, to name a few – will look at that figure, do the math, and discover that the fine will save them money.
Again, for the math challenged: 1,000,000 employees would cost Walmart $2Billion-with-a-b in fines. Sounds like a whacking huge amount of money…until you calculate the cost health insurance benefits for those 1,000,000 employees using the average premium, which runs between $4,000 (single coverage) and $10,000 (family) per year. The fine would save Walmart $4-10Billion a year. They could even offer their employees help buying coverage, and still save some serious money.
And break the tie between group coverage and employment.
What would happen then? I think the American people can get together and drive the market as one big coast-to-coast group, using consumer-driven health plans** (CDHPs) combined with health savings accounts (HSAs). I believe that one of the causes of the healthcare cost conundrum in the US is the passive attitude most Americans have about their health, and healthcare. Decades of coverage paid for with “other people’s money” (employer-sponsored plans) have turned us into a nation of mindless medical consumers. We want cutting-edge care, we want second, even third, opinions, we bitch about $100 co-pays, we want to never have a bad outcome. Oh, and by the way, we don’t want to pay for it.
CDHPs would help make us mindful again: about the costs of healthcare, about the impact of our choices and behavior on our health, about how to get the most value for our healthcare dollar. A consumer-driven plan – also called a high-deductible plan – has a lower premium than traditional PPO or HMO plans due to that higher deductible. It also has no co-pays. You pay for care until you max out your annual deductible – between $1,000 and $5,000 per year – and are fully covered after that. Some CDHPs cover preventive and screening care, like annual physicals and mammograms, outside the deductible.
To be truly effective, CDHPs must be tied to HSAs, both to help consumers pay their deductible costs and to encourage them to save money for future healthcare costs. Making HSA contributions with pre-tax money makes HSAs “IRAs for healthcare,” with tax penalties for non-healthcare withdrawals. Since consumers – patients – will be paying for healthcare out of their HSAs, they’ll have an incentive to both ask what a procedure or prescription costs, and to ask questions about the cost of treatment options.
We’re a consumer nation. We shop for deals on flat screen TVs, cars, iPods, and breakfast cereals. Isn’t it time we did the same thing for prescriptions and hospital costs? I for one would jump at the chance to enroll in a CHDP – unfortunately, they’re not offered to individuals in the state where I live.
Don’t get me started on state insurance commissions…
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* [2021] I no longer subscribe to this idea – not that tort reform is a terrible idea, just don’t think it would help move the needle, or the mind-set, of what I call dinosaur docs (MDs over 60 years old who have “we’ve always done it this way” syndrome)
** [2021] CDHPs have proved to be a trash fire, since too few employers have elected to fund HSAs, and individuals who have bought insurance on the Affordable Care Act exchanges have found that CDHPs are basically just catastrophic care coverage. Their out of pocket expenses are high enough that many are now foregoing care rather than seeking medical care and paying out of pocket until their deductible is met.
