Wednesday, February 13, 2019

Medicare for All, or "Eat well, take your medications, and good luck!"

I have often written about the need for a universal national health insurance plan in the US, even more frequently recently. This is in part because the rise in costs and cuts in health coverage for Americans, including especially those who are in states that did not expand Medicaid as part of the ACA, have continued to erode our health coverage and increase our cost. It is also in hope that the Democrats in Congress will not abandon a real “Medicare for All” program in favor of a non-solution such as “Medicare for More” or almost anything that maintains for-profit insurance companies.

A Nurse Practitioner friend writes:
Many patients I see are very complex and, I think, not NP (Nurse Practitioner) appropriate but no one else is there for them because they are uninsured. And they tell stories of meeting with cardiologists who talk about several interventions and then when the MD finds out no insurance just says to them, “Well, be sure to eat well and take your medications and good luck”. 
And every day I see the effects of having so many people without insurance. I see the ones who ended up in the ED because of preventable problems. Yesterday I saw a 33 year old mother of two who had hypothyroidism, no insurance, ended up with severe cardiomyopathy [heart muscle disease] and heart failure all for lack of thyroid medication due to lack of care due to lack of insurance -- and she works in an MD office doing billing to keep our health care system going for those with insurance!!!

This situation is neither rare nor new. It happens to that particular NP every day. NPs in many states work under “collaborative agreements” with sponsoring physicians, and in others have independent practice privileges. When the patients are too complex for them, “their” doctors may be unwilling to take them, if they are uninsured. In addition, in many cases, the NPs (or PAs) practice in remote sites – sometimes very remote. But, the reality is that even if the physician is willing to see them, even if the patient is seen initially by a physician and not an NP, ultimately there is a similar outcome for those people without insurance or with poor-quality insurance. This scenario happens all providers, physicians included, except those who refuse to care for poor, uninsured, and poorly insured people.

It is essential that everyone who cares for, or about, people realize this, including the politicians who make the decisions and the pundits who opine about such things. They may be well insured, and likely most of the people that they know personally are (although every day that number grows smaller and the financial and health exposure of those who thought they were well insured grows larger), but many, many people are not. Whatever sticker shock insured middle class people have when they get sick or need medication (see the graph on the cost of Humalog ®, the most common insulin for people who need that drug to stay alive, vs inflation), it is much worse every step you go down the ladder of income into poverty, down the levels from “good” to “fair” to “poor” to “no” insurance.

It is also critical to remember that any reform plan that does not cover 100% of everyone will leave people like the woman described above out, and the stories that physicians and other health providers have to tell about how their patients cannot get the care they need will keep coming. For a plan to not only be “good”, but to be affordable, every single person in the US needs to be IN. It is most affordable if it goes all the way, putting everyone in one plan (Improved and Expanded Medicare for All), because that would eliminate the massive profits of the insurance companies that have administrative overheads of over 30% (compared to Medicare’s 1-3%) and would tightly regulate the profits (and whatever your favorite expression is for money made over costs for “non-profits”) of providers. Other plans that are seen as compromises are, like so many “compromises”, lose-lose. By dealing in the insurance companies and their profits so they won’t oppose the change (as ACA did) we build in this cost to our system, siphoning off at least 1/3 of the dollars ostensibly spent on health care to overhead!

One of the most widely supported bad ideas is continuing Medicare Advantage, also known as Medicare Part C. Basically, the insurance company that sponsors such a plan takes the money you’d get for regular Medicare (Parts A and B) and you kick in an additional payment, and you are covered, as in an HMO, for a variety of other services that traditional Medicare does not. It sounds like a good deal, and it generally is for the recipient with all the plusses (extra services at usually lower cost) and minuses (limited choice of providers, limit to geographic coverage area) of an HMO. At first, it seems to be a win-win, for patients and the insurance companies represented by America’s Health Insurance Plans (AHIP). AHIP has garnered letters of support just recently from 302 House members and 66 Senators, of both parties. The problem is that the insurers get extra money that traditional Medicare doesn’t, costing the public a lot (and sometimes involving fraud). Continuing Medicare Advantage not only gives some people better coverage, and makes a single Medicare for All again financially challenged, it costs the government more and makes insurers richer.

A real Medicare for All – not a bunch of different plans, some of which cost more money and spend a lot of that on insurance company profit -- is not an unrealistic pipe dream. What is actually unrealistic is keeping the current system (or, better, non-system) we have, or some minor modification of it, and expecting that it will lead to better health for more people and lower cost. That won’t happen, and the idea meets Einstein’s definition of insanity: doing the same thing over and over and expecting different results. High costs – proportionately higher for low-income people – and poor health outcomes – also higher for low-income people – are baked into that system.

Or, we can not do a comprehensive include-everyone program. We can stay with what we have, or some “part way compromise”. Read the story above again. Memorize it. Because, if we don’t have a universal health plan like every other developed country, it will continue to repeat thousands and thousands of times a day, in every city, state, and rural area in the USA.

If not, be sure to eat well and take your medications and good luck!

Monday, February 4, 2019

Venezuela and Medicare for All: Don't forget who benefits!

The mainstream media is not an evil, liberal-to-radical behemoth by any means. It is, however, often a willing, and sometimes self-deluded, ally and shill for the interests of the well-to-do in society, as well as for many questionable government policies. The latter is particularly important in the drumbeat buildups to wars, and is recently apparent in the coverage of Venezuela in journals such as the NY Times. The US government is making the case not only that Venezuelan president Nicholas Maduro is illegitimate because it has decided his election was “unfair” and “tainted”, as well as an evil and violent dictator, but that it will recognize unelected self-declared Juan Guaido as president. The Times has gone so far as to publish a self-congratulatory op-ed by Guaido, and it news coverage is typified by ‘Venezuelans Opposed to Maduro Pour Into Streets for Day of Protests’ and a Sunday Review piece by a Guaido supporter called ‘Venezuela’s Very Normal Revolution’.

I do not doubt that thousands marched against Maduro or that millions oppose him (or probably that millions support him). I certainly am not saying Maduro and his government is good, or that there is not justifiable opposition to his violent repression of opponents. I am not saying that revolutions are bad. I am saying that this one is funded and supported by the US government not because Maduro is bad -- the US has supported and continues to support dozens of brutal dictators around the world. It is because he is not our dictator, not one who supports US policy, and this is critical because Venezuela is the country with the largest oil reserves in the world. As for the NY Times -- as with most leftist governments, the support for the one in Venezuela comes more from the poorest people, while those with access to the NY Times are among the most privileged.
And this is the connection to domestic health policy, and in particular coverage of the Democratic candidates for president’s positions on Medicare for All. The NY Times (and all mainstream media) is of course owned by the very wealthy, and as individuals they see the world as members of the class of which they are part. But, possibly more important, the editors and reporters are middle and often upper-middle class, and they see the world from this perspective, from that of their families, and friends, and neighbors who are – amazingly – also privileged! The people who have access to these editors and reporters are very skewed away from the most needy, or indeed most people (who are not the same as most people in an upper middle class suburb).
In specific, we get essentially uncritical coverage of the statements of billionaires like Michael Bloomberg and Howard Schultz that “Medicare for All” is unaffordable, despite the clear fact that it is the current system that is unaffordable, and that a universal health system is going to cost less. One key part of this lower cost is the elimination of private health insurance companies’ profit, and their incentive to increase it by decreasing the availability of care. Yet the Times article covering Elizabeth Warren’s increasing iffiness on the issue contains phrases like ‘would people lose the choices offered by private insurance?’ That is, your ability to choose (maybe, depending upon what their employer offers) which overpriced-to-unaffordable policy, offered by which rapacious, obscenely-profit-making insurance company, to cover you so that, even after paying the premiums and co-pays and deductibles, you find out that, whoops, it doesn’t really cover what you thought it would or should, and you’re out of luck, and either have to pay out even more money you cannot afford or go without the health care you need. Wasn’t that what the insurance you bought supposed to get you?
Nope, not necessarily, and often not at all. The first goal of private insurance companies is to make a profit. That profit has to be maintained and expanded. The two major ways of doing so are 1) by raising the prices people (and their employers, if they are lucky enough to have employers who pay offer health insurance) pay, in premiums, deductibles, and co-pays, and 2) by denying coverage for care, or paying less for it, which often results in providers not, well, providing it to you. The insurers hire “pharmacy benefit managers” to get them the ‘best’ prices on drugs, often requiring your doctor to keep writing a different brand-name drug-of-the-month (again, see Danielle Ofri, “The Insulin Wars”), with the cost to you always going up.
What would Medicare for All offer? Or, more explicitly, Improved and Expanded Medicare for All, as in the House Bill that was H676 and will get a new number this year? First, everyone would be in the same program. No more shopping around for the least bad deal among the universe of bad insurance. Everyone would get the same benefits. The benefits would include all medically necessary health care: inpatient, outpatient, nursing home, home care, drugs, mental health, dental, eye care. Even hearing aids. Nothing excluded, except perhaps truly cosmetic surgery. Providers could not refuse to accept this insurance because they would have no business. Oh, maybe some doctors and hospitals could make a living caring for Howard Schultz and Michael Bloomberg and Saudi sheikhs who pay in cash, but there aren't very many of them, and so even the supplemental insurance we now buy would be unnecessary. There would be, you see, no deductibles or co-pays. Everything would be 100% covered. It sounds good. It would be good.
And it is not unaffordable. Currently, the government funds over half of health care (Medicare, Medicaid, government employees and retirees at all levels, military), and it is about 60% if you also count the revenue lost because employer contributions to health care premiums (unlike salary) are tax-deductible. The majority of the sickest and most needy (elderly, blind, and disabled) are already in Medicare. Most vulnerable children are in Medicaid or S-CHIP. To make up the additional cost, employers and individuals would continue to pay, but in taxes rather than premiums, co-pays, and deductibles, and for most (maybe not for Schultz and Bloomberg!) it would cost them a lot less. Most estimates of the excess costs in the US health care non-system are in the 30-35% range, for profits and administrative costs in the private sector (Medicare’s are in the 1-3% range). Administrative costs include insurance companies hiring armies of workers to deny claims, while providers have other armies to fight them, and demand more. This is money spent for no health benefit for the population, but it would be a mistake to minimize the extent to which those – insurers and providers and drug and device manufacturers – who are pocketing it would go to keep it coming.
Thus the role of the mainstream media, and the mainstream Democrats – to appeal to the needs (not desires, real needs!) of most of the people for health care and at the same time not threaten the wealthy and profitable sectors that can fund campaigns for or against them. Thus the concerns of “don’t people want to have their private insurance?” and even more ludicrous their choice of insurance company (“I’ve always been an Aetna man! So what if it costs a little more and I get just as little? I’m worth it!”). Thus the nonsensical pieces on how much a single payer Medicare for All program will cost, which ignore the cost of our current arrangement. And, somehow, manage to not address the fact that this current arrangement leaves concern for people’s health to last, and so doesn’t deliver it.
I understand that people are worried about change. But the cost, in dollars and health, of the current system has moved the majority of the population to want something different, something that meets their needs and costs less.  It is available, if we seek to do it, if we can resist the pressures from the industries and billionaires who profit from the current way of doing things.
When we read about the need to overthrow foreign dictators, or hang on to private insurance companies, we always must remember to ask: cui bono?

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