SCOTUS Saves Obamacare, But More Change Is Needed
What a relief, that the U.S. Supreme Court ruled favorably on the Affordable Care Act, that people living in states without exchanges can receive subsidies for insurance through federal exchanges.
Great! Because without that support, millions would miss meeting payments on their premiums. Despite its imperfectness, the ACA supports health care access for all. It’s a firm step, making it harder to take away insurance from someone who’s had, say, leukemia.
In principle and by law, any person should be covered regardless of her health history and actuarial likelihood of winding up in the hospital or needing costly treatment. Hooray! (with caveats, see below)
In the Upshot, David Leonhardt reminds us that conservative champion Ronald Reagan initially decried Medicare as a step toward socialism. Two decades later, as President, he defended the national health care program (and, I might add, had a colon cancer removed by surgery at age 74, back in 1985). Another 20 years later, George W. Bush expanded the program. By extension, one might hope and consider the possibility that 20 and 40 years from now, Republicans and Tea Party types might value and promote our national health care system.
Last week, the Arizona Daily Star ran this story: Pay upfront or no Surgery, cancer patient is told. As reported, Green Valley AZ resident Jacqueline Bouchard received a call from Banner-University Medical Center in Tucson around 8PM in a May evening before surgery that had been scheduled to remove a mass from her uterus. As described, she’s 59 years old with an aggressive form of advanced breast cancer. Despite having Medicare insurance through disability, she’s racked up thousands of dollars of out-of-pocket expenses since her 2013 diagnosis.
As told, the hospital representative insisted she pay $1000 in full, the night before surgery. The patient couldn’t provide that amount on the spot, and her surgery was cancelled. In June, after some apology and financing arrangement, her procedure was rescheduled and done. But that’s not the point: having a serious illness, being in pain is scary enough without the added experience of being intimidated by collection-like agencies (and true collection agencies), so much so that you don’t get, or delay, getting needed care. Before this year, Bouchard had cancer surgery, radiation and chemotherapy without receiving pre-treatment pay-or-no-care calls.
Banner Health, which now includes the Tucson hospital where Bouchard has received care, recently merged with the University of Arizona Health Network. Banner is nominally a not-for-profit hospital system with an academic affiliation, a combination sounds great and may indeed be so for patients whose insurance is accepted, for whom hefty co-pays and big deductibles are not obstacles, or who belong to the uber-rich category of people for whom having health insurance doesn’t really matter. You can find the corporation’s 990 IRS form for 2013 here, see some info on GuideStar, or view somewhat different graphs of Banner’s $billions in assets, annual income and expenses compiled by the Economic Research Institute.
By all accounts, Banner health is doing well. Its executives are well-compensated.
But Banner is not alone in its patient-as-source-of-revenue outlook. Nor is Ms. Bouchard alone in her predicament. This problem isn’t just about the quantity of accessible health care, but about the quality: Around the country, privately-insured patients are getting closed out from narrow provider networks. Having the wrong brand, or inadequate level of coverage, effectively denies access to some top cancer centers and orthopedics hospitals with which I’m personally familiar.
So much – too much – depends on an individual’s insurance, and capacity to pay for particular doctors and treatments. For people with low income, Medicaid, the government plan that needs (and should) expand now with Obamacare, has in the past been woefully inadequate in providing reliable quality or timely health care.
Not that long ago, when I took care of Medicaid patients with mysterious conditions causing low platelets, or with sickle cell anemia, or rare lymphomas, the hospital where I worked would receive approximately $50 for each visit – which typically took an hour of my time, involving physical examination, reviewing labs, talking to the patient (sometimes with an interpreter), writing prescriptions and answering questions. That time didn’t include any reading I might do about the patient’s case, or follow-up phone calls to other physicians, social workers or the patient’s family. The paltry Medicaid payments were unlikely to cover the overhead costs – rooms, computers, staff including nurses, etc.
That’s no way for a doctor to make a living, or to make herself “valuable” to her employer. No wonder, USA Today reports physicians are declining to see new Medicaid patients in Nevada with lower payments on the horizon, and NPR says that in California patients are, already, waiting too long for care. So one thing that definitely needs improvement, unless we want something like steerage class in our metaphorical health care ship, is how much physicians get paid for evaluating patients with Medicaid.
Now, some readers may be puzzled how I, who generally favor lots of health resource “use” – including preventive care and counseling, occasional examinations of healthy people by physicians, high-quality cancer screening, and best treatments for each patient, individualized, no less – can advocate for universal access to care for all Americans. Or all people, as I do. But I’m confident that top medical care can be rendered affordable, for everyone.
Fixing this – the problem of people with illness who need care that is costly – will take more than Obamacare, although the ACA is a huge step. It will take a hard, critical review of how, and by whom or what, U.S. health care is distributed and administered.
In my view, doctors and nurses and (a few) administrators should be compensated well for their hard work. With rare exception, the problem with health care costs cannot be attributed to doctors earning too much. Many U.S. physicians don’t earn enough income, given the nature of their responsibility, education and constant work. This leads too few of the bright young people I know to go to medicine, among other failings of our system. And I can’t see why a company, like an old pharmaceutical or new biotech firm, shouldn’t profit by developing a new drug. Medicines do save lives, after all.
But we can reduce waste in the system. From a doctor’s perspective, this would involve greater respect for – and knowledge of – Choosing Wisely program. This initiative, put forth by the ABIM and Consumer Reports, includes many sound recommendations. More generally, providers need to think more and order fewer tests than many do, too often by rote, such as upon a patient’s entry into a hospital.
Another slash should take aim at health care administration. This would include cuts in hospital executives’ salaries, which run unfathomably high compared to those of highly-trained physicians. And although not all readers may agree with me on this point, I think it’s crucial: we need to shift toward single-payer. The business of private insurance, which is just that, is too costly. The fact is that in much of Europe, where national health programs dominate, all citizens have access to state-of-the-art medical care, and those countries spend less per person and achieve better outcomes than do we.
Still what’s needed, perhaps most of all, is greater (moral) stewardship of health care resources. Providers, including doctors, and policy-makers need confront the R-word, which is rationing, and has nothing to with the ACA. It’s morally crazy to provide a 95 year old person with advanced cancer, kidney failure and stroke a $100,000 medicine and ICU care while depriving the same to, say, a 40 year old man with a heart attack who might and probably would, after the acute event, go on to live for another forty years.
No one likes to talk about rationing, but that doesn’t mean that we – or health care policy leaders – should continue avoiding the topic. It’s got to be discussed, and not just in medical ethics classrooms or as theory, but officially, and transparently. Rationing is crucial to the judicious use of resources, including new drugs and ICU care and doctors’ limited time. Besides, it’s happening regardless, but based on wealth, as if a CEO’s life is worth more than a schoolteacher’s. Which is a totally un-American concept, among other problems with how we provide care now.