We’re not having the right discussion

Depending on who you listen to, you have definite ideas as to what is wrong with health care in this country. Depending on who you listen to, you have definite ideas about who is to blame. Depending on who you listen to, you have definite ideas as to what should be done.

I’m tired of arguing with most people because most of these definite ideas — per everything I know — are myopic at best, could charitably be classified as misguided, and, if I’m brutally honest, I think are willfully dishonest and driven by partisanship.

Understand, I claim no special knowledge or insight. But I do claim we’re not having the right discussion.

In the words of one of our leaders, who knew health insurance was so complicated? Everybody. Everybody knows, but they still all want an easy answer, a silver bullet.

Before I tell you what I think, I’m going to give you some links. That’s right; you got a reading assignment.

Here’s the thing . . . if you are not going to click on any of these links, stop reading right now. Don’t make any comments at the bottom. Don’t engage in any discussion about what we should do. And especially don’t cast any votes on anything related to health insurance. I say all that because — in my humble and brutal opinion — it’s better for everyone if people who are not informed just remove themselves from the conversation.

Clear? Great.

Here is the first link.
U. S. Health Care from a Global Perspective

This report covers the US and 12 countries and compares health-related data information gathered through 2013 before the ACA went into effect. There are charts covering procedures, costs, health indices, and so on.

The second link.
International Federation of Health Plans

This is a less comprehensive set of data from 2015 but still comparing between countries.

The third link.
Health Care: How the U. S. Compares With Other Countries

This is a PBS report from 2012 also comparing costs and services of different countries. One could argue it’s old data, but that ignores the fact we’ve had no significant changes that could be called improvements in the data.

The fourth link.
U.S. versus European healthcare costs: the data

A deeper look at the data and some commonly explored reasons behind the discrepancies in cost and services. This is worth reading carefully as they explore some of the assumptions that people make about numbers that are thrown around.

OK, then . . . if you read all that, you at least have some information you can marshall in forming your opinion about health care and the issues we face when it comes to cost and coverage.

Want to hear my conclusions?

Well, before we go on, I want to touch on something else.

The ACA

While the ACA was being discussed, I was very much against it. Way back then, while many people were voicing emotional arguments about insuring the uninsured, I argued that the ACA was not a good way to do it. I had many heated arguments, and some friendships ended because of those discussions.

Disclosure: they were ended by me for one reason; the willingness of people to economically hurt one group of people to help another. That goes against my notion of helping everyone.

One can hear many voices positively hating the ACA, and invariably those voices are labeled in less than flattering terms. Sure, some are detractors primarily because of political reasons, but let me show you some numbers.

Picking states with different plans and coverages, I present this chart showing the 2017 yearly premium with and without subsidies for a couple making $55,000 a year if they choose a Silver plan. The cutoff for subsidies is $64,080. If your income is $1 above the cutoff, you get $0.00 subsidy. (Note: these are states we had considered at one time or another when looking to move)

Do you see anything interesting about that chart? Two things to note.

If your family of two is making $55,000 a year and you get a $10,000 raise (or you work overtime, or make a bit of money on the market) at best, you break even. In most cases, you’re actually losing money because you’ll pay a higher premium than the additional money you earned. (Note: Hawaii has a higher cutoff because costs here are higher.)

Here’s the second observation . . . if one of you two is not employed by a company that provides insurance, and you make $65,000 a year, more than a third of your income goes toward health insurance. Likely more because you also have a large deductible.

While you might be glad someone who makes less money gets a break, it might also kind of piss you off that they are making less money than you but are financially better off.

You give a passing thought to perhaps having a kid so that the cutoff is raised to $80,640 and you qualify for a subsidy. But, how much is a kid going to cost you? Can you afford a kid? What if you don’t want a kid?

Now, I urge people to get their own examples. Pick any state you like, choose a plan, choose a family size, choose a salary level, and compare costs with and without subsidies or even different levels of subsidies.

As written, the ACA typically helps lower-income individuals, inconveniences higher income individuals, but can negatively affect people in the middle of the Middle Class. Something like half the country is in that range.

That’s one of the reasons the ACA can and does find vociferous opponents. There are other reasons, but those are outside the scope of this article. Just know that there are other problems with the law as written.

My Opinion

First of all, the ACA, flawed as it is, is what we got. I was against it, but now that we have it, I don’t want to see it repealed. Not because I like it or think it can work as is, but because another upheaval helps no one. I want to see it “fixed” and that gets us into the rest of my opinion.

It should be clear there is no one solution or reason that we find ourselves in the situation we’re in. Well, there is a general reason. Politicians respond more to the needs of political interest groups than the needs of their own citizens, and that is one of the problems we have to address.

However, specifically for healthcare, I see a lot of issues come into play. One is a population that is largely ignorant when it comes to health. It’s also susceptible — because of that ignorance — to all sorts of advertising for medications and medical procedures that may not be necessary. This is, in part, a result of conflicting interests when it comes to how health care is run. The industry is profit-driven. Not necessarily a bad thing, but conflicts can arise and are never kept in check.

An example illustrating the point: When I hurt my rotator cuff (twice), the doctor prescribed an MRI to confirm a tear. I looked at the MRI and I could not tell either the extent or location of the problem but deferred to the doctor. An injury was indicated by other means (weakness in the arm, pain, etc.)

Just before the second operation, I was looking at the MRI scans with the doctor and asked him where exactly the tear was, and he said something like “in this general area, but it’s hard to see on the MRI. I’ll know more when I go in to fix it.”

So, why did I have the MRI? I have one possible reason. The doctor, who was one of the partners in the practice, was also a part owner (along with his partners) of the lab that ran the MRI machine. The insurance was charged something like $3K for an MRI that basically showed my shoulder but had no benefit as far as the operation was concerned. I can’t very well accuse the doctor of unnecessary tests, but I have my strong suspicions. Maybe the MRIs helped, or maybe they just helped him buy new golf clubs.

Let’s then talk about the subsequent physical therapy. After the first operation, I went for the full number of sessions (something like 13 or 15, I can’t remember). The majority of those was just them making sure I did my exercises, meaning I went in, did my exercises, and left. The place where I went for the therapy is also owned by the partnership of doctors, and they charged the insurance for my sessions.

After the second operation, I told them I would only come in every three weeks for a check on the progress, and I did the exercises on my own at home. Each half-hour of therapy was charged at something like $75.

What I’m trying to say is that most people — me included — do not question when a doctor prescribes a test or procedure. And, to be fair, if you have a health problem, you would like to have confidence in the diagnosis, and a test can go a long way to confirming or eliminating a prognosis.

But, here’s the problem . . . there should not be any conflict of interest situations. A doctor should not receive a bonus for prescribing a given number of pills, or have a deal with a pharmaceutical company to push a particular kind of medicine, or personally profit from prescribing a given test.

“What about the insurance company?” you ask. “Don’t they have to approve it?”

Yes, and this is where it gets even more onerous.  Let me say this about insurance companies. As long as they still make money and they are not the ones to pay for something, they won’t care a whole lot. This is why the same blood tests cost $800 in Chicago versus $130 in Colorado Springs versus $300 here in Hawaii. Different insurance companies agree on different costs which they then pass on to their customers in the form of higher premium. There are oversight boards, but there too we have a lot of incestuous relationships.

I’ll give you another example, one more recent. I recently had a physical and asked about an odd-looking skin blemish that was bothering me. The doctor said he could quickly treat it right then and there. Sure enough, he grabbed a little sprayer that used liquid nitrogen to freeze the area. It took literally four minutes and that included him going to get the sprayer. I paid a $30 copay.

When I receive the statement, I saw that the insurance was charged $635 for the procedure. Spraying a bit of nitrogen cost $635.

Obviously, the insurance must have approved it . . . but, here’s the interesting part. My insurance is from Kaiser Permanente. The doctor I saw works at a Kaiser Permanente clinic which is where I got the procedure. Basically, the insurance company — Kaiser — approved the cost of a procedure performed by one of their doctors at one of their clinics.

Guess who actually paid for that procedure? People who pay their premiums. If they (the insurance or the insured) get a subsidy toward their premiums, then all of you readers and all of the taxpayers helped pay $635 for me being sprayed with some nitrogen to remove a blemish about a quarter inch across.

Is that a fair price to pay? I don’t know.

And, that’s the other problem. Where do I go to ask or complain about a given charge?

Some people would point to the government, but many of the people overseeing these things either come from or eventually go to the industries they are overseeing. It’s all on the up and up . . . but it’s frustrating because I know human nature. I know greed. I know that opportunistic behavior is not necessarily nefarious, but is nonetheless a problem.

Summary

If someone tells you fixing health care here in the US is easy, know they are idiots. I only touched on a few things but if you read the articles in the links, you know the road to get where we are was long and tortuous, and the road back is not a straight and paved highway.

There are many interconnected problems — social, economic, educational, political — few people are speaking about, and solving these problems involves rethinking our approach to health and things that go beyond health, including our expectations, and some measure of acceptance that not everything can be fixed. The system can’t be perfect, but it can be better.

We should provide a level of care to everyone from the moment they are born to when they die. We should hold people responsible for a portion of their overall health even as we help people manage things they have no control over. We should understand that as long as the system is run for profit, nothing will change (look at the defense industry if you want an example). We should strive to educate and offer incentives reinforcing positive behaviors and punishing negative behaviors (a contentious notion).

We should do things differently, we should discuss novel solutions, push the comfort zone in our thinking, and admit no solution can ever work if it doesn’t deal with the totality of the problems we have.

And here’s why I’m pessimistic . . . We should be talking about a comprehensive approach, and we’re not.

I estimate the solution requires a slow progression of improvements — some we’ve not even thought of — in a large number of interconnected areas, often with some trial and errors and with continuous oversite with an eye toward optimization.

Unfortunately, a realistic estimate for how long it might take to overhaul health care in this country is “decades, ” but people present solutions tied to election cycles, and no one is calling bullshit on these opportunistic bastards.

I further estimate a lasting solution requires compromises across political parties and social groups by people willing to put the issue of healthcare for everyone ahead of personal, political, or monetary gains.

In other words, I think we are royally screwed.

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