Who Am I?

Health Care in the US

Posted: September 20th, 2010 | Author: | Filed under: Celiac, Personal | Tags: , , , , , , , , , , | 10 Comments »

As a rule, I don’t tend to post on political issues, mostly because I don’t tend to write about or otherwise wrestle with such matters at any significant level. I do stay generally informed, and I also find that much of what passes for political discourse in our country is pretty abysmal.

Health care, however, is one issue which does concern me a great deal, especially since at least two of my children have inherited celiac disease from me. Personally, my wife and I are somewhat insulated and secure from the worst of what has happened to health care in the US over the past decades. I’m a federal employee and as such we are covered under the FEHB. Twenty years ago, the FEHB offered pretty average employer insurance plan with low to average benefits and costs. Over the past couple of decades, I have watched our health care coverage become better and less expensive than that of almost everyone else I know.

And my health care plan has not significantly changed.

Let me say that again. Over the past twenty years, I’ve seen my health care plan go from, at best, a middle of the road plan, to one that seems to be better than that of most of the people I know without changing. I have watched the overall level of health care access and coverage dramatically decline for almost everyone else around me.

That’s not to say they aren’t constantly tweaking and adjusting my health care plan each year. Some years we pay a bit more in deductibles and other copayments. Some years we pay a bit less. Premium costs have pretty much risen every year, but at a less dramatic pace than that of many people I know. They did add a PPO network in the nineties, and reduced coverage for care received by non-participating medical practitioners and facilities. But the plan’s PPO network is so large, that’s been a non-issue. I don’t think there’s ever been a doctor or facility we wanted to use that was not a preferred provider on our plan.

As a result, my wife and I have been somewhat insulated from the abuses in health care coverage in this country and it’s less likely to ever be a critical issue for us personally. However, at least two of our children inherited celiac disease from me — that is they’ve been tested and positively diagnosed with active celiac disease. Thus, they already have one strike for a pre-existing condition and it’s a condition which can manifest in a huge variety of ways. They also have a family history for a variety of other conditions they could develop over the course of their lives. So from a personal perspective, the issue of health care does strike close to home.

However, that statement is true for every single one of us. The odds that we or someone we love will face some sort of serious, life-threatening, and individually unaffordable (unless you happen to be a Bill Gates or Warren Buffet) health crisis at some point in our lives approach certainty. And within the context of the privatized, for-profit system we allowed to balloon over the course of the past two decades, the odds were unacceptably high that during that almost inevitable health crisis, we would not have access to the level of care we might expect and our family would be crippled by debt for the care we did manage to receive. This is clearly the sort of problem that can only be mitigated by sharing the risk, responsibility, and cost as a society. It’s for reasons like this that we group together as a society and a country. There are many things we can do together that we simply can’t do alone.

Of course, it’s a scientifically demonstrated fact that the way our minds function leaves us remarkably poor at evaluating and acting on those sorts of risks. Even when we know the odds, we tend to have irrational optimism that we can beat the odds in some situations. (That’s one reason why, in every flood here, there are usually people who get in trouble and even die from driving around barriers and into flooded low water crossings.) Conversely, we tend to inflate threats that seem riskier, but which actually have a comparatively lower and often even minimal chance of impacting us. The biggest risk many of us personally encounter on any given day is the risk of simply driving to work, school, or the grocery store. But if you ask people to list or rank risky activities, that rarely makes the list at all.

In this instance, managing health care at the societal level in some way is the common sense thing to do from a self-oriented, pragmatic perspective. Ironically, it’s also the only thing you can do if you claim to love your neighbor. In this country, we have organized ourselves as a form of representative democracy. One of the things that means is that we all share in the responsibility of ruling our country. As Christians, that has particular implications. It means we face, though perhaps on a more distributed scale, exactly the same sort of dilemmas that Christian emperors and other rulers have faced throughout history. We are the powers and authorities who will be held accountable by Jesus for the way we have exercised that power. We cannot escape that responsibility and we cannot abdicate it. There are no easy answers to the proper use of that power. There never have been.

Unfortunately, there is no easy button.

So what are our options? I’ve studied what other countries do to some extent and it seems to me that most employ variations of one of three different general approaches. (Yes, I know there are a lot of ideas out there, but most countries seem to actually end up doing one of three things.) It also seems to me that part of our problem is that we are trying to use them all in a disorganized and hodge-podge manner rather than selecting one approach for everyone in our country. If we are going to truly share the risk, responsibility, and cost, it doesn’t seem effective to me to take that approach, especially if, as you’ll see, we segregate pools of those with higher risks and costs from those with lower risks and costs.

So what are these options?

  1. Government run health care. In this system, the government owns the hospitals. Most doctors and other health care practitioners work for the government in those institutions. And basically, health care is delivered directly by the government. England is one example of a system like this. There are many variations and permutations.
  2. Single payer health care. In this system, the doctors and other practitioners largely do not work for the government, nor does the government own or directly operate most of the hospitals and other facilities. Instead, the government is the single payer for health care services. They negotiate payments and they usually distribute the costs to some degree across the populations based on your ability to pay. Canada is one example of a system like this. Again, there are a lot of different ways to do it, but they do share the same common characteristics.
  3. Government regulated health care insurance exchange. Here, the government does not directly pay most health care costs. Instead, it establishes and regulates an insurance exchange and mandates the participation of all citizens in order to spread the risk across the population. Such a system typically must include subsidies for groups like the poor. Switzerland’s system is generally the model for a system like this.

Those are the basic, widely used options. And here’s where the arguments of those who seem to oppose almost anything that is proposed turn irrational. Why? Because we employ all of the above approaches in our country and have for a very long time. Yes, I know there has been widespread demagoguery over government taking over health care or socialized medicine, but though it has been noisy, it’s had no basis in reality. I don’t personally have any strong preference for one system over another. But my life has been such that I prefer to maintain some connection to the world as it actually is rather than my fantasy about it.

Let’s start at the top of my list. Because we are so large as a country, we actually have a government run health care system that rivals that of some smaller countries. It’s called the Veteran’s Administration. While the VA operates many programs on behalf of veterans, one of the largest is certainly the network of doctors, hospitals, and clinics it runs. We hear about it in the news when there is a problem with a VA hospital, but they mostly do pretty amazing work — especially when you consider that we usually choose to underfund them. If a government-run health care system is good enough for those who have served us in our military, tell me again why it wouldn’t be good enough for all of us? Be careful how you answer that question. Though I’m not eligible for care through the VA, I am a veteran.

Or let’s move to the next item on my list. Our government-operated single payer system is the largest single health care system in our country and is much larger, I believe, than Canada’s entire health care system. Our single payer system, of course, is called Medicare. In the debates over health care, both Republicans and Democrats publicly defended Medicare. I remember some of my older relatives, especially the ones with serious illnesses and inadequate coverage, anxiously waiting to reach the Medicare enrollment age. It has problems, of course, because of the way we’ve chosen to structure and fund it over the years, but as a system it works well enough that threats to take it away seems to raise the ire of those who have it.

Finally, even before the recent Act, we had government-regulated insurance exchange option available. It’s the one that has covered my family and me for most of my life, the Federal Employee Health Benefit (FEHB) program. OPM has regulated the program pretty well over the years and overall it’s worked pretty effectively.

The recently passed health care reform act requires that similar exchanges be established at the state level (or the state can opt into a national exchange), but the only population of those exchanges will be those who do not have health care coverage through their employer and who do not participate in any of the above health care systems. (And yes, I know I left Medicaid off my list, but it’s similar to Medicare in the way it functions.) That’s certainly an improvement over our current situation, but it means the pool will be a lot smaller which isn’t very good for sharing the cost and risk across the population.

Personally, I believe we need to move toward some single system. As I said, I don’t have any strong feelings about any particular system. Since I’ve participated in the FEHB for twenty-five years, I probably have a slight preference for expanding it to be the single exchange for all United States citizens. That’s not necessarily easy. In order to fund it and make it affordable, we would probably have to mandate that large businesses pay at least the same portion of the premium for their employees that the Federal Government does for its employees. And then we would need to develop appropriate subsidies for individuals and people in various categories such as the poor and the elderly. And it would obviously require a larger regulatory body than OPM currently has in place. But it could work if we had the will to make it work. Switzerland has proven that it’s possible.

In the interim, the health care act has some excellent features. The changes to prohibit denial of coverage of preexisting conditions and the end of the evil practice of rescission alone are very worthwhile. The extension of coverage under parental plans until the age of twenty-six means I will be able to keep my younger two children (both with celiac disease) on my insurance for as long as should be necessary. The insurance reform requiring that a minimum of 85% of premiums be used to cover medical loss is a great first step. I still remember when the typical medical loss by our mostly non-profit insurance companies was 95%, so I’m not impressed by the 85% number. Still, it’s better than the current 70%-80% medical loss. 85% is at least less egregious than the current situation. There are others, but those were the ones that I found particularly relevant.

Nevertheless, it’s a patchwork law that really doesn’t do enough. That doesn’t upset me terribly. That’s how things usually work with us. The health care reform act was a good start. Now we just have to keep making it better while trying not to take any steps backwards.