healthcare costs

Illness as Financial Ruin (US only)

R. Horton

Every human who has drawn a breath has faced illness, injury, and death. The universal experience of illness creates vulnerability, loss of identity, anxiety, diminished autonomy, and fear. The inescapable battle between health and illness defines human experience and shapes our personalities, our worldviews, and spiritual depth.

For most of the developed world, though, it does not mean financial ruin. In the United States, alone among developed nations, even a relatively minor injury such as broken bones or illness requiring a brief hospital stay can lead to economic disaster. As a result, when we in the US get sick, we don’t think about how we can recover, how we can endure the pain, or the spiritual significance of our pain; rather, we think of how we will pay for our bills.

poorunclesam-800pxAs we face our anxiety over possible diagnoses, we must constantly be prepared to battle with insurance companies, aggressive hospital billing agents, and doctors exhausted from dealing with insurance paperwork. Few things in life create as much anxiety as financial insecurity, and illness always brings the threat of insecurity to US residents. When people have serious accidents, they balk at calling an ambulance because they fear the bills—they worry over whether the ride will be covered and whether the ambulance will take them to a hospital that is in-network. As a result, many people suffering medical emergencies drive themselves to the hospital.

When it isn’t an emergency, Americans often forgo treatment altogether. A Gallup poll in 2014 found that one-third of Americans skip needed medical treatment because of cost concerns, even when they have insurance.  According to the report, “Some 34% of Americans with private health insurance say they’ve skipped out on care because it was too expensive, up from 25% last year. Additionally, 28% of households that earn $75,000 or more report that family members have delayed care, up from just 17% last year.” The Affordable Care Act succeeded in insuring more people, but it also created greater financial burdens for middle-income families through higher deductibles and co-pays. Many people who have been accustomed to being able to afford healthcare now find that it is out of reach.

While healthcare inflation has slowed a bit in recent years,  catastrophic medical events put the costs incurred out of the reach of most of us. The United States alone finds medical fundraisers to be normal and routine. According to an article in Journal News, the number of GoFundMe contributions for medical expenses “was up more than 293 percent in 2014, when more than 600,000 medical campaigns were launched, compared to just over 158,000 in 2013.”  Families with or without insurance cannot afford their medical bills. A serious accident or illness such as cancer creates an existential crisis while forcing people suffering from illness and their families to scramble to avoid destitution.

I don’t write this impersonally, my wife and I buy our insurance through the healthcare exchanges. We pay $682 per month ($8,184 per year) with a $4,000 deductible per person. The out-of-pocket limit on expenses is $13,700 per year. Balance-billed charges do not apply to the out-of-pocket limits, so there really is no upper limit to possible charges. Ignoring balance billing, my costs could easily exceed $20,000 per year.

I often hear the argument that universal healthcare coverage is too expensive and will require raising taxes on the middle class. As I see it, I would still benefit from a tax rise of $15,000 or even $20,000 each year. It is true that others are not in my position, but all Americans should realize they are at risk. No one stays young and healthy. Eventually, everyone will be at greater risk for catastrophic illness, but even those who are currently young and healthy can face illness and injury, though we may not like to think about it. Further, everyone’s income is subject to great variability. Those who have employer-provided health insurance may not want to pay in to a national system, but employer-provided insurance is never guaranteed. Employers may cut benefits, employees lose jobs through layoffs and termination, or illness can end employees’ ability to work.

The same is true for business owners. The tides of fortune shift. When the Affordable Care Act was passed, Mary Brown brought a lawsuit against it, saying she did not want to be compelled to purchase health insurance. Mary Brown owned an auto repair shop that went under due to the pressure of economic recession and the Gulf oil spill in 2010. Of note, her bankruptcy filing listed “among the couple’s unsecured creditors several providers of medical care – a hospital and a physician group in Florida; an anesthesiology group based in Mississippi; and an eye care center in Alabama.” https://newrepublic.com/article/98145/affordable-care-act-mandate-lawsuit-nfib-mary-brown-bankruptcy-court-standing

Like many people, when she was doing well, Mary Brown thought that guaranteed universal access to healthcare was something the government was providing to other people. It didn’t occur to her that she might ever be in a position where she could not pay for her own medical care, but that is exactly what happened. I recently had the opportunity to speak to a Swedish citizen about Sweden’s healthcare system. He was a middle-aged man who explained that healthcare was paid through higher taxes. He said he didn’t mind the taxes, though, because you never know when you will be the one needing care.

It seems many Americans are not able to make this basic calculation of risk. Most people, even those who consider themselves well off, are not immune from the financial ruin that illness and injury can bring. Once people realize their own vulnerability, they support universal coverage for healthcare. The time for a more sober and accurate assessment of risk is well past due. We must wake up to the fact that the US healthcare system is not sustainable, that it leaves us at risk of financial failure, that it makes the experience of illness exponentially more stressful, and that we can do better.

It will not be easy. The US spends far more than other developed nations on healthcare. Each excess dollar we spend is profit for an insurance company, hospital, testing facility, pharmaceutical company, biotechnology company, or other player in the healthcare industry. Many people profit from the dangerous, expensive, and inefficient system we have in the United States. Every reduction in healthcare spending will be a reduction in profit for someone, and each person (or business) facing a loss of income will argue vehemently and vociferously that such a loss of income is a horrible tragedy and an impossible feat.

We will be told that reducing healthcare spending will reduce the quality of care. We will be told it will reduce our choices and control. We will be told it is impossible. We already have little choice or control, and we already have higher mortality rates than the rest of the industrialized world, so we have nothing to lose and everything to gain. We have plenty of ideas on how to improve the system. What we lack is political will, but I think the will is growing. If we want universal coverage, we must demand it, and the time to demand it is now.

 

Medicare at 50: Our Moral Imperative

R. Horton1 Comment

Last year, on the 49th anniversary of Medicare, I wrote a post advocating the expansion of Medicare to ensure that everyone in the United States can have access to basic healthcare. In the past year, I have read and heard many arguments against the expansion of Medicare and, in fact, single-payer systems in general. As I read the arguments, I realize that in a sense “Medicare for All” and “single-payer” have become a shorthand way of saying we need to guarantee “universal access to healthcare,” but I still think Medicare for All is the way to go in the United States.

I happily admit, though, that my commitment is to universal access to healthcare, not Medicare. The first step, in my opinion, is to declare that we will provide access to medicare for allhealthcare to all United States citizens. Take this simple idea, and make it law: We will provide healthcare to every citizen of the United States. Once that law is passed, we can have extended debates about whether Medicare can fulfill the purpose of guaranteeing that all citizens will have access to healthcare (my repetition is intentional).

Here are some of the objections I’ve heard and read to expanding Medicare along with my replies:

I don’t want to pay for healthcare for people who are too lazy to work.

Many people I talk to are extremely optimistic about their ability to pay for their healthcare in the case of extreme illness or injury. The fact that you’ve made it so far only means you’ve been lucky, not self-sufficient. Mary Brown, who sued the government over the Affordable Care Act because she didn’t want to purchase insurance, went bankrupt and was unable to pay her bills. In response to her own bankruptcy, Brown reportedly said, “”I believe that anyone has unforeseen things that happen to them that are beyond their control.”  Yes, and the Affordable Care Act was designed to reduce the impact of unforeseen illness and injury. Unlike Mary Brown, many people who become medically bankrupt had insurance but weren’t able to cover their medical bills, anyway. A study in 2007 found that three-fourths of people who were medially bankrupt had insurance.  A study by NerdWallet Health found in 2013 that “Despite having year-round insurance coverage, 10 million insured Americans ages 19-64 will face bills they are unable to pay.”

For people who do have insurance, most get it through their employers. Too many people seem to forget that when they face unforeseen illness or injury, they will also be unable to work and are likely to lose their employer-provided insurance. If not immediately, it will happen sometime further down the road. Whether the road is long or short, it leads to bankruptcy. While some are rich enough to be impervious to mounting medical debt, most of us are not. A few hundred thousand dollars may sound like a safe cushion against medical disaster, but many life-saving treatments exceed that amount quickly. Selling your house and other assets to pay your medical bills may not be a solution. In fact it probably is not a solution.

The fact is that supporting a national program to guarantee access to healthcare free from the risk of burdensome medical debt is not something you should do only for other people. It is something you should do for yourself. And it is something we should do for our country.

As a nation, we share many burdens: national defense, national safety, public health, personal security. Like infrastructure and security, we are not talking about items we can choose to forgo in leaner times. These are basic human needs. Any society that does not meet the basic needs of its citizens will falter. If we can share the cost of providing a strong military, food inspectors, fire fighters, and police, we can share the cost of providing health services. The financial life you save may be your own.

Most countries don’t have a true single-payer system.

The argument here is that many countries that do guarantee universal access to healthcare do not use a “true” single-payer system. I am willing to concede that even Medicare for All might technically require the use of more than one payer. What is important, really, is that the payers are not invested in fleecing their clients, which often seems to be the case with for-profit insurance companies. In fact, if we had a single for-profit insurance monopoly, we might find our processes somewhat more efficient but not beneficial for consumers, so it matters who the single payer is as well. Just to repeat: we must have a system that guarantees access to healthcare without the risk of bankruptcy.

Medicare is fraught with fraud and abuse.

No one can deny that fraud and abuse exist within the current Medicare system. We need greater transparency, oversight, and regulation of the system and of the providers. Also, Medicare must have the ability to negotiate prices, unlike the disastrous Medicare Part D that currently exists for prescription drugs.

Corporations will game the system.

It is true that for-profit providers, whether they are pharmaceutical companies, for-profit hospitals, biotechnology companies, medical equipment suppliers or food vendors, will strive to earn as much profit as is humanly possible. This is why we need a system that empowers taxpayers to hold bad actors accountable and demand transparency regarding pricing and profit. Corporations will serve the common good only when common people demand that they do. Fatalism is an excuse to avoid the hard work of diligence.

We need price controls.

Again, simply removing all but one payer will not, on its own, lower prices. If Medicare simply sent checks to providers for whatever charges they submitted, the United States would continue to have the costliest healthcare system in the world. Medicare must have the ability to negotiate prices and set limits on unchecked profits.

We must limit unnecessary tests and treatments.

In a pay-for-service system, hospitals, labs, equipment manufacturers, and others make money every time someone is tested or treated for anything at all. More and more studies are finding that many tests lead to unnecessary treatment, waste money, and (even worse) cause more injury and death than they prevent. Unfortunately, limiting the number of tests and treatments available to patients is likely to be perceived as (shriek) rationing.

With our current system, we trust insurance companies to refuse payments for useless or harmful tests and treatments, but we know this does not always happen. When it does, clients fear they are being denied necessary tests and treatments. They fear this largely because it is sometimes true. Whether Medicare is expanded or not, we need better ways to evaluate what tests and treatments are beneficial, and we need better ways of educating patients on what is and is not beneficial.

Movements toward paying providers for results, not services, may reduce unnecessary and harmful services greatly. It may also force patients to become more responsible for their own health.

Finally

The only real imperative here is that we, as a nation, must decide whether we will provide access to healthcare for all our citizens. Once we agree that we will, we can begin to work out the most efficient and cost-effective means for achieving our goals. Almost no one in the United States is immune from the possibility of medical disaster and bankruptcy. This is a matter of caring for our fellow citizens, but it is also a matter of caring for ourselves.

On the 50th anniversary of Medicare, take a stand for healthcare justice.