Vote: Your Health Depends On It

Earlier this month, the prestigious New England Journal of Medicine took the unprecedented step of publishing a political position paper in the name of the entire editorial board. Entitled “Dying in a Leadership Vacuum,” the journal urged Americans to vote out our “current leaders.” They based their argument on the mismanagement of the Covid-19 pandemic by America’s political leaders, naming no names but asserting that “when it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.”

While the disastrous handling of the pandemic is the most egregious failing of President Donald Trump, Senate Majority Leader Mitch McConnell, and others who could have made a difference, it is not the only area where our leaders promoted misguided health care policy—with disastrous consequences. I argued in an earlier post that “Trump is Bad for Your Health.” Today, as we approach the end of election season, I am going to spell out why Trump, Pence, their appointees (such as Alex Azar, Secretary of Health and Human Services), their Republican supporters in the House and the Senate, and fellow travelers in state governments (both legislators and governors), will be bad for the health of all Americans, older Americans in particular. It’s not just the pandemic performance that’s the problem: it’s the limitations on access to insurance, the roll-back of regulations that protect the environment, and the attacks on Medicare and Medicaid. 

Limiting access to health insurance: One of the major “accomplishments” of the Trump administration and endorsed by Republican legislators is its relentless attacks on the Affordable Care Act. The administration eliminated the “mandate,” the tax penalty on those who do not purchase health insurance. The mandate is an important part of what allows the ACA to work without driving up the cost of insurance: the fundamental principle of insurance coverage is that it works by distributing the risk over a large population; if people can opt out, only those who are sick will remain insured, raising the cost for everyone. And indeed, with the end to the mandate, health care costs have risen—making this a leading issue for the electorate, young and old. 

Rollbacks of environmental regulations: As of October 15, according to the NY Times, the Trump administration has rolled back or is in the process of rolling back almost 100 environmental regulations. Twenty-one involve air pollutants (plus 5 in progress); six involve water pollution (plus 3 in progress); and six involve toxic substances and safety (plus 2 in progress). Estimates are that these changes will result in thousands of extra deaths per year, affecting older people as well as those who love and care for them.

Attacks on Medicare: just this month, Trump issued an executive order designed to promote the privatization of Medicare. Ostentatiously and misleadingly titled “Protecting and Improving Medicare for Our Nation’s Seniors,” the order calls for shifting costs to beneficiaries, limiting choice of providers, and moving more and more patients into the private sector by joining Medicare Advantage Plans. 

Limiting Medicaid: among the many ways in which the Trump administration has undermined the role played by Medicaid in providing health care is a rule allowing states to cap Medicaid spending for poor adults. Through its endorsement of what are essentially block grants, the federal government is enabling states to reduce health benefits for those who gained coverage to Medicaid thanks to the ACA. In 2018, 12.2 million people were dually eligible for both Medicare and Medicaid. In addition to opting to cut back benefits under Medicaid, states have the option of refusing to allow Medicaid expansion. This is an approach authorized by the ACA that enables the near-poor to receive health insurance through Medicaid. To date, the governors and legislatures of 39 states (and the District of Columbia) have accepted Medicaid expansion; 12 states have not.

Regardless of where you stand on issues such as taxes, immigration, and reproductive rights, whatever your views on foreign policy, your health and that of your children and grandchildren is too important to allow supporters of Trumpian policies to remain in office. Whether they are found in the federal government (as senators, representatives, or in the executive branch) or state government (as legislators or governors), vote them out. Do it now. 

Insuring You Have Insurance

It was really outrageous. It sheds light on our crazy health insurance system—and it is a warning to anyone considering going without health insurance or who thinks mandatory insurance is unnecessary. Here’s what happened:

A family member recently received an “explanation of benefits” from his insurer. He had had had a CT scan for which the hospital performing the test charged $1717. Leave aside for a moment that this is a preposterous fee. He was billed $237.21. Why the difference? The difference was due to the “discount” he received because his insurer had negotiated a rate with the hospital that was 14% of the rate the hospital wanted to charge. The insurer didn’t actually pay a cent—my relative has a “high deductible plan” and has to pay all medical fees until he his family has spent $5000 in a given year. But because he has insurance, he had to pay $237, not $1717. Put differently, if my relative didn’t have health insurance, he would have been charged the full $1717 for exactly the same test.

The system is a bit like scalpers charging extraordinarily high rates for tickets to popular shows or sports events. As long as the system of multiple private insurers is in place, where each insurer negotiates its own deals with “providers,” it’s terribly important to have insurance. If you don’t, you’ll be scalped.

With the Affordable Care Act once again under siege, it is critical to remind everyone why having health insurance matters. This is important for the over-65 population even though virtually everyone over 65 qualifies for health insurance in the form of Medicare. It’s important to older people because their caregivers tend to be under 65: if they get sick and don’t seek treatment because they lack insurance, they won’t be able to serve as caregivers. And it’s important because if those who are not quite old enough for Medicare don’t have private insurance, they may opt to defer taking care of medical problems until they reach 65. This then puts a significant strain on Medicare when they do enroll, potentially raising the cost of the program and putting it in jeopardy.

Mandating that everyone have health insurance makes sense because insurance is only viable if low-risk individuals subscribe along with those at high risk. If sick people are the only ones who buy health insurance, it will become inordinately expensive. Imagine, for example, that nobody bought car insurance until after they had a car accident—and then they expected the insurance to kick in immediately. Then the only people paying a premium would be those who filed claims. The insurance company would have to charge rates that were high enough to make good on all the claims—which means you would probably end up paying the same amount for your policy as you would have paid to fix your car—or to cover the costs of medical care for anyone injured—after an accident.  In the case of health and disease, insurers can get around this problem by deciding that if people wait until they get sick to buy insurance, they won’t be covered for precisely the condition that led to their deciding to insure!

Just keep in mind, that in addition to all these reasons for everyone having health insurance, there’s one more. As long as we have a system of private insurers that negotiate rates with health care “providers” (hospitals, physician groups, etc.), you will pay much less for medical care if you have insurance than if you don’t, even if your insurer pays nothing at all. If this seems absurd, it is, but that is how the system works.

Now, there are other ways to address this problem other than exhorting or requiring everyone to purchase health insurance. We could give everyone health insurance—as is done with Medicare Part A for people over 65—and use tax revenues to pay for the policy.  Medicare sets rates (as long as it has a monopoly, it doesn’t have to negotiate with each provider individually) and in many states, providers are required to “accept assignment.” That means your doctor cannot turn around and bill you the difference between what they charge and what Medicare pays them. But in the current world, you go without health insurance at your own peril.

Act Now!

        This time “repeal and replace” is just repeal. And because it’s tucked away in the massive tax cut bill rather than being labelled as health care reform, Congress is hoping Americans won’t notice. Or that we’re suffering from protest fatigue. But quite apart from the concern I expressed last week that passage of the proposed tax bill will lead to enormous cuts in Medicare and Medicaid, the only plausible way to begin to pay for the planned handouts to corporations and the wealthy, there’s another issue: basic access to health care. Medicare, for all its imperfections, has for fifty years assured that people over 65 have access to medical care. Out-of-pocket expenditures have been rising as co-payments and drug prices have gone up, but the big-ticket items such as hospitalization are covered. The Affordable Care Act was intended to provide comparable access to medical care for the 47 million Americans without health insurance. While there are still millions without insurance today, the ACA has cut that number of 47 in half. The tax bill that will go to both chambers of Congress next week would eviscerate the ACA by removing the mandate to buy health insurance. The way that insurance works is by spreading the risk; if healthy people can opt out of sharing in the risk, the system collapses. Health care is no different.

            The access to health insurance, and by inference to medical care, that is at stake is primarily an issue for people under age 65. But it affects those over 65 as well—if fifty-year-olds don’t have health insurance and get sick, they won’t be able to serve as the support system for their parents and grandparents. And the 62-year olds who were laid off and are unemployable because of their age will soon, if they can hang in there just a few more years, enroll in Medicare. If they've been uninsured for several years, they will likely enter Medicare in less than vigorous health. The effect will be an influx of sicker people into the Medicare program—placing a further stress on Medicare resources. So don’t let protest fatigue sink in—contact Susan Collins and John McCain and Lisa Murkowski and any other senator who isn’t ready to repeal the ACA, now, before it’s too late.

Why Do We Need Health Insurance Anyway?

            Despite the seemingly endless barrage of articles stimulated by the equally endless efforts of the Trump administration to kill the Affordable Care Act, relatively little attention has been paid to why we need health insurance in the first place. Liberal Democrats assert that health care is a “right” and right-wing Republicans maintain that it’s a “privilege” and that the only business government has with health care is to facilitate the business of medicine. Some of the disagreement among the parties stems from differing assumptions about just exactly what health insurance is for. Is it to protect people in the event of catastrophe—a devastating car accident that results in multiple operations and an extended hospitalization, or metastatic cancer that triggers several rounds of chemotherapy, radiation therapy, and numerous hospital stays? Or is to maintain individual and public health—ensuring that people receive immunizations and cancer screening, along with treatment of high blood pressure and high cholesterol? We can begin to answer the question by looking at the example of one group in American society with universal coverage, the older population.

            Medicare (and its sister program, Medicaid, providing insurance coverage for poor people) went into effect on July 1, 1966, after what was effectively a 30-year battle. Franklin Roosevelt wanted the government to provide health insurance for everyone, but couldn’t make much headway with his idea; Truman campaigned actively for health insurance for all Americans, but his plan failed. Finally, after decades of wrangling, Congress and President Lyndon Johnson agreed to begin with those in greatest need: people who were either old, poor, or both. Medicare had the immediate effect of boosting the number of older people hospitalized—suddenly, they stopped neglecting that chronic cough that turned out to be lung cancer or decided to get medical attention for that stomach pain that proved to be an ulcer. The likely effect (though to be fair, it’s hard to disentangle the effect of Medicare from the effect of other concurrent changes) is that older people began to live longer—a lot longer. But what was really striking were the countless indirect ways in which Medicare promoted the health of the entire older population: for example, by promising to pay for effective technology, it stimulated the development of incredibly successful interventions such as the pacemaker and the artificial hip.

When we compare the health of Americans to that of their counterparts in other developed nations, we find, rather shockingly, that everyone else is generally better off than we are—if they are under 65. Among older people, the stark differences between the U.S. on the one hand and Europe, Australia, and Japan on the other hand vanish. The only plausible explanation is that older people in the U.S. all have health insurance, rendering them comparable to older people in other parts of the world.

            From a population perspective, ensuring that everyone has health insurance is desirable because health is desirable. Good health is like education: without it, we are not productive, creative, prosperous, or happy.  Health insurance is the means to assure good health, so just as public education is a means to a skilled labor force. Environmental regulations are the means to assuring a safer, more healthful country.

            From an individual perspective, health insurance is critical to well-being because it’s the gateway to good health. It’s simply not true that we can expect to stay perfectly healthy as long as we eat well, exercise, and lead a virtuous life. We never know when disease will strike, whether in the form of cancer or heart disease or a chronic neurologic disorder such as Alzheimer’s disease or multiple sclerosis. No matter how cautiously we drive, we cannot guarantee that a drunk driver won’t unexpectedly plow into us, causing no end of medical problems if we survive the crash. Nor can we expect that the cost of even routine medical care will be affordable: a plain x-ray, used to diagnose pneumonia and other lung conditions, typically costs hundreds of dollars when you add up the cost of the procedure and the cost of a radiologist’s reading. 
          Everyone needs basic medical care and it’s not just “catastrophic care” that is expensive. Hence, the rationale for covering each and every American isn’t just that health insurance only works when everyone shares the risk—though it is true that the only way to keep premiums manageable is for everyone, the sick and the healthy, to have coverage, rather than confining coverage to those who are known to be sick and are guaranteed to use huge amounts of service. The rationale for covering everybody is that health care is essential if we are to have enough energetic, healthy, educated workers to provide the services and the innovations that we all need, and the only way to make sure that everyone has access to health care is to provide insurance.

          Health care, and the insurance coverage to pay for it, isn’t a right, nor is it a privilege. But it is critical to promoting a strong, vibrant, capable citizenry.

Rescue and Reform

A new poll conducted by the Kaiser Family Foundation found that nearly 80 percent of Americans want Congress and the President to modify the Affordable Care Act to make it work. They don’t want repeal and replace. 
       The numbers are impressive: 95 percent of Democrats and 52 percent of Republicans favor a legislative fix to the current law. Even among Trump supporters, an absolute majority (51 percent) support such an approach. In fact only 17 percent of the public (although 40 percent of Republicans) believe the Trump administration should act to initiate the infamous “death spiral” by taking such steps as eliminating the universal mandate and withdrawing subsidies to poor people. Taking Medicare as a model of sweeping, comprehensive health care legislation, we can look at just how much the program was reformed by Congress in the first 15 years after the law went into effect.
       Passed by Congress in 1965, Medicare first became a reality on July 1, 1966. In 1972, Medicare eligibility was extended to people under age 65 with long-term disabilities as well as to those with end-stage renal disease. This was no minor tweaking of the program: today 9.1 million people out of the 55 million on Medicare are in the under-65-with-disabilities category. In the last year for which data are available, Medicare spent a whopping $30.9 billion on end-stage renal disease out of total expenditures of $646 billion. 
       In 1973, “Medicare HMOs” were introduced. The federal government established standards for what benefits had to be provided, but basically outsourced plan design, management and marketing to private insurance companies. The name of this program has evolved over time, from Medicare Choice + to the current Medicare Advantage plan, but the idea remains unchanged: instead of enrolling in Medicare Parts A, B, and now D with deductibles and co-pays, Medicare enrollees can opt for one-stop shopping. Today, a record 17 million people, or 31 percent of all Medicare beneficiaries, are enrolled in a Medicare Advantage plan.
       Jumping ahead to 1980, the decision was made to broaden coverage of Medicare home health services, allowing more people to stay out of hospitals and nursing homes because they received physical therapy and occupational therapy, as well as visiting nurse services at home. At the same time, supplementary Medicare insurance plans (“Medigap”) for those people not enrolled in an HMO, came under federal oversight to cut down on all too common abuses found at the time. 
       And then in 1983, in what was perhaps the most far-reaching reform of the Medicare program ever instituted, prospective payment was introduced for hospital care. What this meant was that instead of hospitals charging whatever they wanted—with Medicare dutifully paying soaring bills—Medicare set rates that were based on the expected length of stay for a given condition. The hospital got paid that fixed amount (adjusted for co-morbid conditions and geographic variation in the cost of living) regardless of how long a patient was in the hospital. In other words, patients with an unusually long length of stay cost the hospital money and patients who were discharged unexpectedly early generated revenue for the institution. The result of this innovation, in addition to controlling how much money Medicare spent on hospitalizations, was to shorten length of stay, moving much “post-acute” to the home or the skilled nursing facility.
       Reforming Medicare didn’t stop in the 1980s. But my point is not to present an extensive history of the Medicare program (though if your interest is piqued, you might like my forthcoming book, Old and Sick in America: the Journey through the Health Care System); rather, it is to emphasize the complex, innovative, health care legislation seldom bursts onto the scene fully and impeccably formed. It usually needs to be fixed. The ACA is no exception.

       After chanting “repeal and replace” for so many years, the Republican majority needs to save face. But the way to do t do that is not to sabotage what we have, a compromise bill designed to save private health insurance rather than jettisoning the industry in favor of single payer coverage. The Republican Party should appropriate the idea behind the ACA as its own, acknowledging its true founding father, the extremely conservative Heritage Foundation. Maybe what’s needed is a new mantra. How about “rescue and reform?”

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