A majority of Americans are worried about health care costs -- and a majority of Congress doesn't care

People in the US are worried about a lot of things, but apparently the top one is whether, and how, they are going to be able to pay unexpected medical bills. The chart below, based on an August, 2018 survey, is provided by Drew Altman, President of the Kaiser Family Foundation, in the September 24 Axios. Indeed, concern about medically-related costs come in not only as #1, but as #2 (health insurance deductible), #4 (prescription drugs), and #6 (monthly health insurance premium), making up 4 of the top 8 concerns, all of them ahead of “rent or mortgage” (#7) and “food” (#8). All 8 of these concerns are upsetting; it is outrageous that over one-third (37%) of Americans are very or somewhat worried about being able to afford food, or 41% rent or mortgage. But a twice as many people, two-thirds, 67%, are very or somewhat worried about being able to afford unexpected medical bills, and over half (53%) about their health insurance deductibles.

 Of course, those who are worried are not evenly distributed among all Americans. They are not the suburban men who are turning more toward Trump, as they sit on the golf course by their $500,000 homes. They are certainly not the people in power in Washington, whether in the administration like Jared Kushner, who pays no income tax, or his father-in-law, President Trump, who has not released his tax returns, or the senators and even congressmen who make policy, or the members of the Supreme Court.

They certainly do include the poor, including many who are members of minority groups; those who, even in the best of circumstances are barely hanging in there – or often are not. These are the folks for whom paying for housing and food is an all-consuming concern, who do not know where their next meal may be coming from. For them, extraordinary medical bills are not even something that they can spend time worrying about, although they would certainly not be able to afford them.

Those worried, however, also include the large percentage of Americans (see the numbers) who are not poor, but are not all that far from it, people who are not that many paychecks from homelessness (a good measure of real risk). These are people who do not qualify for Medicaid (especially in the states that have not expanded it under the ACA), do not yet qualify for Medicare (and even many of those who do), and who often have health insurance either through their employers or through the ACA marketplaces. The employer health plans, overall, are cutting back on benefits, increasing employee contributions (#6), requiring higher deductibles (#2), and even instituting lifetime caps on benefits as well as excluding many times of illnesses. Fortunately for these people, the ACA has important requirements that help protect them: that people with “pre-existing” conditions be eligible for health insurance (without that, many folks with chronic disease would not be covered), and that there be “community rating”, which means insurance companies can’t charge individuals with particular conditions many times more than they charge others (without which most folks wouldn’t be able to afford the premiums).

It is also true that the current administration and Congress have been trying very hard to limit, when they cannot repeal, these very protections that provide a minimum safety net for most Americans. They are also keeping up a drumbeat about the “cost” of programs such as Medicaid (it’s just poor people, after all, except it is also your elderly parents and grandparents in nursing homes, and this is the bulk of the cost), Medicare (a bit of a “third rail” in politics, but which lots of Republicans keep bringing up as needing to have its benefits cut), and even Social Security, the program that keeps many, many American seniors from being in real poverty even as it continues them in near-poverty. The fear of losing insurance because of having a pre-existing condition is, scarily described by Kurt Eichenwald in a NY Times Op-Ed on October 16, 2018.

The fear of #1, “unexpected medical expenses” is, I assume, primarily about getting sick when you weren’t planning on it. Most folks are not hoping to get sick, but for some the exposure is particularly great because part of the way they handle #6, monthly health insurance premiums, and #2, high deductibles, is not be either uninsured or poorly insured. The latter is particularly common, both in many employer plans and even in ACA individual plans. Indeed, while they call it something different (“free choice” and “granting Americans the freedom to buy health care across state lines”[1]), the administration and Congress are actively encouraging high-deductible, low-coverage policies. This makes premiums seem affordable (or more affordable), but is a disaster when someone gets sick (back to #1).

In addition, limited networks are a quicksand trap for many people, who try to carefully go to doctors and hospitals that are in their networks, only to find themselves faced with huge bills from emergency room physicians, specialists, surgical assistants, and lab and imaging services that are not. This is truly a kind of “gotcha”, a quicksand trap. It is unbelievable; or maybe it is too believable. What may be more unbelievable, to many Americans, is that in most other developed countries health care systems are designed to serve people’s health, not trick and bait-and-switch for the purpose of corporate profit.

Medicare, as currently structured, is not a panacea; 31% of US seniors go without health care because of cost. But it is much better than nothing, and could be really good if it was better funded, and for-profit insurers were not skimming the “cream” (the least sick) into Medicare Advantage plans (which have much higher overhead/administrative costs than traditional Medicare).

Sadly, the issue of whether Americans should have adequate and affordable health care has become highly partisan. This is in some part because at least a portion of the Democratic Party has moved to positions in support of health care as a right, and a universal health insurance system (such as Medicare for all). But it is much more because the Republican Party has moved into complete opposition to any plan to expand health coverage to more Americans (e.g., Medicaid expansion, ACA) and is actively and aggressively moving to cut funding for ACA, for CHIP, for Medicaid, and even for Medicare (“we can’t afford it” is the stated reason, although it really means “we can’t afford it while giving multi-trillion-dollar tax cuts to corporations and the wealthiest”).

Sadder is the fact that many of those most affected, many of those with the greatest worries about health costs, whether unexpected illness, high deductibles, high prescription drug costs, high premiums, are reliable Republican voters. The Associated Press published a piece describing how the Democrats are focusing on health care for the midterm elections, citing the senate race in my state, Arizona. It describes how the Republican candidate, Martha McSally (currently my congressperson) tries to talk with business executives about the tax cuts but is regularly interrupted with questions about health care:

‘They are asking about Democratic ads saying McSally, currently a congresswoman, supported legislation removing the requirement that insurers cover people with pre-existing medical conditions.

"It's a lie," McSally said quickly, accustomed to having to interrupt a discussion of the tax cut to parry attacks on health care. But she had voted for a wide-ranging bill that would have, among other things, undermined protections for people with pre-existing conditions and drastically changed and shrunk Medicaid.’

Actually, then, it is she who is lying. Hopefully she, and other GOP legislators, will pay a price because people vote for those who are actually trying to solve their health care problems, regardless of party. We can hope that more and more Americans will, at least on this important issue, stop voting against their own interests.

I hope.

[1] This is actually the phrase used in the “survey” – completely non-scientific and filled with leading or directive questions – that Trump sends out to his supporters.