Tuesday, September 28, 2010

Complexity, compassion, (health) care

For some time--weeks, months--I've meant to post something about healthcare and health insurance.  While the initial debate was on, I had quite a lot to say.  But since passage of HCERA, which became the Affordable Care Act, I've not been sure what to say.  And now the dust devil of debate is cycling again and storming toward November 2.

The election.  And will healthcare 'reform' be overturned?  repealed?  The odd spectacle of the Republicans picking up the banner of ACA's most popular provisions (no lifetime limits, ability to keep your kid on your policy until age of 26, no pre-existing condition denial for children, for example) and running with it, while at the same time telling everyone that, hell, no, you're not going to be forced to buy health insurance.

Excuse me?  And how is that going to work?  Have we forgotten, people, that insurance is method of managing risk and that, in the private market, you can't provide benefits to people who need them without having a whole lot of people in the pool who don't need them at this time?

I am, geez, a charter member of the You Can't Tell Me What to Do Club, but even I get this.  And if people are so upset about this, why aren't we organizing mass marches on the DMV so we don't have to buy auto insurance, which is required by every state?  I mean, who has the right to do that?  Don't I have a god-given right to smash up my car if I want to?

So no one wants anyone, or at least particular Anyones, to tell them what to do.  But everyone wants healthcare to be nearly free.  A doctor friend of mine talks about the experience within her practice when they toyed with the idea of simply not taking health insurance.  My own internist does not accept insurance.  All this means is that you pay upfront for your medical care, the practice prints out a standard form with diagnostic codes, physician number, and other data required to file a claim with an insurer, and you take that home and fill out the claim form required by your insurance carrier, stick a stamp on it and mail it.  In a few weeks, you get a check for some portion of the amount you spent.

Sound complicated?  A little, but it's what health insurance looked like 30 years ago before HMOs became an industry standard.  Doctors are starting to like the looks of this model, because it saves them money.  They have less administrative overhead.  If a patient requires lab work, other tests, and/or a hospital stay, the patient has that work done at a facility that accepts their health insurance.

Anyway, the whole idea of this change caused many of the patients at my friend's practice to completely flip out.  What do you mean?  It's going to cost me more than $10 to see a doctor?  These are the same people who go to Nordstrom's every other weekend and drop a few hundred bucks.

The HMO model has convinced most Americans that healthcare should be cheap.  So they don't budget for it.

Another friend who works for a public relations firm that handles many healthcare clients, tells me that the biggest problem with healthcare reform is cost.  This after I try vainly to tell her that heavily subsidizing care for the healthy is the problem.

So, who's going to pay?  is the second theme of the healthcare debate.  Second to 'you can't tell me what to do.'  And everyone, myself included, is running from that discussion.

Many people are pretty sure that they shouldn't be paying because they're just incredibly healthy.  The people who should pay are the sick ones.  So themes one and two cross paths here because a big portion of the healthy people don't want to buy an insurance policy.  Which just brings us back to the huh? factor when the majority of Americans seem to want to keep the insurance system that we have now.  Um, right, so that would be the same as not wanting to buy auto insurance because you've never been in an accident, and only the people who have been in accidents should have to buy insurance?  Right.  So tell that to me again after you figure out how you're going to get a new car after the guy who just lost everything in the stock market runs a red light and destroys your Subaru.

Insurance is, I suppose, a way of redistributing funds to people who need them by collecting money from all.  OH MY GOSH!! Insurance is a socialist plot!  Even if people are making a profit!  No, wait, it's a socio-capitalist plot!

And this is the juncture at which the public option (may it rest in peace) is supposed to make things so much simpler.  Because in this model, money is collected from all to be doled out to those who need care, but nobody makes a profit on it.  So it's just a socialist plot.

Simpler, simpler, simpler.  Policy discussions frequently snag on the fence between making things simpler and maintaining the current complexity because constituencies have developed.  That is, do you stick with the devil you know or the one you don't?  'Know' being the operative word because knowledge is power in these situations.

Which is precisely the problem with the ACA.  That's right, the law that allows us to keep our current complexities while promising to make everything simpler. Here's the website.

Would a public option be better than this?  Honestly, I don't know.  There's a part of me that is reluctant to subject the level and quality of my son's care to partisan politics.  Look what happens with Medicare and Medicaid.  Robert has what is still an undiagnosed condition.  Would we have found the treatments that we have if he had been enrolled all this time in what is an anti-poverty program?  And we know how our politicians use poverty as a political football.

I know I've been lucky.  One way or another, by hook or by crook, I've managed to find good health coverage or outsmart the people giving us bad coverage.  In short, I've learned to game the system.  I've had to, as Maryland does not automatically enroll children with disabilities in Medicaid.  What has my learning curve cost me?  Money, time, peace of mind.  What have I gained?  The right to pursue answers.  The freedom to find them.

Would I have had that with a public option?  I don't know.  I would like to believe that Robert would have had good basic care.  But basic care would not have been enough.  The odyssey through our weird, convoluted medical system, with its blend of private and public care, research institutions, highly specialized physicians and scientists is what yielded treatments and theories.  Participation in employer based plans gave us cover we wouldn't have had in the individual policy market.  Without these, Robert would have died years ago, or he'd be so locked into his body that he'd be a vegetable.  Would a public option have given me access to researchers and the gold-plated physicians we've seen?

And as I type these words, I can imagine those faceless, juvenile commenters who cluster like flies on national news sites saying that Robert's life is worthless either way, that all I've accomplished is wasting resources.  And I can also hear the echo of the health care policy debates from last summer, the ones in which actual policy persons facilely separated the economics of healthcare from the human face of treatment.  And when they talked about rationing care and incentivizing people against the 'over-consumption' of healthcare,  I couldn't help feeling defensive.  And angry.  Who were these policy wonks to tell me what I could and couldn't do for my child?  Where was their compassion?  Were they laying the groundwork for an argument that the disabled should not have access to cutting edge care?

Political hacks like to say that the moment Michael Dukakis definitively lost the 1988 presidential election was in the debate in which Bernard Shaw asked the governor whether he'd favor the death penalty if his wife were raped and murdered.  Dukakis said, no, and cooly went on to describe his position without a hint of emotion or a sense of compassion.

The moment the healthcare debate shifted out of control for the Democrats was when Obama used the example of his grandmother to illustrate a problem of cost containment with healthcare.  Near the end of a terminal illness, she broke her hip and had to choose between pain management and being bedridden until the end, or, having an expensive operation with an uncertain outcome.  She chose the latter, and Obama served this up as a bloodless example of the problems of allocating resources.

This post was not meant to be a tribute to our current insurance system, nor a dismissal of the public option. And by no means was it meant to suggest that reform is not an urgent matter.

On my car, I have a bumper sticker with a quotation from the Dalai Lama, Compassion is the radicalism of our time.  As every day goes by and the political weather system overhead rumbles and threatens rain and thunder, I learn more about what that sentiment means.  Until each of us can set our thoughts toward compassion for our fellow human beings, we will continue to live in a country with exceptional resources for treating disease and disability, but only some of us will have access to treatment and care.


Autism Mom Rising said...

Great, nuanced portrait of the issue. Now, would you send it to Washington!

Elizabeth said...

I have been waiting for this -- your proclamation. And once again, it's excellent and worthy of publication or at least massive, viral spread!

erika said...

Excellent, excellent post. It is so refreshing to read an opinion that looks at the different sides of this complex issue. I think your last paragraph perfectly captures the core of the debate. A society without compassion is a dangerous place.