Oh, sure. Nothin' broke here:
With median annual compensation of more than $12.4 million, C.E.O.’s at the big health-care companies make two-thirds more than their counterparts in finance and are the highest paid of any industry. The health-care industry’s total annual profit has grown to an estimated $200 billion, and it doled out nearly $170 million in campaign contributions in 2007 and 2008. It now spends more than any other industry lobbying the federal government—$3.5 billion over the past decade and a record $263 million in the first six months of this year. That’s six lobbyists and nearly half a million dollars for each member of Congress. It’s been a good year on K Street, too.
It should come as no surprise, then, that we spend 17 percent of our G.D.P. and more than $7,500 per American per year on health care. That’s 50% more than any other industrialized nation. Meanwhile, the quality of care we get in return has fallen to embarrassing lows. According to the World Health Organization, our health-care system ranks 37th in overall quality and fairness, placing us between Costa Rica and Slovenia. We rank 41st in infant-mortality rates, alongside Slovakia and Serbia, and dead last among 19 leading industrialized countries in preventable deaths. Nearly two-thirds of personal bankruptcies in the U.S. are caused by illness, yet more than three-quarters of those people actually had health insurance when they fell ill. In other words, we’re all getting ripped off.
So here's the thing. It's easy to make fun of someone for a typo. Left of the Dialian DT, for instance, although an excellent writer, can rarely go more than five sentences without one, often with unintentionally hysterical results.
A follow-up to yesterday's post:
Blue Cross of California encouraged employees through performance evaluations to cancel the health insurance policies of individuals with expensive illnesses, Rep. Bart Stupak (D-Mich.) charged at the start of a congressional hearing today on the controversial practice known as rescission.
[...] one Blue Cross employee earned a perfect score of "5" for "exceptional performance" on an evaluation that noted the employee's role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care.
WellPoint's Blue Cross of California subsidiary and two other insurers saved more than $300 million in medical claims by canceling more than 20,000 sick policyholders over a five-year period, the House committee said.
"When times are good, the insurance company is happy to sign you up and take your money in the form of premiums," Stupak said. "But when times are bad, and you are afflicted with cancer or some other life-threatening disease, it is supposed to honor its commitments and stand by you in your time of need.
"Instead, some insurance companies use a technicality to justify breaking its promise, at a time when most patients are too weak to fight back," he said.
The committee investigation uncovered several rescission practices that one lawmaker called egregious, including targeting every policyholder diagnosed with leukemia, breast cancer and 1,400 other serious illnesses. Such investigations involve scouring the policyholder's original application and years' worth of medical and pharmacy records in search of any discrepancies.
In November 2007, The Times reported that insurer Health Net Inc. paid bonuses to employees based in part on their involvement in rescinding policyholders. According to internal corporate documents disclosed through litigation, Health Net saved $35 million over six years by rescinding policyholders. The disclosures were part of the evidence that led a private arbitration judge to levy $9 million in damages against Health Net in a case involving the company's rescission of a woman diagnosed with breast cancer.
You want to talk about death panels? There's your death panel, right there. The difference is, this one is real. And it's the way the system is designed.
Just because it's a central fact and it sometimes gets obscured:
Such as, say, living.
The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's "death panel" so his bureaucrats can decide, based on a subjective judgment of their "level of productivity in society," whether they are worthy of health care. Such a system is downright evil.
As someone who has spent an unusual amount of time dealing with insurance companies—although only the smallest fraction of the time Top Management has spent—I couldn't agree more. Such a system is indeed downright evil.
Where the former governor is confused on this point, however, is this: that's the system we have currently.
Palin is sort of right on one point -- there are people who weigh whether children like Trig are worthy of insurance. They're called insurance companies, and they have decided that these children are not in fact worthy of coverage. That's because Down Syndrome is a "pre-existing condition."
In other words, if Palin didn't have insurance through her husband's job—I assume she's no longer on the state's insurance plan, as of a few weeks ago—and tried to land it through the private market, she would not be able to get health insurance. Because of Trig. Because that's the way the invisible hand of the market works; after all, kids with Down's Syndrome are wicked expensive, and it doesn't make even a shred of sense, from a business point of view, to insure such children. So insurance companies don't. Which means the kids and their families are utterly screwed. Unless the government steps in, and either forces the insurance companies to cover such individuals, or the government covers them themselves.
Margaret Demko, the mother of three-year-old Emily, testified before the Ohio Finance Committee on February 27, 2008, on how waiting for health care coverage has impacted Emily and her future. Emily was born with Down Syndrome. After receiving Emily's diagnosis, the family decided that it was important for Margaret to stay home in order to best meet the needs of their child. They explored numerous options after losing their employer-sponsored coverage, but due to Emily's pre-existing condition, the Demkos were denied private coverage. Luckily, they qualified for Medicaid. However, by their 6-month reauthorization meeting, the monthly family income was $135 over the allowable limits.
The medical bills, in excess of $3,500 a month, were devastating, forcing the family to make difficult decisions regarding therapy. Emily's medical condition requires orthotic shoe inserts, physical therapy, and corrective eye treatments, as well as hearing and blood tests. The Demkos cannot afford to incur all the expenses at once.
So. We sort of need to ask ourselves some basic but hard questions: do we care about children with Down's Syndrome if they're not ours? Do we feel like paying a few extra bucks per year so a family a few thousand miles away we don't even know can get their kid the therapy he or she needs? Is it, in fact, in our best interest as a society to help each and every member of that society reach his or her full potential? Does our self-interest dictate that in the long run this is to our own benefit? And is it simply the moral thing to do? And, in either case, are we willing to pay for it? And, if so, how much?
These are tough questions, and they're not really getting discussed. Because people with billions of dollars are paying other people to go to town halls to gin up false outrage over absurdities like "death panels," rather than get to the heart of the matter: do we believe we should continue to be the only industrialized nation without universal health care? Do we believe that children like Emily Demko should be on her own, left to sink or swim? Is that the right thing to do? Is it the smart thing to do?
I suppose I should mention that there's at least one other problem with Palin's statement, and that's the fact that it's a lie. There will be no "death panel" under any health care plan passed this year. One has never been proposed and one never will be proposed. For a high-ranking politician, even a former one such as the former governor, to make such a statement is simply absurd. There are two choices: stunning ignorance or simple lying. I'm going to give her the benefit of the doubt and say she's lying. That's actually the more generous of the two options.
So I heard some one yell about wait times the other day. And I thought, "...really? That talking point? Still?"
I think the US consumer economy would still be in free-fall if we hadn't come back. We show up from China needing new of everything. Clothes. Camera. Two computers, plus monitors and backup drives. Housewares. Shoes. At least one fridge, probably a stove. Radios/sound system. TVs. You name the item, and the version we have is road-worn, obsolete, broken, or gone. (Sadly for Detroit, not cars: Our two, vintage 1999 and 2000 respectively and stored with friends, still seem just fine. Sorry!) Our house needs to be repainted-- and re-roofed, and re-drivewayed, and its trees trimmed. That's just a start. Good thing we saved up in those days of 20RMB noodle/dumpling dinners. And, yes, many of the items we're getting were made in China. You just can't buy them there.
Here's the surprise: We call to get service appointments, and people show up right away. Air conditioning not working in 90-degree DC swelter? We make a call one evening, and the next day it's all fixed. Plumbing clogged and leaky? A few hours later, it's not. Need the car looked at, after three years in the shed? Call the service place and the only question is: do I want to bring it in this afternoon? Or wait till tomorrow? On a Sunday, we see that a tree is dying in the back yard. By Monday afternoon, it is converted into neatly stacked wood.
These are all people and services we'd dealt with before, but in those days we learned to plan weeks in advance for service calls. America still looks incredibly rich and lush. But this little indicator suggests lots of slack in anything considered a discretionary purchase. Not startling in principle, but impressive to encounter first-hand.
Only exception: I call to get an appointment for a physical exam with our doctor -- a good but "normal" doctor, not some fancy physician to the stars. First available slot, mid-November. I have no theory for this anomaly.
So because I am the very epitome of the patriotic American, I took the Rose to Target this President's Day, since nothing expresses my admiration for GeoWash and Honest Abe like handing over many many many pieces of paper plastered with their visages.
Doctors drive me insane, even the good ones.
As I have written about at some length, I love doctors, responsible as they are for saving the lives of two of my chillens. But they’re human and sometimes I swear I buy into the whole God complex thing. Or maybe they’re just so damn removed from the plane of existence where the rest of us live.
Had some dental work done today by an endodontist who seemed to know her stuff—although, really, how would I know? (Another thing wrong with McCain’s health care “plan,” as it places the burden of knowing what treatment is needed upon the patient—I mean, if we knew that, we wouldn’t be at the doctor’s, now would we?) But she was friendly and explained what she was doing.
And when she was done, she wrote me out a pair of prescriptions, one for an antibiotic, just in case, and one for pain relief, and advised me I was really going to want to take that before the anesthesia wore off.
So I get ‘em filled and I’m walking out and I look at the bottles, one of which says “ibuprofen.” And I say...is this just Advil or is there some, you know, good stuff mixed in there? And the pharmacist says, no, it’s just Advil. But it’s 800 mgs. Advil’s just 200 mgs.
And I think, right...so you take four of them.
And I do some math in my head and compare and contrast a bottle of Advil with the ten bucks I spent for the twenty pills here and realize these lil puppies cost twice as much per milligram.
Why the HELL didn’t she just tell me to take Advil?
Show up for dental appointment at 8:21, 9 minutes early. Ask once again about how long the procedure will take. Be told, once again, “an hour, hour and a half.”
Sit for fifteen minutes, cognizant you were told you were lucky to score “her first appointment of the day.”
Be brought back at 8:34.
Sit some more.
Sit still more.
Hear her come in fifteen minutes later and greet colleagues and be asked how her weekend was.
Many minutes later, after she has graced you with her presence, be pronounced good to go and walk out. Note it is now 11:18, two hours and fifty-seven minutes after you walked in.
Adjust for your own earliness, and realize it took them an hour and eighteen minutes longer than they thought it would, or roughly twice as long as they estimated.
Hope desperately they get that exact level of service in every single restaurant they ever go to for the rest of their lives.
"While he reportedly plans to call for up to $200 billion to continue a war that his top general can't even say is making the country safer, George Bush is rejecting the idea that we would spend less than one third of that amount for the health of America's children.
"That says all that needs to be said about this President's priorities."
—Senator Chris Dodd
I had no idea until just a week ago that Chris Dodd’s father was a prosecutor at Nuremberg. Wow, pretty stark contrast to the current president’s grandfather, who made a fortune by trading with the Nazis during WWII and who was involved with a plot to overthrow President Roosevelt and install a military dictatorship. So apparently a love of fascism ain’t nothin’ new—can such a thing actually be genetic?
(Have y’all heard about that one? It’s one of them rare conspiracy theories that is actually indisputable—congressional inquiries found it to be true—and yet you’ve pretty much never heard about this attempted coup, have you? Thank Allah for the integrity of our military. As compared to the historical immorality of the richest of the rich in this country.)
I've never taken John Stossel seriously. I mean, the guy is such a transparent hack and blatant shill that it never even occurred to me someone might actually think he has something worthwhile to say. Which was stupid of me: the guy's been on a major television "news" show for years and years, so clearly someone thinks the guy has something to add, or at least the suits think someone thinks that. And, no, his hideously cheesy 70s pornstache has nothing to do with my low esteem of his bandwidth.
Well, okay. Not much.
So I didn't read the hit job he did on this poor woman, and I assume it's behind the Wall Street Journal's firewall. But it certainly is in keeping with his previously-observed standards.
Has he no decency? Has he no shame? Clearly not. Which is not a surprise. But is still disappointing.
My name is Julie Pierce. My husband was Tracy Pierce. I am featured in Michael Moore's documentary 'SiCKO.' In the movie, I share my deceased husband's story — his unsuccessful battle with our insurance company to receive what could have been life-saving treatments for kidney cancer.
I just read your Wall Street Journal article written on Sept. 13, 2007, titled "Sick Sob Stories." You begin by talking about Tracy's role in 'SiCKO,' and claim the bone marrow transplant denied by our insurer would not have saved him. You also accuse me of "sneering" over our situation.
In your 'reporting' of this story, you did not contact me, and you did not contact my husband's doctors. I cannot believe that a publication like the Wall Street Journal would print such an accusation without talking to anyone involved — especially in such a personal matter, which resulted in the death of my 37-year-old husband and the father of my child.
If you had contacted me, I would have told you that bone marrow transplants became a last option, only after our insurer denied many other treatments again and again and again.
I would have shown you a letter from our doctors at the Blood and Marrow Transplant Program at the University of Kansas Hospital, in which they argued strongly for the bone marrow transplant, citing "strong evidence" supporting the past success of that treatment — they wrote that it could "give him a chance to achieve complete remission." In fact, they called the bone marrow transplant "his only chance of survival."
Instead of calling me up and doing real reporting, all you can do is throw around studies from 1999 about the supposed inefficiency of bone marrow transplants for breast cancer patients — even though Tracy didn't have breasts. He had kidney cancer! I understand that you want to try to prove that private insurance in this country really isn't that bad. And I can see that you won't let the facts get in the way.
You go on to claim that Tracy wouldn't have received his transplant in a country with socialized medicine, either. Where is the evidence? Not only are more bone marrow transplants performed every year in Canada, but they invented the technology! So much for your ridiculous claim that "profit is what has created the amazing scientific innovations that the U.S. offers to the world. If government takes over, innovation slows, health care is rationed."
You are simply carrying water for the for-profit insurance industry that killed my husband. And then you have the nerve to accuse me of "sneering" about it. My husband has only been dead since January 18th, 2006. It is still fresh to me and my family, and comments like this are inhumane.
I have since tried to contact you via email, but you have not responded. I don't expect an answer. People like you just write with an agenda, without coming to the source or getting any facts, because your main goal is to try to discredit Michael Moore and universal health care. I understand it's a game — you did it without thinking about how you would hurt a family who have suffered — and are still suffering — such a tragic loss.
My family is not a "Sick Sob Story." We are a normal, American family that has had a significant member die from a horrible cancer that ravaged his body due to repeated denials from a health insurance company. We will never know for sure what would have worked because Tracy was never given a fighting chance. Over 18,000 Americans die each year because they don't have health insurance. I suppose theirs are "sob stories," too.
I don't want a hit-piece. I want answers. Why does our wonderful profit-driven system of medicine kill 18,000 Americans each year? Why do we pay far more for our health system than any other country, but have some of the lowest life expectancies and highest infant mortality rates in the Western world? Would you discredit the work of your late colleague Peter Jennings who, while suffering with lung cancer, did an excellent report titled "Breakdown: America's Health Insurance Crisis"?
I hope you have answers, but I am not optimistic. I pray that you will never have to go through what we went through — if you did, you wouldn't be so quick to cheerlead the system we were victimized by.
There is no excuse for a country as wealthy as ours to allow innocent children to go without access to basic health care. And if policymakers take steps that result in a net increase in the number of children without access to care, they have a moral duty to find a way to fix that problem immediately. As far as I'm concerned, the Bush administration is morally responsible for what happens to the children who lose access to health care as a result of these new rules. If any of them die or suffer permanent harm from a condition that could have been prevented with routine care (and it's bound to happen), the Bush administration bears the blame.
While I think they are terribly misguided about the realities of health care policy, I understand that there are people out who, for principled reasons, believe that it is important to limit the role the government plays in providing health care to its citizens. And I understand that these folks believe in their hearts that if the market were simply left to work it magic, we'd soon find ourselves in a health care utopia where every child had top notch care. I know they don't mean any harm. But people like this need to realize that this isn't some grand experiment. We're not dealing with hypotheticals here. When policies like this are put in place, real children--ones with real hopes and dreams and fears--are made to suffer. Some even die. And that is unconscionable.
Opponents of government-funded health care often argue that most of the uninsured in this country are so by choice. Putting aside the merits of that (very weak) argument, it is undeniable that children do not choose to go without health insurance. They have no say in the matter. It is therefore unacceptable to treat children as pawns in a struggle over policy principles.
Another fine column pointing out the absurdity not only of our current health care system but the flaws in one of the most common arguments in favor of keeping it.
This is a consistent theme among opponents of universal care. They act like universal care is some crazy utopian fantasy like communism that has no realistic prospect of working and has failed miserably whenever tried. They never acknowledge the fact we are the outliers, that every other first world country has long since moved to a system of universal care and that there are now a multitude of different, fully-functioning systems out there for us to choose from. In other words, we're well past the experimental stage. It's like mocking someone's idea for a "flying machine" in, say, 1954 ("when that contraption crashes it will prove to the world that man was never meant to fly!").
I thought this comment also explained quite nicely one of the reasons we haven't made any serious progress on this issue, despite the majority of Americans haing the current system:
Under a socialist health care system, the government hires all the doctors, nurses and other health professionals. The government owns and runs all the clinics, hospitals, ambulance services — the whole enchilada.
Anyone who thinks that system is absolutely no good better be prepared to explain why presidents, Cabinet members, 535 members of Congress and the whole sprawling U.S. military find it overall satisfactory or better. Because that's exactly the health care system those Americans have.
In other words, the politicians already have the best system in the world. So they have no pressing need to fix ours.
Because, after all, they got theirs. Screw everyone else.
Although that's not even the system folks are really clamoring for.
What folks on the left want is a single-payer, universal health insurance system, with the federal government doing the honors. So, consumers get the coverage they need at a price they can afford for care from whomever they choose to get care from.
Businesses get relieved of the burden of co-funding expensive insurance plans. They also will be relieved of the temptation to push 59-year-old Marge, who's already had a lumpectomy, into an early and meager retirement because she (and other less than completely healthy older workers) will run up the premiums for the whole company if they're kept on the payroll.
Well. That does sound radical.
So I had today off, thanks to our megacorp's groovy policy of giving us one Friday off per month in the summer. Last month the fambly went to the beach to celebrate, our first real trip to a real Pacific beach (although we'd been to smaller beaches to wade and such before).
What did kinda fun stuff did I do this time? Well, I took The Rose to have some blood drawn. Yay!
I'd heard great things about the San Diego Children's Hospital. Those must be about their outstanding in-patient services. Because I am most assuredly not impressed so far.
We've tried to make appointments with a plethora of different doctors and in each case there's been a considerable wait. Most vexing is their cardiology department. In order to get an appointment, you need to leave a voicemail with the patient's name and other pertinent info. Then, at some point, they call you back and tell you when your appointment in. That's right, tell you. You have no say in the matter; they simply schedule it for you. If that time doesn't work for you? You call back and leave another voicemail and someone will eventually get back to you with your new appointment. Needless to say, but I'll say it anyhoo, these appointments are generally several months away.
Today wasn't that big a deal. The Rose saw a dermatologist who wanted some blood work done, and insisted it be done at the hospital. So I took her and The Boy to the outpatient lab—no appointment necessary.
Leaving aside Mapquest problems which can't be blamed on the hospital and some really lousy signage—which, I'd argue, can—we park and find the lab with little difficulty. I'm surprised by just how small the waiting room is, giving the size and niceness of the entire hospital complex, as well as how little kid stuff there is: a couple toys…and by "a couple," I mean "two." But I decide that maybe that's a good sign; they have such rapid turnaround that kids—the exclusive patients here—don't even have time to get bored.
What's not such a good sign is how few chairs there are; the three of us had to share one chair for the first fifteen minutes, until finally the sulky fifteen year old listening to his iPod and sporting a tasty "Eat the Rich" t-shirt was called.
Thirty-five minutes later we're finally called…and we're only the third folks called. Speedy this joint innit. But the tech couldn't have been more awesome, so that's good. Still, that was a fair-sized wait in such a small and featureless room for such a simple procedure.
As I'm walking out, the receptionist asks if I want my parking validated, and thank Allah for that; I'd meant to ask a half-dozen times but forgotten and would I have been upset had I not had it done? I would have.
Which is why I was less than entirely enthused when it turned out that I still had to pay three bucks to park for less than hour. What would it have been without validation? Two bucks…every fifteen minutes. And, no, there are no other options when it comes to parking; this garage is the only game in town.
That did not make me happy.
My point, from which I've strayed a bit, is this: I've been fascinated to see in the past week a meme rocketing around Left Blogistan, as one writer after another seems to have picked up on the exact same and utterly irrefutable argument in favor of changing our current health care system.
For years, whenever folks talked about universal coverage, the immediate rejoinder was always: "socialized medicine! Horrible wait times in Canada and the UK! No choice of doctors!"
Which may or not be true. The fact that they spent roughly half as much as we do per capita and get far superior care in return is unquestionably true. Still, who wants to wait? We're Americans, dammit. We want the world and we want it now.
But the thing is, we do have to wait for appointments. Today's experience wasn't terribly onerous—in fact, it pretty damn easy compared to our family's average experiences.
Every time I've called for an appointment in the past ten years I've had to wait. If it was an emergency, they're almost always able to squeeze me in that day. But for New Patient appointments or even just a yearly check-up, I often have to wait up to three months. And this is the argument that has suddenly come into vogue. And with good reason. I'm not sure why it wasn't made before, but there 'tis.
I'm not sure I understand why socialized schools and socialized roads and a socialized military are inherently good things, if imperfect, but socialized medicine is supposed to be bad. Actually, I know why. Because Big Bidniz knows they'll lose billions of dollars for doing nothing—literally, that's how insurance companies make their money, by doing nothing, rather than providing the services required, which loses them money—if they don't fight it tooth and nail. So they do, and their lapdogs in Congress and on rightwing radio and television parrot these talking points and Americans just swallow it.
Or at least, they used to. But I don't know anyone who's really happy with their insurance company. I have outstanding insurance, thanks to the aforementioned megacorp, and even so, they keep trying to get me to pay for the MRI that, I was assured, was completely covered and done in network. But they've been sending me bills for four months now and once again threatening a collection agency. And I'd guess I've got better insurance than 97% of Americans.
But that's nothing compared to the following story. You've seen the bumper sticker that reads: "If you're not outraged, you're not paying attention." Well, if you're not sick with fury and frustration when you're done reading this story, you haven't read the story.
This is our current system. It is broken. We need a new one. We need universal coverage. It's the only morally-acceptable choice. Moreover, it's the fiscally prudent one. There is no reason not to do it. Except that Big Bidniz doesn't want it. And what they don't want, they almost never have to get. Let's hope this is a rare loss.
Here's a large excerpt, but you should really click through to read the entire thing.
Now that Michael Moore's SICKO has raised again the question why the Canadian health care system functions so much better than ours, supporters of the current mess have gone back to chanting
Hip replacement! Rationing! Hip replacement! Rationing! Markets! Markets! Markets! Markets! Sis, boom bah!
or words to that effect.
The response, of course, is that rationing, including rationing by queuing, is just as much a feature of the U.S. system as it is of competing systems. And while waiting for a hip replacement sounds pretty bad, there are worse things to have to wait for. Take it from me.
In the spring of the year 2000, after several months of what in retrospect was intolerable negligence both by me and by my internist, I was diagnosed with cancer. I had fancy-dancy health insurance through my employer, which as it happens also owns one of the world's dozen best medical centers.
The diagnosis of cancer, based on symptoms plus the chest X-ray that should have been done several months earlier, was made very early in May. By then, I had dropped forty-some pounds, had almost no voice, couldn't walk more than 30 yards without puffing, and had a resting respiration rate of 20 breaths per minute. My friend Gary Emmett, who made what turned out to be the correct diagnosis a month earlier just by listening to me on the telephone, came out to visit, and told the rest of my friends that if they wanted to see me alive they'd better make their plane reservations in a hurry. (The technical term is "Stage IV-B." Not good.)
But of course you can't treat "cancer." You have to treat some specific cancer. And you can't treat it until you figure out what it is.
That process took just about one full month, a month during which my chances of survival were dropping fairly steadily and the intensity — and therefore the side-effect profile — of the treatment that would be required if we ever got the damned thing figured out was rising in parallel. It would have taken longer — quite possibly fatally longer — if Al Carnesale, whom I'd known when we were both at the Kennedy School, and who by then was the Chancellor of UCLA and thus at some ethereal level responsible for both me and the hospital, hadn't sent a note to the guy who runs the entire UCLA medical area (hospital and medical school). The note politely hinted that it would be at least marginally preferable if my department didn't have to go through the hassle of recruiting a replacement. After that, things speeded up somewhat.
What absorbed that month? Mostly waiting.
After the chest X-ray, I needed to see an oncologist. I couldn't make an appointment until I had the approval of the insurance company for the referral. That took a few days. Getting on the oncologist's schedule took a few more days.
After the oncologist saw me, he wanted a bone marrow sample to send to the pathologists to figure out what the cancer might be. I couldn't make an appointment for the bone marrow procedure until the insurance company approved it. Then I had to wait for the bone-marrow extractor to have time on his busy schedule.
When it turned out that there wasn't enough marrow to test, I needed a lymph-node biopsy. More waiting for an insurance approval and more waiting for an appointment.
Having seen the head-and-neck surgeon who was going to do the biopsy, I couldn't have the biopsy right away because the insurance company wouldn't approve it as an in-patient procedure and there was queue for outpatient biopsy operating room time. Anyway, the guy who had seen me didn't have any time free on his dance card for the next several weeks, so he sent me to another surgeon to actually do the procedure.
When I showed up for the outpatient biopsy, the anaesthesiologist took one look at my chart and flatly refused to put me under for the procedure except in an in-patient setting, on what seemed like the reasonable grounds that otherwise I could easily die on the table. That meant, of course, more waiting for another approval and another appointment.
All this, let's recall, with the Chancellor breathing down the neck of the boss of the medical area on behalf of a full professor at the university that owns the hospital. So my experience with the system was probably about as good as it gets except for corporate executives using places like the Mayo Clinic or family members of people on the boards of directors of hospitals. (Apparently it's generally understood that if you stump up enough in the way of contributions to get on the board of the hospital, you're entitled to priority care; that's how not-for-profit hospitals raise capital.)
It was only later that I discovered why the insurance company was stalling; I had an option, which I didn't know I had, to avoid all the approvals by going to "Tier II," which would have meant higher co-payments. The process is designed to get very sick or prosperous patients to pay to jump the queue.
I don't know how many people my insurance company waited to death that year, but I'm certain the number wasn't zero. As I say, in my case it was a damned close-run thing. (Fortunately, the eventual diagnosis was of a curable cancer, and the actual treatment I got once the diagnosis was made was prompt, well-executed, and entirely successful.)
That's on top of the procedures the insurance companies simply refuse to pay for at all because some clerk decides they aren't "medically necessary," which for most people means that the queue for that service is of infinite length.
So can we hear at little less about how long Canadians wait to get their hips replaced?
We can't let this continue.
It's time. This is one of those issues where Americans are way, way ahead of the politicians. If you don't want to talk about how it's necessary from a moral standpoint, well, then, it's just good business.
Young, Ill and Uninsured
by Bob Herbert
Fourteen-year-old Devante Johnson deserved better. He was a sweet kid, an honor student and athlete who should be enjoying music and sports and skylarking with his friends at school. Instead he’s buried in Houston’s Paradise North Cemetery.
Devante died of kidney cancer in March. His mother, Tamika Scott, believes he would still be alive if bureaucrats in Texas hadn’t fouled up so badly that his health coverage was allowed to lapse and his cancer treatment had to be interrupted.
Ms. Scott, who has multiple sclerosis, understood the grave danger her son would be in if he were somehow to be left without the Medicaid coverage that paid for his chemotherapy, radiation and other treatment. She submitted the required paperwork to renew the coverage two months before the deadline.
“I was so anxious to get it processed,” she said, “so we wouldn’t have a lapse of coverage.”
In Texas, as in many other states, there is a concerted effort to undermine programs that bring government-sponsored health care to poor and working-class children. It is not an environment in which bureaucrats are encouraged to be helpful, not even when lives are at stake.
“They kept losing the paperwork,” Ms. Scott told me, her voice quivering with grief. She submitted new applications, made dozens of phone calls and sent off a blizzard of faxes. Despite her frantic efforts, the coverage was dropped.
When the coverage lapsed, the treatment Devante had been receiving ceased. “They put us on clinical trials,” Ms. Scott said. “They changed his medicine, and he started getting sicker and sicker. After awhile it was like his body was so frail and he was so weak he could barely walk on his own.”
Four months after the Medicaid coverage lapsed, the mistakes were finally corrected and the coverage was reinstated. By then, there was no chance to save Devante.
“I believe he would be with me now if they hadn’t let his insurance lapse,” said Ms. Scott.
Across America children by the millions are being denied the health care they need and deserve — and some are dying — because the U.S. has no coherent system of health coverage for children.
Stories like Devante Johnson’s are not unusual. Three months ago a homeless seventh grader in Prince George’s County, Maryland, died because his mother could not find a dentist who would do an $80 tooth extraction. Deamonte Driver, 12, eventually was given medicine at a hospital emergency room for headaches, sinusitis and a dental abscess.
The child was sent home, but his distress only grew. It turned out that bacteria from the abscessed tooth had spread to his brain. A pair of operations and eight subsequent weeks of treatment, which cost more than a quarter of a million dollars, could not save him. He died on Feb. 25.
There’s a presidential election under way and one of the key issues should be how to provide comprehensive health coverage for all of the nation’s children, which would be the logical next step on the road to coverage for everyone.
That an American child could die because his mother couldn’t afford to have a diseased tooth extracted sounds like a horror story from some rural outpost in the Great Depression. It’s the kind of gruesomely tragic absurdity you’d expect from Faulkner. But these things are happening now.
“People don’t understand the amount of time and stress parents are going through as they try to get their children the coverage they need, in many cases just to stay alive,” said Marian Wright Edelman, president of the Children’s Defense Fund and a tireless advocate of expanding health coverage to the millions of American children who are uninsured or underinsured.
Medicaid and the State Children’s Health Insurance Program provide crucially important coverage, but the eligibility requirements can be daunting, budget constraints in many jurisdictions have led to tragic reductions in coverage, and millions of youngsters simply fall through the cracks in the system, receiving no coverage at all.
It is time for all that to end. American children should be guaranteed nothing less than comprehensive health coverage from birth through age 18. This can be achieved if an effort is mounted that is comparable to that which led to the first moon shot, or the Marshall Plan, or the postwar G.I. bill.
Keeping American children alive and healthy should be at least as important as any of those worthy projects.
So someone on one of my mailing lists recently lamented the boneheaded state of our judicial system and used, as so often happens, the case where a woman sued McDonald’s because she spilled hot coffee on herself—and an idiotic jury found in her favor.
This case is famous and is now, in fact, shorthand for how awful the state of our overly litigious society has become. The facts of the case, however, are far different from popular perception. A recap can be found here.
A couple things to note:
• The car was parked when the woman spilled the coffee on herself; it's often erroneously reported that she was driving at the time. She wasn’t, she was in the passenger’s seat and was simply trying to take the lid off to add cream and sugar when it spilled—as could easily happen to anyone.
• The ER doctor who treated the woman was stunned by the extent of her burns—her sweat pants had actually fused to her genitals from the intense heat of the coffee. She ended up hospitalized for over a week and required skin grafts as well as continued treament for the next two years.
• The woman tried to settle with McDonald's—all she wanted initially was for McDonald's to pay for her hospital bills. But McDonald’s was the one who insisted the case go to trial.
• They discovered that McDonald's knew their coffee wasn't just hot—it was dangerously hot, as doctors testified it was literally impossible to drink it as served without doing damage to one's mouth; coffee at home is usually less than 140 degrees, whereas McDonald's is served as high as 190. Moreover, McDonald's had already had 700 complaints about the unusually high heat of their coffee at the time of the woman's accident. McDonald's own quality control manager testified that this number of injuries was insufficient to cause the company to evaluate its practices and conceded that McDonald's coffee would burn the mouth and throat if consumed when served
• The jury came up with the number they did—$2.7 million—by fining the company the amount of money they earn in two days' of coffee sales; it really doesn't sound exactly crippling when put that way, especially given what a low percentage of the corporation's sales are from coffee.
Of course, in the end, the actual number was reduced to $480,000.
Given the size of the corporation involved and how it has refused to alter its stance even when people were being injured—a practice the judge who reduced the verdict called callous and reckless—that actually sounds pretty unfair to me; I don't know what price most people would consider fair compensation for a burned labia, but I'm guessing it'd be considerably higher if you knew the person in question.
McDonald’s served a product which is inherently defective—its coffee cannot be consumed without damaging human tissue. To blame the victim in this case is as absurd as blaming the victims of Firestone’s defective tires. And the situation is similar in another way: in both cases, the manufacturor’s knew about the problem but decided it would be cheaper to ignore it and settle than actually fix it and save people pain or even death.
McDonald’s defense of its dangerously hot coffee? Their researach showed that their customers “like their coffee hot.” What constitutes “hot?” Their research didn’t show that. In other words, they never bothered to determine if, say, 170 degrees was still “hot” as far as their customers were concerned. Or maybe 160 is “hot,” or 155 degrees. Who can say? Not McDonald’s. They never bothered. And it’s that sort of negligence and arrogance that lead the jury to find in favor of the grandmother with the melted labia.
And, you know, I don’t understand why so many people hate our legal system so much. Seems to me the whole “trial by a jury of ones’s peers” thing has, by and large, with some admittedly egregious exceptions, worked pretty well for a couple centuries now.
Like so many other situations, folks just hate lawyers and juries…until they need one to go to bat for them. Then all their previous arguments, built up over years of simply outrageous decisions, go right out the damn window.
I've ranted on here about the insanity of our nation’s health insurance situation a-plenty. Well…can you ever really, truly rant about that insanity a-plenty? I don’t think so either.
But it’s rather gratifying to discover that National Review’s John Derbyshire shares my pain.
My health insurer has just notified me, in a brief form letter, that my monthly premiums are to rise from $472.33 to $857.00 on January 1st. That's an increase of 81 percent. ***E*I*G*H*T*Y*-*O*N*E* *P*E*R*C*E*N*T*** Can they do that? I called them. They sound pretty confident they can. Ye gods!
Can't really talk about this, I'm still in shock. But yes, anyone who says right now that our entire health-care financing system is nuts to the fourth power, won't be getting any argument from me. And from a social-libertarian point of view, the thing is pernicious, as it strongly discourages individuality & enterprise. As is the case with the tax code, the message you get loud and clear is that the govt. wants us all to be employees so we can be tax-farmed more easily. Strike out on your own, step off that corporate hamster-wheel, and you get socked with sudden 81 percent hikes in your health-care premiums. Hoo-ee.
Next stop: socialized medicine!
Because if we don’t, the terrorists will have won.
Sometimes one has to wonder about priorities.
Over at The Wall Street Journal, Sharon Begley has an important column on the underfunding of the National Institute of Health and all the promising research that's falling by the wayside. She tells the story of Dan Welch, a molecular oncologist who discovered a molecule that suppresses metastases (and thus, cancer's progression) and sought to test whether it could be switched on to fight the disease. But when he went to the NIH, they said he needed to gather preliminary breast cancer tissue from hundreds of women, a project he simply lacked the funding for.
That, replicated over and over again, is the story of the modern NIH. Clinton had accelerated the agency's funding, but, in 2004, Bush and the Republican Congress shut off the spigot, and money has flat-lined since. That's left a significant gap between the number of promising proposals from reputable scientists that get submitted and the number of promising proposals from reputable scientists that get funded. Even worse, the NIH, like all big institutions, is a bit hidebound and loathe to gamble, so it's been the boldest and riskiest ideas that are getting shot down. Most of these would evaporate, but if a mere couple worked, the implications would be tremendous.
I’m not a fan of ballot initiatives in general. They sound like a good idea but if my understanding of their history is at all accurate, they tend to be used by politicians interested only in getting re-elected, as opposed to the best politicians, who merely care mostly about being re-elected. What’s more, they’ve proven to be a slippery slope, with one initiative leading to another until there’s such a mass of them that it gets to a point where virtually nothing substantial can get changed without passing yet another initiative on the prospect of getting things done.
And yet I’d surely love to see one put before the American people asking if:
a) the Iraq war should continue to be funded at currently levels, higher, or lower and
b) cancer research should continue to be funded at current levels, higher, or lower.
I think that would be most interesting indeed.
Sometimes I wonder if one of those rare A’s I got in college was really in logic. [Yes, hard as it is to believe, it was.] Because this sure doesn’t seem to make any sense to me, but then I’m not the leader of the free world:
The federal government has a national breast and cervical cancer early detection program, run by the Centers for Disease Control and Prevention. It provides screening and other important services to low-income women who do not have health insurance, or are underinsured.
There is agreement across the board that the program is a success. It saves lives and it saves money. Its biggest problem is that it doesn't reach enough women. At the moment there is only enough funding to screen one in five eligible women.
A sensible policy position for the Bush administration would be to expand funding for the program so that it reached everyone who was eligible. It terms of overall federal spending, the result would be a net decrease. Preventing cancer, or treating it early, is a lot less expensive than treating advanced cancer.
So what did this president do? He proposed a cut in the program of $1.4 million (a minuscule amount when you're talking about the national budget), which would mean that 4,000 fewer women would have access to early detection.
As one of the doctors interviewed by Herbert said:
"It won't save money," he said. "You don't save money by not diagnosing cancer early. You end up spending more money because anyone who develops cancer will get into the health care system and they will be treated. And the cost at that point will be a lot more. The logic here is very simple: the later you diagnose cancer of the breast or cervix, the more expensive it is to the country."
This is just one program in a range of cancer services that rely on support from the federal government. As if immune to the extent of human suffering involved, President Bush has proposed a barrage of cuts for these programs.
"What's really amazing," said Mr. Smith, "is that the president cut every cancer program. He cut the colorectal cancer program. He cut research at the National Cancer Institute. He cut literally every one of our cancer-specific programs. It's incomprehensible."
Now, admittedly, maybe this hits a little close to home, what with having a kid with cancer. And, hey, we’re not made of money and fiscal responsibility dictates that you don’t want to run up huge deficits, right? I mean, as I recall Reagan proved that deficits do matter.
But then I try to think about it logically:
$1.4 million a year for this cancer program.
$200 million every single day in Iraq.
$3.9 thousand a day for this cancer program.
$200 million a day in Iraq.
$3,900 a day for this cancer program.
$200,000,000 a day in Iraq.
Yeah, that works out to $3.8 million dollars every single day.
$3.9 thousand a day for this cancer program.
$3.8 million dollars a day given away to the oil companies.
$3,900 a day for this cancer program.
$3,800,000 a day to the oil companies.
So in twelve hours, it'd pay for an entire year's worth of that cancer program.
Yeah, I’m still having trouble making any of that math work.
Took Max for her yearly check-up at UVa. Lovely place. Clean, efficient, friendly. Best of all, they take a ton of time doing the check-up, testing her reflexes, making her walk in a straight line, checking for curvature of the spine and all that. It’s kinda funny how thorough they are, since the blood test is really what we’re there for, and that could be done at our local doctor’s office, ninety seconds from home.
But hey, I don’t mind the fifteen minutes once or twice a year where they ask her about her various bodily functions, she explains about her recurring muscle pain (her thighs, mainly the right one), her sinus problems (she takes three times as long to get over colds as anyone else and probably always will) and that stuff. Better safe’n sorry, right? I mean, once you’ve said to your wife, "Hey, don’t worry about those three dozen bruises—she’s a toddler. They toddle. They fall down. Of course she has bruises." And then it turns out to be leukemia…well, you know. Watching her charm each new doctor as she gets poked and prodded is an afternoon well-spent.
We loved our hospital in New York. Well, mainly. We adored most of the doctors and nurses and staff there—kinda hard not to be fond of people when they’ve saved your kid’s life several times—and we really dug a lot of our fellow patients and families. What we didn’t so much dig is how incredibly overcrowded the joint was. Not that it was their fault: there are a whole lot of kids with cancer in New York and our hospital was one of the two best covering an enormous area. And of course everyone wants the best for their kid.
The result was that procedures—from a bone marrow biopsy to a simple fingerstick—could run three or four hours behind. They did their best to keep the kids entertained, usually with excellent results, but after a few years it starts to wear on you a bit. I mean, you know—it’s a fingerstick. And when your kid hasn’t eaten in fourteen hours because she’s scheduled to get anesthesia and is still a few hours away from being allowed to eat again because first she needs the fingerstick and then they need to do the actual procedure and there could be hours in between each step…
So we were thrilled and amazed when we moved down here and started going to UVa’s hospital. It was so neat and orderly. The waits were a fraction of what they had been. It was really pretty stunning. The doctors were able to spend three times as long with each patient and you’d still get called from the waiting room after only ten minutes. It was heavenly.
That’s no longer so much the case. It’s something that’s been happening gradually over the past four years, and I’d been chalking it up to being an anomaly each time. But I’m starting to think that if something happens three or four times in a row, well, maybe, just maybe, there’s a pattern in there somewhere.
Because each time we’ve gone lately (lately being anywhere from six to twelve months between visits), we’ve had a harder time finding parking, a longer wait to check-in, a longer wait in the waiting room, a longer wait in the exam room and a longer wait to be told we could go.
Now, this last time was pretty extreme—turns out they actually forgot we were in the room and we could have left at least half an hour earlier than we did. Which kinda sucked. On the other hand, it gave me and Max time to play one of her favorite games—doing cubes and cube roots. Yes, she’s bizarre.
She’d been cubing progressively larger numbers—laughing scornfully when I said "what’s the cube of three?"—and we’d just finished the cube of nine. I asked what the cube of ten was and she just looked at me with disdain before sighing. "Fine," I said, when the nurse came in to ask something. As soon as the nurse left, Max smiled and said, "1331."
"What?" I asked.
"1331," she repeated. When I looked blank, she smiled and said, "The cube of eleven."
Top Management has a lot to answer for.
Anyhoo, each time the place has seemed more crowded and more hectic and the waits longer and longer. The people are just as nice as ever and I have no reason to doubt that the care is as good as it ever was. But I can’t help but wonder if what happened in New York is happening here. If the number of kids with cancer is continuing to rise and we can’t keep up with it and we have little to no idea what’s causing. It’s a distressing thought. And what’s most distressing about it, in some ways, is that it seems so obviously true.
Below is a very, very, very long piece by Malcolm Gladwell, the author of "The Tipping Point" and "Blink." If you’re pressed for time, you might want to just read the first dozen or so paragraphs and then skim the one-sentence paragraphs. You’ll miss a lot of good stuff but you’ll still get the point.
For whatever it’s worth—and, yes, I know, it’s worth very, very, very little—I am convinced that the health-insurance situation is going to be radically different in ten years, and maybe as soon as five. When the previous attempt at universal insurance got shot down, it was largely because Big Bidniz didn’t want it, and fought tooth-and-nail against it (and maybe rightly so—I don’t know the particulars, because I had stellar insurance at the time so what the hell did I care?—but I’m under the impression that the proposed plan was something of a mess).
This time, however, much of the Big Bidniz community is coming to the conclusion, led by the automotive and airline industries, that they simply cannot continue to operate in this country much longer without a universal health care policy in place. And that will make all the difference. When Toyota decides not to build a new plant in the U.S., despite hundreds of millions of dollars in financial incentives from several states who’d gotten into something of a bidding war for the new plant, but chooses instead to place the factory in Canada largely because of the health care situation, that is bound to have an effect.
From a purely financial point of view, it’s almost impossible to understand why we stick with our current system. From a moral point of view, it’s completely impossible.
And, just to give you too much information, I haven’t been to the dentist in eight years. Since our insurance stopped covering dental.
THE MORAL-HAZARD MYTH
The bad idea behind our failed health-care system.
by Malcolm Gladwell
Tooth decay begins, typically, when debris becomes trapped between the teeth and along the ridges and in the grooves of the molars. The food rots. It becomes colonized with bacteria. The bacteria feeds off sugars in the mouth and forms an acid that begins to eat away at the enamel of the teeth.
Slowly, the bacteria works its way through to the dentin, the inner structure, and from there the cavity begins to blossom three-dimensionally, spreading inward and sideways. When the decay reaches the pulp tissue, the blood vessels, and the nerves that serve the tooth, the pain starts—an insistent throbbing.
The tooth turns brown. It begins to lose its hard structure, to the point where a dentist can reach into a cavity with a hand instrument and scoop out the decay. At the base of the tooth, the bacteria mineralizes into tartar, which begins to irritate the gums. They become puffy and bright red and start to recede, leaving more and more of the tooth’s root exposed. When the infection works its way down to the bone, the structure holding the tooth in begins to collapse altogether.
Several years ago, two Harvard researchers, Susan Starr Sered and Rushika Fernandopulle, set out to interview people without health-care coverage for a book they were writing, "Uninsured in America." They talked to as many kinds of people as they could find, collecting stories of untreated depression and struggling single mothers and chronically injured laborers—and the most common complaint they heard was about teeth.
Gina, a hairdresser in Idaho, whose husband worked as a freight manager at a chain store, had "a peculiar mannerism of keeping her mouth closed even when speaking." It turned out that she hadn’t been able to afford dental care for three years, and one of her front teeth was rotting. Daniel, a construction worker, pulled out his bad teeth with pliers. Then, there was Loretta, who worked nights at a university research center in Mississippi, and was missing most of her teeth. "They’ll break off after a while, and then you just grab a hold of them, and they work their way out," she explained to Sered and Fernandopulle. "It hurts so bad, because the tooth aches. Then it’s a relief just to get it out of there. The hole closes up itself anyway. So it’s so much better."
People without health insurance have bad teeth because, if you’re paying for everything out of your own pocket, going to the dentist for a checkup seems like a luxury. It isn’t, of course. The loss of teeth makes eating fresh fruits and vegetables difficult, and a diet heavy in soft, processed foods exacerbates more serious health problems, like diabetes. The pain of tooth decay leads many people to use alcohol as a salve. And those struggling to get ahead in the job market quickly find that the unsightliness of bad teeth, and the self-consciousness that results, can become a major barrier. If your teeth are bad, you’re not going to get a job as a receptionist, say, or a cashier. You’re going to be put in the back somewhere, far from the public eye. What Loretta, Gina, and Daniel understand, the two authors tell us, is that bad teeth have come to be seen as a marker of "poor parenting, low educational achievement and slow or faulty intellectual development." They are an outward marker of caste.
"Almost every time we asked interviewees what their first priority would be if the president established universal health coverage tomorrow," Sered and Fernandopulle write, "the immediate answer was ‘my teeth.’ "
The U.S.health-care system, according to "Uninsured in America," has created a group of people who increasingly look different from others and suffer in ways that others do not.
The leading cause of personal bankruptcy in the United States is unpaid medical bills.
Half of the uninsured owe money to hospitals, and a third are being pursued by collection agencies.
Children without health insurance are less likely to receive medical attention for serious injuries, for recurrent ear infections, or for asthma.
Lung-cancer patients without insurance are less likely to receive surgery, chemotherapy, or radiation treatment.
Heart-attack victims without health insurance are less likely to receive angioplasty.
People with pneumonia who don’t have health insurance are less likely to receive X rays or consultations.
The death rate in any given year for someone without health insurance is twenty-five per cent higher than for someone with insur-ance.
Because the uninsured are sicker than the rest of us, they can’t get better jobs, and because they can’t get better jobs they can’t afford health insurance, and because they can’t afford health insurance they get even sicker.
John, the manager of a bar in Idaho, tells Sered and Fernandopulle that as a result of various workplace injuries over the years he takes eight ibuprofen, waits two hours, then takes eight more—and tries to cadge as much prescription pain medication as he can from friends. "There are times when I should’ve gone to the doctor, but I couldn’t afford to go because I don’t have insurance," he says. "Like when my back messed up, I should’ve gone. If I had insurance, I would’ve went, because I know I could get treatment, but when you can’t afford it you don’t go. Because the harder the hole you get into in terms of bills, then you’ll never get out. So you just say, ‘I can deal with the pain.’ "
One of the great mysteries of political life in the United States is why Americans are so devoted to their health-care system. Six times in the past century—during the First World War, during the Depression, during the Truman and Johnson Administrations, in the Senate in the nineteen-seventies, and during the Clinton years—efforts have been made to introduce some kind of universal health insurance, and each time the efforts have been rejected. Instead, the United States has opted for a makeshift system of increasing complexity and dysfunction.
Americans spend $5,267 per capita on health care every year, almost two and half times the industrialized world’s median of $2,193; the extra spending comes to hundreds of billions of dollars a year.
What does that extra spending buy us?
Americans have fewer doctors per capita than most Western countries.
We go to the doctor less than people in other Western countries.
We get admitted to the hospital less frequently than people in other Western countries.
We are less satisfied with our health care than our counterparts in other countries.
American life expectancy is lower than the Western average.
Childhood-immunization rates in the United States are lower than average.
Infant-mortality rates are in the nineteenth percentile of industrialized nations.
Doctors here perform more high-end medical procedures, such as coronary angioplasties, than in other countries, but most of the wealthier Western countries have more CT scanners than the United States does, and Switzerland, Japan, Austria, and Finland all have more MRI machines per capita.
Nor is our system more efficient.
The United States spends more than a thousand dollars per capita per year—or close to four hundred billion dollars—on health-care-related paperwork and administration, whereas Canada, for example, spends only about three hundred dollars per capita.
And, of course, every other country in the industrialized world insures all its citizens; despite those extra hundreds of billions of dollars we spend each year, we leave forty-five million people without any insurance.
A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy—a country that switched to Japanese cars the moment they were more reliable, and to Chinese T-shirts the moment they were five cents cheaper—has loyally stuck with a health-care system that leaves its citizenry pulling out their teeth with pliers.
America’s health-care mess is, in part, simply an accident of history. The fact that there have been six attempts at universal health coverage in the last century suggests that there has long been support for the idea. But politics has always got in the way. In both Europe and the United States, for example, the push for health insurance was led, in large part, by organized labor. But in Europe the unions worked through the political system, fighting for coverage for all citizens. From the start, health insurance in Europe was public and universal, and that created powerful political support for any attempt to expand benefits.
In the United States, by contrast, the unions worked through the collective-bargaining system and, as a result, could win health benefits only for their own members. Health insurance here has always been private and selective, and every attempt to expand benefits has resulted in a paralyzing political battle over who would be added to insurance rolls and who ought to pay for those additions.
Policy is driven by more than politics, however. It is equally driven by ideas, and in the past few decades a particular idea has taken hold among prominent American economists which has also been a powerful impediment to the expansion of health insurance. The idea is known as "moral hazard." Health economists in other Western nations do not share this obsession. Nor do most Americans.
But moral hazard has profoundly shaped the way think tanks formulate policy and the way experts argue and the way health insurers structure their plans and the way legislation and regulations have been written. The health-care mess isn’t merely the unintentional result of political dysfunction, in other words. It is also the deliberate consequence of the way in which American policymakers have come to think about insurance.
"Moral hazard" is the term economists use to describe the fact that insurance can change the behavior of the person being insured. If your office gives you and your co-workers all the free Pepsi you want—if your employer, in effect, offers universal Pepsi insurance—you’ll drink more Pepsi than you would have otherwise. If you have a no-deductible fire-insurance policy, you may be a little less diligent in clearing the brush away from your house. The savings-and-loan crisis of the nineteen-eighties was created, in large part, by the fact that the federal government insured savings deposits of up to a hundred thousand dollars, and so the newly deregulated S. & L.s made far riskier investments than they would have otherwise. Insurance can have the paradoxical effect of producing risky and wasteful behavior.
Economists spend a great deal of time thinking about such moral hazard for good reason. Insurance is an attempt to make human life safer and more secure. But, if those efforts can backfire and produce riskier behavior, providing insurance becomes a much more complicated and problematic endeavor.
In 1968, the economist Mark Pauly argued that moral hazard played an enormous role in medicine, and, as John Nyman writes in his book "The Theory of the Demand for Health Insurance," Pauly’s paper has become the "single most influential article in the health economics literature." Nyman, an economist at the University of Minnesota, says that the fear of moral hazard lies behind the thicket of co-payments and deductibles and utilization reviews which characterizes the American health-insurance system. Fear of moral hazard, Nyman writes, also explains "the general lack of enthusiasm by U.S. health economists for the expansion of health insurance coverage (for example, national health insurance or expanded Medicare benefits) in the U.S."
What Nyman is saying is that when your insurance company requires that you make a twenty-dollar co-payment for a visit to the doctor, or when your plan includes an annual five-hundred-dollar or thousand-dollar deductible, it’s not simply an attempt to get you to pick up a larger share of your health costs. It is an attempt to make your use of the health-care system more efficient. Making you responsible for a share of the costs, the argument runs, will reduce moral hazard: you’ll no longer grab one of those free Pepsis when you aren’t really thirsty. That’s also why Nyman says that the notion of moral hazard is behind the "lack of enthusiasm" for expansion of health insurance. If you think of insurance as producing wasteful consumption of medical services, then the fact that there are forty-five million Americans without health insurance is no longer an immediate cause for alarm. After all, it’s not as if the uninsured never go to the doctor. They spend, on average, $934 a year on medical care. A moral-hazard theorist would say that they go to the doctor when they really have to. Those of us with private insurance, by contrast, consume $2,347 worth of health care a year. If a lot of that extra $1,413 is waste, then maybe the uninsured person is the truly efficient consumer of health care.
The moral-hazard argument makes sense, however, only if we consume health care in the same way that we consume other consumer goods, and to economists like Nyman this assumption is plainly absurd. We go to the doctor grudgingly, only because we’re sick.
"Moral hazard is overblown," the Princeton economist Uwe Reinhardt says. "You always hear that the demand for health care is unlimited. This is just not true. People who are very well insured, who are very rich, do you see them check into the hospital because it’s free? Do people really like to go to the doctor? Do they check into the hospital instead of playing golf?"
For that matter, when you have to pay for your own health care, does your consumption really become more efficient? In the late nineteen-seventies, the Rand Corporation did an extensive study on the question, randomly assigning families to health plans with co-payment levels at zero per cent, twenty-five per cent, fifty per cent, or ninety-five per cent, up to six thousand dollars. As you might expect, the more that people were asked to chip in for their health care the less care they used.
The problem was that they cut back equally on both frivolous care and useful care. Poor people in the high-deductible group with hypertension, for instance, didn’t do nearly as good a job of controlling their blood pressure as those in other groups, resulting in a ten-per-cent increase in the likelihood of death.
As a recent Commonwealth Fund study concluded, cost sharing is "a blunt instrument." Of course it is: how should the average consumer be expected to know beforehand what care is frivolous and what care is useful? I just went to the dermatologist to get moles checked for skin cancer. If I had had to pay a hundred per cent, or even fifty per cent, of the cost of the visit, I might not have gone. Would that have been a wise decision? I have no idea. But if one of those moles really is cancerous, that simple, inexpensive visit could save the health-care system tens of thousands of dollars (not to mention saving me a great deal of heartbreak).
The focus on moral hazard suggests that the changes we make in our behavior when we have insurance are nearly always wasteful. Yet, when it comes to health care, many of the things we do only because we have insurance—like getting our moles checked, or getting our teeth cleaned regularly, or getting a mammogram or engaging in other routine preventive care—are anything but wasteful and inefficient. In fact, they are behaviors that could end up saving the health-care system a good deal of money.
Sered and Fernandopulle tell the story of Steve, a factory worker from northern Idaho, with a "grotesquelooking left hand—what looks like a bone sticks out the side." When he was younger, he broke his hand. "The doctor wanted to operate on it," he recalls. "And because I didn’t have insurance, well, I was like ‘I ain’t gonna have it operated on.’ The doctor said, ‘Well, I can wrap it for you with an Ace bandage.’ I said, ‘Ahh, let’s do that, then.’ " Steve uses less health care than he would if he had insurance, but that’s not because he has defeated the scourge of moral hazard. It’s because instead of getting a broken bone fixed he put a bandage on it.
At the center of the Bush Administration’s plan to address the health-insurance mess are Health Savings Accounts, and Health Savings Accounts are exactly what you would come up with if you were concerned, above all else, with minimizing moral hazard. The logic behind them was laid out in the 2004 Economic Report of the President. Americans, the report argues, have too much health insurance: typical plans cover things that they shouldn’t, creating the problem of overconsumption. Several paragraphs are then devoted to explaining the theory of moral hazard.
The report turns to the subject of the uninsured, concluding that they fall into several groups. Some are foreigners who may be covered by their countries of origin. Some are people who could be covered by Medicaid but aren’t or aren’t admitting that they are. Finally, a large number "remain uninsured as a matter of choice."
The report continues, "Researchers believe that as many as one-quarter of those without health insurance had coverage available through an employer but declined the coverage. . . . Still others may remain uninsured because they are young and healthy and do not see the need for insurance." In other words, those with health insurance are overinsured and their behavior is distorted by moral hazard. Those without health insurance use their own money to make decisions about insurance based on an assessment of their needs. The insured are wasteful. The uninsured are prudent. So what’s the solution? Make the insured a little bit more like the uninsured.
Under the Health Savings Accounts system, consumers are asked to pay for routine health care with their own money—several thousand dollars of which can be put into a tax-free account. To handle their catastrophic expenses, they then purchase a basic health-insurance package with, say, a thousand-dollar annual deductible. As President Bush explained recently, "Health Savings Accounts all aim at empowering people to make decisions for themselves, owning their own health-care plan, and at the same time bringing some demand control into the cost of health care."
The country described in the President’s report is a very different place from the country described in "Uninsured in America." Sered and Fernandopulle look at the billions we spend on medical care and wonder why Americans have so little insurance. The President’s report considers the same situation and worries that we have too much. Sered and Fernandopulle see the lack of insurance as a problem of poverty; a third of the uninsured, after all, have incomes below the federal poverty line. In the section on the uninsured in the President’s report, the word "poverty" is never used. In the Administration’s view, people are offered insurance but "decline the coverage" as "a matter of choice." The uninsured in Sered and Fernandopulle’s book decline coverage, but only because they can’t afford it. Gina, for instance, works for a beauty salon that offers her a bare-bones health-insurance plan with a thousand-dollar deductible for two hundred dollars a month. What’s her total income? Nine hundred dollars a month. She could "choose" to accept health insurance, but only if she chose to stop buying food or paying the rent.
The biggest difference between the two accounts, though, has to do with how each views the function of insurance. Gina, Steve, and Loretta are ill, and need insurance to cover the costs of getting better. In their eyes, insurance is meant to help equalize financial risk between the healthy and the sick. In the insurance business, this model of coverage is known as "social insurance," and historically it was the way health coverage was conceived. If you were sixty and had heart disease and diabetes, you didn’t pay substantially more for coverage than a perfectly healthy twenty-five-year-old. Under social insurance, the twenty-five-year-old agrees to pay thousands of dollars in premiums even though he didn’t go to the doctor at all in the previous year, because he wants to make sure that someone else will subsidize his health care if he ever comes down with heart disease or diabetes. Canada and Germany and Japan and all the other industrialized nations with universal health care follow the social-insurance model. Medicare, too, is based on the social-insurance model, and, when Americans with Medicare report themselves to be happier with virtually every aspect of their insurance coverage than people with private insurance (as they do, repeatedly and overwhelmingly), they are referring to the social aspect of their insurance. They aren’t getting better care. But they are getting something just as valuable: the security of being insulated against the financial shock of serious illness.
There is another way to organize insurance, however, and that is to make it actuarial. Car insurance, for instance, is actuarial. How much you pay is in large part a function of your individual situation and history: someone who drives a sports car and has received twenty speeding tickets in the past two years pays a much higher annual premium than a soccer mom with a minivan.
In recent years, the private insurance industry in the United States has been moving toward the actuarial model, with profound consequences. The triumph of the actuarial model over the social-insurance model is the reason that companies unlucky enough to employ older, high-cost employees—like United Airlines—have run into such financial difficulty. It’s the reason that automakers are increasingly moving their operations to Canada. It’s the reason that small businesses that have one or two employees with serious illnesses suddenly face unmanageably high health-insurance premiums, and it’s the reason that, in many states, people suffering from a potentially high-cost medical condition can’t get anyone to insure them at all.
Health Savings Accounts represent the final, irrevocable step in the actuarial direction. If you are preoccupied with moral hazard, then you want people to pay for care with their own money, and, when you do that, the sick inevitably end up paying more than the healthy. And when you make people choose an insurance plan that fits their individual needs, those with significant medical problems will choose expensive health plans that cover lots of things, while those with few health problems will choose cheaper, bare-bones plans. The more expensive the comprehensive plans become, and the less expensive the bare-bones plans become, the more the very sick will cluster together at one end of the insurance spectrum, and the more the well will cluster together at the low-cost end. The days when the healthy twenty-five-year-old subsidizes the sixty-year-old with heart disease or diabetes are coming to an end.
"The main effect of putting more of it on the consumer is to reduce the social redistributive element of insurance," the Stanford economist Victor Fuchs says. Health Savings Accounts are not a variant of universal health care. In their governing assumptions, they are the antithesis of universal health care.
The issue about what to do with the health-care system is sometimes presented as a technical argument about the merits of one kind of coverage over another or as an ideological argument about socialized versus private medicine. It is, instead, about a few very simple questions.
Do you think that this kind of redistribution of risk is a good idea?
Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes?
In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be. The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem.
You can read the original here: The New Yorker.
So, remember them Wonder Drops that Treebeard the doctor ordered for The Boy’s ear infection? Of course you do, it was just yesterday. And if you don’t, go get yourself checked out, pronto.
But first look closely at your insurance company’s co-pay policy. Because when pal Dave and I went to pick up the Wonder Drops at our small but marvelous local drug store, the very nice lady behind the counter put the tiny little bottle, much smaller than a bottle of food coloring, in front of me and said, "that’ll be fifty dollars."
Pal Dave swears I looked like a cartoon character. He says my mouth dropped open and I just stared at the nice lady with my eyes bugging out. I don’t remember that part. What I sorta remember is seeing, out of the corner of my eye, other shoppers turning to look at me as I yelled, "HOW much?!"
Nice Lady repeated the price and I shook my head. "No, that can’t be right," I said. "Did you run the insurance?" She nodded and said the fifty bucks was just our co-pay.
I pressed my lips together, and I guess I looked a mite perturbed because I think Nice Lady asked me if was all right—I’m not SURE she asked me, because everything kinda got fuzzy about then and tinged with red and having to gaze through a sheen of red fuzz doesn’t make for clarity, generally speaking, but Dave later recounted some of the conversation for Top Management and his boss Lisa, so I’ve got at least a rough roadmap of what was said. "No, not really," I think I replied. "I’m kinda thinkin’ about killin’ someone."
Which was a dumb thing to say, given our troubled times. "Oh my goodness," Nice Lady said. "I certainly hope it isn’t me."
I hastened to reassure her it was not. "No, no, no," I continued. "It’s the executives at the insurance companies. Because I can guarandamntee you that if *their* 19-month-old gets an ear infection, they don’t have to pay fifty damn dollars for some stupid little bottle of Wonder Drops. Tell you what, why don’t you keep this bottle and sell me some crack instead? It’s gotta be cheaper.
"You know what gets me through the day?" I asked, probably wild-eyed and drooling slightly by this time. "It’s knowing that those executives are going to spend all eternity burning in a lake of fire. That brings me great comfort."
Nice Lady behind the counter looked shocked for a moment but then burst out in very loud and what sounded like very real laughter, perhaps relieved that my bizarre anger—I suspect I didn’t *look* very comforted—was at least targeted very, very far away. Of course, I was aiming through a blanket of red fuzz, so...
And, yes, I know, pleasantly imagining someone boiling in hell for eternity is not exactly the way to get to heaven yourself. I never talk the talk if I can help it and I rarely claim to walk the walk. But I find something truly, truly morally reprehensible about an executive—either at the insurance company or the pharmaceutical company—earning millions of dollars while fleecing families who need their goods to cure their children. I know, I’m kinda funny that way.
Ah, The Boy, The Boy, The Boy. His butt’s doing much better, thank you very much for asking and, yes, I am a little disturbed by how many people know so much about my kid’s ass. But his tailbone seems to be healing quite nicely and he even took his first car ride today which means, alas, no more housecalls from the good doctor. Now *there’s* something a person can used to. Too bad that we’ve had the opportunity to do so.
And why did The Boy take his first car-ride post-surgery today? Why, because his ear’s been bleeding for nearly two weeks, of course. Tailbone’s healing, hernia’s healing, so The Boy apparently decided he needed to spice things back up a little. And what better than an ear that bleeds for two weeks?
So the good doctor checked him out during housecall after housecall but couldn’t see anything obviously wrong. Maybe his tubes fell out, maybe not. And so to the E.N.T. he did go.
Turns out the little rat has an ear infection. How do we know? Because he could barely hear, of course. Oh, wait, that’s right—that’s normal for him. No, turns out the E.N.T. (whom we’ll call Treebeard, just for giggles, even though it’s probably a joke he’s heard so many times it lost any tiny bit of humor it ever had several years back) can just give a looksee and tell. There were no other symptoms, no fever or nothin’, but according to the redoubtable Treebeard fevers rarely accompany infection, which makes them all the more dangerous to some people such as the elderly or, say, little boys with a plethora of health problems.
But some Wonder Drops in the ear are supposed to do the trick. And then he’ll be hearing right as rain again! Oh, wait…no he won’t. But at least he’ll stop bleeding on the sheets, our clothes and the blueberry Pop-Tarts (long story). And at this point we’ll take what we can get.
And did I mention that I had to rush Max to the opthamologist on Friday because she had a grain of sand EMBEDDED (yes, that was the opthamologist’s word, and yes, I did almost vomit in her office) in her eye?
Well she did. And I’ll spare you the hideous details of how she got it out, even though it involved a scalpel, a small team of Navy SEALs and two quarts of motor oil. And afterwards, of course, we had to finish up the cure with…some Wonder Drops.
Seems like that’s the cure to all our problems these days. I’m now trying to figure out how to score some Wonder Drops to help out with the bank account. My diagnosis: we’re looking at a double-dose. Hey, they can do anything with Wonder Drops nowadays. Or so it appeared. But I just dropped some Wonder Drops on this here piece and it didn’t seem to make it any funnier. Back to R&D.