Monday, August 10, 2009

Health care unfocused ramblings

Late posting today; sorry about that. Mondays are just so...unpredictable.

But I wanted to talk a little bit more about health care reform. Forgive me if this is disjointed and disorganized; I just need to think out loud about a few things.

If we could turn back the clock to a time before health insurance, and could re-do that whole process, I think things would be better than they are; but that's not possible. For better or worse we have a disjointed and complex system that grew out of private risk-sharing agreements, government regulations, and eventually the creation of Medicare and Medicaid. We have to work with what is, unfortunately.

But that doesn't mean that the system we have now is perfect. We need to do better in many ways, and as a Catholic I'm particularly concerned about those who don't have access to employer-provided health insurance. Granted, this insurance isn't "free," as some mistakenly think it is (at least not for most of us--some union employees may not make employee contributions), but if you don't have adequate employment, chances are you also don't have adequate health insurance. And while Medicaid and Medicare may do a reasonably good job of covering many, there are many others for whom any serious health problem would mean choosing between care (and poverty) or illness (and lesser poverty, but still poverty).

Unfortunately, the plans being discussed now seem to be more about moving people away from private insurance and onto government insurance than they are about insuring the uninsured, or increasing the benefits for those who lack adequate health insurance. It's easy to see why so many think this has more to do with creating greater power for those in Washington than creating greater health care options for those whose economic situations restrict what sort of medical options they have when ill or in need of treatment or surgery. The likelihood is that more of us will end up in the second group, being told that we can't have treatment A or surgical procedure B unless we can pay for it out of our own pockets, as the government plan doesn't cover it, or some bureaucrat we'll never meet has decided we don't really need it, regardless of what our doctor thinks.

Further, we have to be realistic about what the plan will cost each of us. If those of us who have employer-provided private insurance find that our employers have decided to dump us on the public plan, for instance, it's unlikely that our salaries will rise--and yet the reason salaries are what they are is because "benefits" are also being offered. The company will pocket the difference, but we're the ones whose taxes will rise and rise to offset the increasingly gargantuan costs of insuring every American on a public plan (in a weak economy with an already huge deficit). On the other hand, small business owners who have private coverage may see a temporary advantage from getting the public plan instead, but their increased taxes might be the difference between staying in business or folding. Those who have no insurance at all will technically benefit from being on a public plan, but young, single people in generally good health (a lot of whom are uninsured) may see so much taken from their wages in the form of taxes to pay for health care that the plan will seem like an unfair trade.

Are there better options? Are there ways of fixing health care that would focus on helping the truly needy to obtain insurance and access to treatment instead of growing the size and power of the federal government? I think there are. One thing I think is worth exploring is the question of how much health care should cost, and how much it does cost in places that offer cash-only medical services. When I broke my toe and had it x-rayed, I payed $157 for the doctor visit and three x-rays at a cash-only medical office. I didn't absolutely have to see a doctor or get x-rays, but I'd never broken a bone before and wanted to be sure what to do about it; doctors can't do much for broken toes, so if I hadn't had the money I wouldn't really have missed out on any necessary care. But since I did go, I was pleased at the cost--$157 seems reasonable to me for three x-rays and a consultation with a doctor.

I know that for a person living near poverty that same amount would be out of reach. But what if communities supported such cash-only centers? What if a local government could offer tax breaks and other incentives in exchange for the doctor's agreement to see and treat a certain number of poor patients at discounted rates, or gratis? What if a doctor could spend a few years working "pro bono" like some lawyers do, in exchange for medical school tuition and some office and living expenses? What if we used tax dollars to finance the educations of a certain number of doctors in exchange for their agreement to spend some hours every week for a time working with the poor? What if we traded a few years' worth of malpractice insurance payments (a heavy burden for doctors) for their services in rural areas or as family practitioners in areas where doctors are sorely needed?

What if, in these cash-based practices, doctors could 'compete' directly with the insurance companies in a manner of speaking? If it got to the point where people could actually afford to go without regular health insurance and only needed to buy catastrophic coverage, I think the insurance companies might notice.

And reasonably priced cash-based medical clinics or practices would also help another group not helped by the government plan: illegal immigrants. We may believe, as I do, that a better job of controlling immigration needs to be done, but in the meantime it's not the attitude of Christians to deny those already here adequate medical care when they are in need.

One more thing cash-based clinics would do would be to shed the light on the actual costs involved in medical care. So many people seem to think that it shouldn't even cost 20 or 30 dollars to see a doctor, for instance; but most of us are aware that it costs ten times that much to spend any quality time with a lawyer. A lawyer and a doctor have similar education costs (though if the doctor is a specialist chances are his education was even more expensive). So why do we get mad if we have to pay a co-pay that costs less than ordering a couple of pizzas?

I found this article about cash-only doctors interesting; it started this whole chain of thought. I couldn't help but wonder, as I read it, what will become of such practices under the Obama plan; will they even be allowed to remain in operation? Or will it be necessary to distance people even further from any realistic notion of what medical care really costs?


Kim said...

Great post; I really like your ideas and totally agree with you. Here
is another great model that is gaining some traction in Madison, Wisconsin and also in California.

Love your blog!

Anonymous said...

My husband has a subchapter S company and 12 employees. currently he offers private insurance with employee contributions. Healthcare runs about 30% of his operating cost. It would be cheaper for him to dump everyone and pay the 8% penalty to the gov't. Actually, it would be cheaper for him to dump all his employees and hire them as "independent consultants" because of the payroll taxes (businesses pay both sides of the payroll tax), but thankfully, we're not there yet.

Anonymous said...

From scotch meg

Doctors and lawyers do NOT have similar costs of education. A doctor's education is four years, while a lawyer's is three. Medical school tuition is about double law school tuition, because of the expense of laboratory equipment (you don't need corpses or chemicals to run a law school). In addition, while a lawyer can practice law independently within months of graduation, a doctor MUST complete an internship year and a residency (a minimum of three years altogether, and often more) in order to obtain a license and hang up a shingle. During that time, unlike the lawyer who is paid as a professional right from the start, the doctor "in training" is paid a wage that won't even cover his/her student loan payments. Even the hours worked at a giant, big-city law firm do not compare with the new doctor's hours, to the extent that some states try to regulate those hours, limiting them to 80/week.

As the wife of a doctor (and I have a law degree, although I haven't used it for a long time), I'd like to see the facts straight... yeah, and I guess you hit a nerve, as we are still making loan payments seventeen years after med school graduation, thanks to loans deferred (and growing) during internship, residency, and fellowship.

Red Cardigan said...

Scotch meg, thanks for the clarification. I suspected as much but couldn't find hard data--and I try not to irritate lawyers when possible. So I appreciate getting this info from someone in a position to know. :)