Open Enrollment Looms
That rhetoric may sound dark and scary, but it is how I think about the open enrollment solution. Why? Well, I’m glad you asked. Settle in because the answer is long.
Insurance vs Care
Years ago the AHCA was at Congress. A long struggle ensued with some strange tactics being used to try to get it passed. The whole time this was going on, I shook my head in anger. It was, for the most part, based on the individual mandate, as the reaction was for many citizens that were against the act, but it was also because being a person who takes frequent trips to the doctor for various reasons, I didn’t see how insurance reform that basically only included the mandate would change the issues I had experienced. I didn’t see a reason for insurance reform, unless it involved more coverage of big expenses and less coverage of little expenses. I did see a plethora of reasons for care reform. Why do hospitals charge for pills every day that patients may not even take? Why do doctor’s offices charge for a “consultant” when the second doctor only poked their head in the room? Why do doctors get to refuse patients sterilization based on age? Why do hospitals get to refuse reasonable care that patients need and request, only because it may hurt their stats? Why do a group of doctors get to decide who is even eligible for organ transplant based on any factors, some of which include moralistic reasons? Why do hospitals get to decide that physical harm is more important than financial harm? Why don’t most hospitals and doctors have to tell patients up front the costs of visits and procedures? These issues have very little to do with insurance. They are caused (and thereby fixed) by the health care industry.
For a personal anecdote (remember I’m not trying to make a generalization by using this evidence but to call your attention to cases of similar problems), there are a lot of forms one has to fill out for procedures. When Patient A went into the Mayo Clinic (considered one of the best hospitals in the U.S. if not the world), A had an EGG attached to their scalp with glue, and it was going to stay there for days and possibly weeks. More than halfway through attaching it to A’s head, a tech handed A a form to sign concerning the procedure. A actually read the form. It said the glue and attachments could cause permanent scalp damage including bald patches. This feels like something A should have been told before the start of application. Lesson: Forms should be given to patients before procedures are initiated.
Another example: A year ago Patient B was looking for a new yearly doctor. B called places that would be convenient or that were recommended and asked for the prices of the visit and the lab work. B picked one that said (without insurance) it would cost $100. When B made the appointment during a second phone call, B confirmed the cost. When they called B to remind B about the appointment, B confirmed the cost again. When B got to the doctor’s office, they told B it would cost about $136. Needless to say, B was angry. The women at the desk tried to tell B that the up charge was due to B being a new patient. B told them that the woman who made the appointment entered B as a new patient and still confirmed the $100. They said she was wrong. B said, well, she could have been wrong, but I expect you to honor the price I was quoted. Some readers may think, it’s only $36, what’s the big deal? The big deal is that as a consumer, B expects the price B was told. Lesson: If you as a consumer ask for a quote, the vendor should honor that quote. To do otherwise is unethical.
If you want examples similar to this, check the doctors and hospitals in your area on Yelp. You’ll probably see a lot of problems on the care level that do not involve insurance.
No Insurance even with Options
The point of AHCA is to make healthy people get insurance to make it cheaper for sick people. The majority of these healthy people, according to a lot of the supporters of the act, are people in their twenties. Well, let’s think about that for a moment. What expenses do people in their twenties have? Many of their parents can’t afford to have them living in their homes rent free, so there’s that plus groceries and utilities. But wait, what if they are in college? Again, many of their parents didn’t really save a lot for them to go to college, so there’s tuition and fees and books. Maybe they live in a dorm, so that offsets their cost of living somewhat but not in all cases. Even with a part-time job, they probably can’t afford all that on their own because they go to a moderate to great school so they are more likely to get a job after school, so they get loans. Let’s say that all that has already happened. They’re out of school, maybe just last May or maybe in the last five years. They need an apartment and the countless accouterments that come with one (for cooking, cleaning, sleeping, hygiene, and just plain sitting). They need a job too. They apply in their industry, but not everyone is hiring as there are no new positions (the companies don’t have the money to grow) or no openings (as no employees are leaving for other companies or retiring), and the few interviews they get have competition with thirty years of experience on them. They do anything for income, ending up underemployed, with a job with no benefits or too little pay to take advantage of the benefits. Six months after getting out of college their student loans come due because while underemployed they make enough so that they don’t qualify for deferment, and now have an extra bill to pay every month. They keep searching for a better job, but one isn’t forthcoming as there are just too many applicants for the few postings that are appropriate for them. I’m not saying this is every twenty-something’s experience, but it seems to describe a lot of them. I’m not just talking about myself. I’ve read a lot of personal accounts that meet this description. Now tell me, how in the world is this person supposed to help anyone? If our Congress wanted to saddle the youth of our nation with subsidizing the AHCA, then they should have subsidized the education of the youth, and that means helping students, not universities.
Oh, but they qualify for subsidies? Before I go into how subsidies aren’t all that helpful, let me just say if the demographic you expect to lower premiums needs subsidies then they really aren’t the people to look to to fix the problems. That’s like building your castle on a crumbling foundation. The subsidies only come once a year while the insurance payments come once a month. This creates an imbalanced fiscal year for people. I may accept this imbalance as workable if the subsidies came before the people had to start paying their insurance premiums so they could set that money aside, but they have to go in the hole and go without until the next tax time instead. Most people, I would think, would want a place to live and food on the table before having health insurance. I’m sure this is why a lot of people stopped paying their premiums. It’s tragically ironic that they have to choose the healthier option (shelter and sustenance) over something that is supposed to make going to the doctor cheaper. In some cases, I don’t think the subsidy offsets the premiums enough. For example, if the premium is a quarter of the person’s monthly income, the subsidy is just not going to make that cost manageable.
The insurance itself isn’t worth the high cost though. Why? Well, as a professor who focuses on health insurance rhetoric once said to me, health insurance is meant to prevent people from going bankrupt because of extreme illness or injury; however, if a person can’t afford a deductible of $10,000 or a procedure with a $50,000 price tag then insurance really didn’t do it’s job. Extreme illness and injury are still a financial death sentence in this country, regardless of the possession of insurance. It makes me wonder why people are willing to pay such high premiums if it is no guarantee against bankruptcy. What was the point then of years of monthly payments? Right now a lot of the options for buying insurance are like choosing between a car missing a frame, a car without an engine, and a car that blows up when you turn the ignition and the salesmen has a gun on the customer and the asking prices are three times Kelly Blue Book. That simile may need some unpacking though. The options are not worth it. They do not have good coverage for extreme illness or injury, the issues that need the most coverage. Back to cars (but not the simile), auto insurance covers accidents and system failures which are the equivalent of extreme illness or injury, but not oil changes and routine tire replacement which is the equivalent of check ups and typical long term medication (such as birth control and asthma inhalers). I’m sure most readers have heard this analogy before, but my point is that I don’t see the point of health insurance if all my options don’t really help me out financially if I were in an accident or developed a serious condition or illness. I can get care; what I need is something to offset large expenses.
What do I mean by care? I’ve found ways in my current large city and in the much smaller city I used to live in to receive the maintenance care I need without breaking the bank. You’d be surprised how resourceful one can be when one starts coughing up bloody phlegm. In my small town, a visit to the doctor meant $10-$35, depending on the type of doctor I saw and not on the procedures I received. For example, it cost me $10 for outpatient surgery. In my current big city, my doctor’s office is not capable of as much as the one in the smaller city but the price went down to $0. In both instances, prescriptions were also included for an addition of $0. I may not go to the dentist every six months (do people with insurance go to the dentist every six months anyway?), but I still can get problems taken care of for an affordable price. But were I to get really sick or hurt, I wouldn’t have much luck, nor would I if I had insurance. Although, there is a hospital in my city that will tell you exactly how much a procedure will cost and has reduced prices for uninsured and under-insured patients. These options are all so much more affordable than health insurance, but not every city/state has these options. Frankly, they should. A lot of these kinds of systems are based on income or have very limited abilities to be flat-out free, and a lot of places just don’t have a system in place to help patients in extreme cases. So all this fixes the oil changes and tire rotation, but not a collision.
I don’t buy products that suck. If the value doesn’t match the price tag, I won’t buy a product. Simple as that. This is why companies compete in the first place. Some try being cheaper, thus lowering the quality of their product. Others raise the quality, thus raising the price. But if a product is both expensive and crap, I’m not buying it. This is the main reason behind me not buying fast food on most occasions. For example, Taco Bell isn’t very good. It’s also not cheap. I can go to Filiberto’s and get much better food for about the same price. I refuse to buy Great Value brand pancake and sausage on a stick. It being vomit-worthy makes any price too expensive. In fact, if I had to eat those I would request that WalMart pay me first. I’m almost always willing to pay more for a better product, because I get more enjoyment out of the higher quality product and if said product is non-perishable, I will most likely not have to buy a replacement item for some time (Remember: The Poor Man Pays Twice). I would rather go without a product than buy a cheaper, going to suck product that I’m just going to have throw in the trash someday soon.
In my personal finance course, I learned this handy dandy rule about product buying: Fast, Cheap, Good–Pick Two. This means a product can only be two of these things at a time. More often than not, I will refuse to buy a product that only lets me pick one. Example: More than a year ago, I was shopping for furniture, and for some reason I believed I needed a dining table because I had a dining room. A dining table would most likely not be used for dining in my life but for projects of another nature (that sounds suggestive, but I just mean drawing and writing). We went to La-Z-Boy and found something we liked. It was small (geeze what’s with all the six to eight people tables) but still had comfortable chairs and was made of wood (why in the world are all four person tables made from metal and glass? this isn’t for my patio!). Unfortunately, it was counter height (why, why, why? who wants this!?), but they did have the option to order table height. It was going to take six to eight weeks, and the set price was high. Okay, so I can have good only. Sorry. Nope. We walked away. But some places don’t have a single one of these attributes, so I don’t ever buy from those companies.
The point of these examples is the consumer’s right to refuse to buy. This sends a message to companies that the attributes were lacking in some way. We shouldn’t buy products that are of no value to us. The three attributes are how we gauge value as consumers. Most health insurance I’ve seen is not good (it does not have good coverage for extreme incidences visible by the deductible), is not cheap (most premiums for good insurance are prohibitively high), or are not fast (reviews of the company show that their turnaround for claims is slow or the fastness of service was not discernible before purchasing and making a claim), so why in the world would I let the company think I like their product by spending money on it? My right to refuse a product tells a company that their product is not satisfactory. Taking away my right to refuse a product means the whole industry doesn’t need to care if their products are satisfactory.
The counter-argument, that the price will go down once everyone has insurance and that coverage is better (no pre-existing condition exemptions, more preventative care, full coverage), is unsatisfactory to me. Why? Because I can’t afford it now, and I’m not the only one. People aren’t going to break their banks, when their banks are already broken, right now for something that is maybe going to pay off in two or three years. Preventative care is great, but you can’t force people to be healthy, nor is preventative care as good as fixing existing problems, i.e. coverage of extreme illness and injury (I will say it again and again: this is the most important point as it is the place where health care destroys lives financially). I don’t need maternity and child care coverage when I’m never going to have a child, nor does a single man need well woman visits. The only good thing to come out of this mess (btw, I did attempt to read the monolith of an act but it was mired by incomprehensible language to anyone but a freaking expert lawyer) was the pre-existing condition exemptions. Us asthmatics and epileptics thank you for that, but please leave your moral judgments at the door when it comes to smoking, and this is coming from someone who hasn’t smoked a day in her life.
Again, I’m sure everyone has heard this argument in some form (i.e. capitalism), but I do think the health care industry was trying to respond to the lack of insurance that typified some of their patients; otherwise, I wouldn’t have the examples in the second part of this post. And the AHCA doesn’t fix the gaps in protecting everyone, insured or not, from extreme illness or injury, so I’m not sure what the whole point was if it was not something seedy like helping health insurance companies get more money.
Regardless of if an employer has to offer insurance or the government offers subsidies, health insurance is still prohibitively expensive to the point that many people just have to do without even if they have a health condition, especially those who are unemployed or underemployed and those with student debt (sometimes a person can have all three attributes: unhealthy, unemployed/underemployed, with student loans). Health care reform would have been very helpful, especially if more subsidies went to hospitals and doctors offices and if they stopped letting doctors make moralistic judgments with their patients. I would rather have more government subsidized clinics staffed with a lot of RNs and a few doctors with prices less than the average water bill.