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Your money or your life

Political speech on health care, quite a bit of it, doesn’t match up well with reality on the ground.

Some of the most critical votes in Congress when time comes, presumably some weeks hence, to vote on health care, will be those of the more skeptical Democrats. One of the Democrats most reluctant to accept the various health plans pushed in recent weeks through committees has been Idaho’s Walt Minnick.

He’s made a number of statements on health care; one (arriving in email) that seemed to need clarification was this: “Third, no ‘socialized medicine.’ The health care system of insurance must be private – not run by the government.” In Minnick’s use of the term (exact definitions can vary by person), what does socialized medicine mean? His press secretary responded:

He is firmly opposed to a public option. We of course have Medicare and Medicaid, and while people who use those services like having the benefits of some healthcare, most people very clearly do not like the process associated with those programs. So that partially informs his thinking.

The other key thing to understand is the reasoning by most proponents of a public option. The proposed plan and its proponents on Capitol Hill very much want a single-payer, single-provider system of health insurance – that is a poorly kept secret in Washington, D.C. They view the public option as a way to not just compete with insurance companies, but drive them out of business. The public option would so effectively kill competition in the marketplace, that the proponents would likely be successful in that endeavor.

For Walt, competition is at the heart of this part of the healthcare discussion. A public company would not have to pay taxes, it could bond without restriction, it could go into debt without being beholden to banks or shareholders and would not have to worry about losses. It could just add those losses to the national debt. Most importantly, it would not have any real incentive to drive down costs, because it would quickly become the dominant, overwhelming force in the marketplace. It would be the largest insurance company in the country, run by the federal government and subsidized by taxpayers at enormous cost. That is socialized medicine.

Walt said something interesting the other day as an off-the-cuff way to oversimplify and explain this. Let’s say you sell bikes. And the bike industry is an absolute mess due to poor standards, a lack of accountability, out-of-control costs which are due to a wide variety of complex factors, and wide spectrum of regulations differing from state to state, etc. The government decides it is critical that the industry be reformed so the cost of bikes stops spiraling out of control. Is the way forward for the government to start its own bike company?

Fairly clear as explanation of philosophy. Now, an explanation of how the matter looks as a matter of governing philosophy, from here:

We have laws, generally accepted across the philosophical spectrum, that prohibit someone from walking into your house (or your convenience store), pointing a gun at your head and demanding “your money or your life.”

That is what our health care system is doing to us, right now, and on an immense scale. It is extortion at the least, robbery at the most. Governmental activism is needed to stop it.

That may sound harsh or extreme. It isn’t. That way of looking at American health care today could be backed up by any number of statistics or studies, but, as Minnick drew on his experience to inform his take on health care, let me draw on some personal events that occurred about 13 months ago. Individual experiences differ widely, of course, but here’s some of what informs my thinking on this:

By way of context, I’m medically uninsured. That wasn’t always the case, even for a number of years after launching my independent business, but eventually the rapid rise of premiums at multiples of the inflation rate caught up with and surpassed us, as it has so many other people. (When we once asked why our rates were being raised so highly and so often when we’d never put in a claim, we were told those increases were the maximum the state allowed – and the company, as a matter of policy, went for the max.) We wanted to eat, have a roof over our heads and operate our business; one or more of those things would have had to go to keep health insurance. Not that insurers were clamoring for our business; although our health has been excellent (with the one recent exception I’ll get to), we have been (like you too) moving on in years. Even without those notorious pre-existing conditions, we were an expendable part of the insurance system. Such limited competition in the world of insurance as does exist did us no good, and we can’t easily imagine how it could absent the kind of really rigorous regulation that utterly changes the industry’s practices. Reality is that the competition in health insurance is not for customers, who the companies have been mostly eager to shed; it is for raw profit and stock price, and that competition does neither us nor even the insured much good. (You could reference here the endless stories of people who are insured and nonetheless medically bankrupted.)

One afternoon in late June of last year, I collapsed at our house, with loss of breath and sudden loss of energy. (It was out of the blue; the docs never did figure out exactly why it happened, though they did work out the what.)

Linda called the local ambulance. She did not pull out the phone book or get on the web to check out various options, as the marketplace theory would suggest a customer operating in economic self-interest might do. For one thing, there was no time. More significantly, there was no choice: As in most places, just one service was available. Take or leave it. The ambulance arrived arrived quickly and the personnel were solidly professional. But there was no meaningful choice about the ambulance. You want a ride? You’re dying here, and you want health care? Then you owe $1,100 (an amount which had to be committed to, blindly, up front, though not disclosed to the payers until later). Take it or leave it. Your money or your life. Literally.

The big bucks come into play on arrival at the hospital. There was no question about which hospital it would be; it would be the one closest. That was the only choice. There was no marketplace decision. There was no shopping around for doctors, either. The doctors would be whoever was on duty. Choice? Marketplace? Sounds fine in theory. Doesn’t work that way in the real world.

I’ll note up front that, notwithstanding the many medical horror stories about how dangerous hospitals are, my case was handled effectively: I was quickly and accurately diagnosed – a blot clot near my lungs – and the treatment of an imminently life-threatening condition resulted in recovery (and yes, I’ve felt fine since). Genuine medical knowledge and skill were on display; fortunately, mine wasn’t one of those horror stories.

But a thriller of another sort was unfolding. On arrival at the hospital, my wife was informed she had to sign a series of forms for me to receive treatment there. One of them committed us to pay for whatever treatment was administered. It was a blank check, and she was pressured to sign it, as she did. Your money or your life. What might have happened had she not signed? She didn’t dare to find out. The metaphorical loaded gun was pointed at my head.

From there I received whatever treatment a doctor (sometimes presumably a nurse) decided I would have. Did I need them all? Almost certainly not. (Someone else, of course, was making some degree of profit on every one.) Had I been consulted and given detailed information about cost, necessity and efficacy, the costs (to my wife and I) could have been cut greatly. (Public policy suggestion: Require such talks with patients, insured or not, with the point made that you never can predict with total certainty what the insurer will wind up covering.) Neither my wife nor I ever were given any significant opportunity to question these bills as they were being racked up. When we did ask, we got no answers. No dollar amounts were disclosed – until later.

There were actually semi-apologies for some of them. I was in the intensive care unit for five days, when no more than one (at a stretch, two) was really necessary, a fact that massively increased the bill we were charged. (We were told that regular-care room space was full.) I was in the hospital eight days, at least two days more than necessary, in part because two of those latter days were on the weekend, and the regular doctors were off and not present to sign off on releasing me. By day seven I’d have stumbled out on my own except that I was still connected to wires and tubes which someone with experience would have to disconnect, and which they would not without a doctor’s order. (Held there, in effect, against my will, while the costs continued to rise.) Expensive tests were run even after the cause of my illness, and its successful reversal, were clear. Again, someone was profiting, but probably not I. I was simply wheeled out to the machinery; the person who was being asked to pay was never consulted about whether these expensive steps should be done.

While my stay there wound up working medically, I can’t say it was especially efficient. While the medical equipment seemed (at least generally) clearly state of the art, the communications system was massively out of date. Everything was on paper, which accumulated on thick clipboards, and no one seemed to be reading the paper. I saw not one doctor, or two, but a whole bunch, rotating around, and same with the other personnel; seeing someone more than twice in the course of eight days was usual.

After the first day, when the crisis passed, we did start asking questions about cost. We were told not to worry, that most of it would be written off by the hospital. A “social worker” appeared and reiterated the cheerful message. Later on – this is not hard to foresee – the bill in fact was cut from its original level, but just to about the level an insurance company might have been asked to pay. In our context, it is immense.

Competition and the marketplace has not helped.

There’s a fair debate, and probably multiple useful options, for improving the system we have now. From this vantage, on the insurance side, single-payer would be a reasonable system, but so might a heavily-regulated private insurance structure along the lines of that in the Netherlands. The even bigger issue is the matter of cutting costs, of eliminating that which is unnecessary or wasteful, and there is a lot of it, and that will be challenging because so many people make their living doing wasteful stuff running up bills for people like me. There are many possible routes to savings, and they need to be pursued aggressively – no meaningful reform on the insurance side, however it’s structured, can work if the charges continue to rise.

What is totally clear is this:

A gun is being pointed at your head, and mine, and everyone else’s, right now. They want your money or your life – if not today, then eventually. And that’s a point at which we need to call the government.

Cops going after robbers is, after all, a socialized activity. Competition and the marketplace doesn’t quite get that particular job done.

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