WK5 DISCUSSION HP-111

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HP111: The U.S. Healthcare System Great Debates – Week 5 Lecture 1

Debate Debated

One thing we try to teach every college student is to examine what is said with a critical eye. Including ourselves. It is a fine line to not be distrustful or think that we are being manipulated or lied to and to know that what is being said is often a one-sided simplified view of the topic. So, while you prepare for the Debate Discussion, let’s explore some of the content in the reading this week. Keep in mind that much of this is historical and quoted by the author, not the author making assertions himself. Essentially, we are playing a “what is missing” in this quote game.

OK, so this is pretty eye-catching. It would be easy to follow the logic and agree. I get his point. But a critical eye points out multiple holes in this argument. The first and most startling is that the “uninsurable are uninsurable”. Well of course this is not true. Uninsurable does not equate to pre-existing condition. Everyone is insurable and there are many countries who do just that. Those with pre-existing conditions are insurable, including me. For most, people with pre- existing conditions are not trying to retroactively buy insurance. They have always had health insurance. I was a relatively low user of healthcare services, mostly for a couple of babies. In spite of (or perhaps because of) working with medical doctors for decades I did not like to visit them as a patient. I was employed and was one of those young and healthy who lessened premiums for those with pre-existing conditions or unexpected emergencies. Until at 55 years old I suffered a cardiac arrest teaching a clinical at a hospital. From that day forward I became one of those pre-existing conditions folks. The vast majority of those with pre-existing conditions spent decades without it before they developed cancer, heart conditions, diabetes. And many of the rest were born with them. Anyone have a stomach for not covering infants born with congenital conditions over which they have no control?

The uninsurable are uninsurable. Let us remember that the definition of “pre-existing condition” is: someone who is already sick. It’s a little like driving your car into a tree and then trying to retroactively buy auto insurance. It won’t work. Insurance is the business of spreading risk. But for someone who, say, has cancer, there’s no risk to spread, just cost. That’s not insurance, it’s paying for health care.

Tanner, 2017 as cited by Jonas, 2022

Much of what is created is subtlety influencing us as we watch how the topic is presented. In an earlier week you watched a video attempting to tell us that free health care caused unhealthful living. And the cartoon caricature showed a slovenly, tubby, short little fellow who obviously deserved what poor health came to him. Did you catch that? How would it have changed that video if they replaced that image with an infant born with a congenital birth defect, a veteran who came home with no legs, an assault victim who suffered brain damage from beatings? Those are all pre-existing conditions and would have occurred regardless of whether or not they had to pay part of their healthcare.

But the most egregious (worse) problem with what this person is attempting to say, however poorly, is that if care is paid for, that is not insurance. Uummmm…so it is only insurance if nothing is paid? The whole point of insurance is to cover care. Of course, some require more care than others, and yes, traditional insurers do spread the risk, they are for-profit. But for decades they excluded all with pre-existing conditions. Examples abound of people who worked their entire lives with insurance, developed a health condition, and were fired. At the same time, they were dropped from their insurance plans. Remember, what I said a bit ago, the number one reason people declare bankruptcy is due to healthcare costs? These people lose everything, life savings, homes, retirement, everything. So yes, insurance pays bills and no, it is not at ALL like driving your car into a tree and then trying to buy auto insurance. It is more like insuring your home against fire or flood, paying premiums for 50 years until you die, never having used the insurance, unless you actually have a flood or fire.

See what happens when you critically evaluate what is being said instead of accepting it at face value?

Let’s try another one.

There is some truth here. Let’s see if we can pick it out. The assertion that we did not have a free-market healthcare system is likely more true than false. In past weeks we have examined the data on how much healthcare was covered by federal programs like Medicare, Medicaid, and TRICARE (military), how much by insurance businesses, and how much self-pay. Arguably, there is a 4th category with unrecoverable/charitable pay for the uninsured/underinsured, but that is a low amount in the grand scheme of things. Insurance companies are generally for-profit and would function according to the free market, one could consider that they do. The concern here is the amount of state and federal oversite for 3rd party payers. Health insurers deal with a lot of regulations, likely more than any other sector. A direct result of this is that healthcare insurers are at the bottom of the profit list of companies. Contrary to how they are portrayed,

No, we didn’t have a “free market” health-care system before Obamacare. Suggest free-market reforms to our health-care system and critics will inevitably suggest that you want to go back to the flawed system we had before Obamacare. But that system had little to do with a free market. Nearly all health care was subsidized in some way, either directly or indirectly. … This third-party and even fourth-party payment mechanism insulated consumers from the cost of their health-care choices and drove up both spending and prices.

Tanner, 2017 as cited by Jonas, 2022

health insurers make less profit than almost everyone else. I am going to say that some free- market forces existed prior to the Affordable Care Act (ACA), the proper name, Obamacare is used as a pejorative by the opposing political party. Subsidizing in this context include the employer paid portions of healthcare. However, those policies were still subject to free market forces. The subsidy is to the person not the insurance company. The use of the term “subsidizing” here is related to the individual, which is not the general use of the term and is inaccurate at best, purposefully misleading at worst.

The worst assertion with this quote is that it assumes free market forces ended with the ACA. This is utterly untrue. The federal portion of expenses did not change with the ACA, the number of insurance providers did not change significantly, and the amount an individual could pay was linked to income. None of this would seriously challenge what free market forces were already in existence, an arguable point as noted.

What the ACA did do was provide multiple protections for ill individuals. Insurers were required to cover pre-existing conditions, those developing cancer, strokes, and other serious illness could no longer be denied coverage. Insurers were required to provide a uniform baseline of benefits (there was little regulation of this prior to the ACA and insurers could do whatever they wanted). The ACA established minimum coverages to assure individuals, poorly equipped to evaluate and understand pages of legalese, were not taken advantage of. The ACA directed the use of nurses, educated to advance practice, be used to their full scope of practice, and provided reimbursement along the lines of the MD. This created serious backlash by MDs who moved into turf wars. This single move opened providers for the underserved, rural, uninsured, and elderly, with outcomes remaining equivalent.

The ACA overwhelmingly helped the individual and should have been celebrated. It, however, did one thing for which politicians were able to crucify it for: the infamous coverage for all. It was difficult for the average person to evaluate this aspect over all the fussing and fuming over individual rights. Keep in mind, uninsured/underinsured individuals cost all of us a lot of wasted money. This group, afraid of incurring bills they cannot pay, wait until they are very ill and present at the Emergency Room (ER). The ER is the costliest level of care there is. Multiple research studies show cheaper and better outcomes if provided with a general health MD or APRN.

Hypertension can be treated with an inexpensive medication, or untreated until a patient needs dialysis. Which is cheaper? Children with a mild illness can be seen by an inexpensive nurse practitioner or in the ER. The young, who are virtually certain they will remain healthy and do not want to have insurance, break their necks in accidents, suffer life-long traumatic brain injuries, or overdose with respiratory arrests. This population, for the sake of a nominal premium expands the coverage for all, this is true, but it also assures coverage for the tens of thousands of ill and injured young that will need it. It was a good and reasonable move to assist in controlling premiums but was tainted by the debate over individual rights. People have the right to refuse to pay for health insurance the headlines screamed. But when they are critically ill, do we get to say, ‘you refused to obtain health coverage so now we refuse to pay your million dollar bill’?

The final sentence should irritate everyone. The clear assertion is that each of us makes such poor healthcare choices since we are “insulated” from the cost that we drive it up. Do you feel that you do that?

I think this assertion speaks for itself. That was the point of the ACA, it certainly did not provide everything that everyone wanted, but it was a start.

Everyone had to give something, all Americans paid something according to their income, reimbursements were lowed, MDs had competition from APRNs, insurers had to provide basic coverage. It felt like a compromise to me. And I have watched the healthcare system for 40 years.

But was it popular? It was actually, considering how much negative publicity it generated.

Select image for larger version

Americans want widely contradictory things from health-care reform. They want the highest-quality care for everyone, with no wait, from the doctor of their choice. And they want it as cheap as possible, preferably for free. At the same time doctors, trial lawyers, hospitals, insurers, pharmaceutical companies, and government bureaucrats are all trying to protect their fiefdoms, hold onto their gains, and shift costs to others. There is simply no way to satisfy all these special interests and produce a health-care plan that will be hugely popular.

Tanner, 2017 as cited by Jonas, 2022

https://www.kff.org/health-reform/poll-finding/5-charts-about-public-opinion-on-the-affordable-care-act-and-the-supreme-court/

This is the last one we will examine for this lecture. America is a nation founded on rugged individualism, on everyone having the opportunity to achieve the American Dream of wealth and fortune. It is not surprising then, that many of those who have been the recipient of this wealth seek to preserve it.

The lament is over taxation without representation for the wealthy. The point is clear and arguable. There is good evidence to refute it. Not all of the uber-rich feel this way. Warren Buffet, one of the richest men in the world, wrote an op-ed in response to another round of laws that would benefit only the wealthy, making point after point against this system that protected the 1% at the expense of the 99%. Stop Coddling the Super-Rich

…the seemingly unfettered ability of an increasingly more powerful federal government to force individuals with wealth to pay for a growing number of public goods and social programs they had had no personal say in approving …Or people like himself, compelled through increasing taxation to contribute to projects they did not wish to support? To Buchanan, what others described as taxation to advance social justice or the common good was nothing more than a modern version of mob attempts to take by force what the takers had no moral right to: the fruits of another person’s efforts. In his mind, to protect wealth was to protect the individual against a form of legally sanctioned gangsterism. (p. xxiv)

Our leaders have asked for “shared sacrifice.” But when they did the asking, they spared me. I checked with my mega-rich friends to learn what pain they were expecting. They, too, were left untouched. While the poor and middle class fight for us in Afghanistan, and while most Americans struggle to make ends meet, we mega-rich continue to get our extraordinary tax breaks… These and other blessings are showered upon us by legislators in Washington who feel compelled to protect us, much as if we were spotted owls or some other endangered species. It’s nice to have friends in high places… My friends and I have been coddled long enough by a billionaire-friendly Congress. It’s time for our government to get serious about shared sacrifice. Warren Buffet

https://www.nytimes.com/2011/08/15/opinion/stop-coddling-the-super-rich.html

I may not be in a position to judge what is fair for the super-rich but certainly Mr. Buffet is. His writing makes clear that the system is legally stacked against the working person and toward the wealthy. 80% of federal income comes from the workers, 20% from the wealthy. This is because taxes are paid on W2s (paychecks). The wealthy do not earn W2s, their wealth grows in infrastructures of business (subject to depreciation), capital gains (taxed at variable rates but much lower than the general tax rates everyone else pays) and squirreled away in overseas (and states like North Dakota) accounts not subject to U.S. taxes.

But it gets worse. The uber-rich increase their wealth using the infrastructure of the US for which they have paid much less than the working poor to develop and maintain. Roads, bridges, waste management, and yes portions of healthcare are being used by the wealthy along with their business empires and pay little to no taxes. 55 major companies paid $0 in federal taxes on their 2020 profits: report

Updates: Billionaire Wealth, U.S. Job Losses and Pandemic Profiteers

The problems with the U.S. healthcare system cannot be fixed by bashing the wealthy and this is no attempt to do so. Remember, where this lecture began, with analyzing what is being written and said about the system with a critical eye. It is difficult to allow the wealthy to complain about reverse social justice (discrimination against the rich) when reality speaks to a system that works toward keeping the rich, rich, while using the resources paid for by the working poor, and even worse, during the pandemic, on the backs of minimum wage employees facing possible illness and death while they hid in million-dollar bunkers on private islands.

If the healthcare system will require more funds, social justice does indeed seem to be an applicable argument for increased support by those who benefit the most from it, while paying the least toward it.