February 08, 2008
An American Health Care Story
A friend wrote this week with this unhappy news:
On Sunday night, my former foster child Josh was beaten up with a baseball bat (after being held up at gunpoint and telling the marauders he had no money) on his way home from a SuperBowl party, and refused admission to the first hospital his sister tried to take him to. He was finally taken to John C.
Lincoln Hospital, which has a Level 1 Trauma Center.
The injury was severe, although he will live. Every bone in his face was broken, his nose was smashed, his teeth were shattered, and his eye sockets all but destroyed. He will need a least three re-constructive surgeries. Never mind the psychological consequences on a kid that already has lost both his parents and, as he aged out of the system, his foster parents.
And, of course, he is uninsured. He is 20, and thought he was immortal. He was also working on and off, sometimes at jobs that provided insurance, sometimes not. So he never registered for ACCCHS, Arizona's version of Medicaid.
So he was thrown out of the hospital on Thursday, because the reconstructive surgeon can't get to his case until Monday, and the hospital won't keep him. He's enrolled in ACCCHS now, because of course the hospital enrolled him immediately so they could get reimbursed for his care. But ACCCHS won't allow him to stay in. So he goes "home" to sleep on the floor of the apartment his pregnant sister shares with another single mom with two kids.
Then comes Super Tuesday, with all the candidates ranting about the need for universal healthcare. But none of them saying it should be paid for by anyone but the insured or the employer. This is an interesting conundrum to me. Let's just say health care was the most important issue for me, which it is. Who should I vote for? Barack, who says there shouldn't be a mandate to buy it? Hillary, who says it should be mandated but doesn't tell us how a kid like Josh will pay for it? The Republicans, who want a "free market" solution?
Folks, as far as I can see, nothing would cover Josh, who works part time and intermittently while trying to go to school, or his sister Amanda, who keeps on losing jobs because of her skills deficiencies, or his brother Jerry, who is working for a company that does not offer health insurance and can't get on ACCCHS because he's a former felon. Or the 47 million who "reject" health insurance that is offered to them because they can't buy it and also buy gas.
Health insurance is not like automobile insurance. You can mandate automobile insurance, and if people can't afford it, they can take the bus. You can't just "mandate' health insurance. Either health care is a right that society provides, or it is not. It's interesting how the system now works. As the system stands, drug addicts, diabetics who don't comply with their regimens, and smokers who give themselves COPD can get care, as long as they either can afford to pay for insurance (pay for their sins by buying insurance and shifting the cost of their care to the rest of us) or are dirt poor. In fact, the poorer they are, the better the care. And the worse people take care of themselves, the better the care they get. You can get a heart transplant more easily than you can get a colonoscopy.
It's the working poor, the people trying to lift themselves out of poverty, who don't get care. And trust me, one day that will include someone from your family.
As I understand Hilary's plan the cost would be a percentage of his income. It may even be free depending on what he makes. So yes he would be covered.
Posted by: Pat Whalen at February 9, 2008 02:23 PMA very moving argument you make here - cuts to the core of issue right away. I just circulated it among my list.
keep on,
Posted by: Myles Duffy at February 9, 2008 03:32 PMOnce health care costs overtook my combined mortgage and property taxes as my single highest monthly payment (by far), I realized how out of control this situation had become. Any new health care initiative has to cover everyone, especially low income Americans, without a self funded mandate.
Mandating that the poor pay for health insurance is like mandating that the homeless buy houses. It simply will not work. It's not a matter of convincing people that they need these basic life needs, but making it affordable for them.
Thanks for the insight, Merrill. Keep up the great writing!
Mark
Posted by: Mark Kirsch at February 10, 2008 01:43 AMgranted all should get the care they need and we don't now provide that. let's stipulate also that the system doesn't deal well with the poor and powerless-- not surprisingly. but this seems to say that this patient didn't require hospitalization, but rather needed a decent caring environment for a period of several days until a reconstructive surgeon could get to him. this could have easily have happened to someone with insurance. is assumption that (a) hospital stay during the wait was appropriate and (b) that normal insurance would have readily paid for it. not sure the there's an obvious positive answer to either.
Posted by: jim jaffe at February 10, 2008 03:51 PMMerrill--
This is a terrible, terrible story.
And let's note that ERs are not required to --and do not--take any poor person who comes in, even if they are seriously injured. The rule now is that the ER doesn't have to take you if you
are capable of walking out the door.
The national health reforms the Democrats are proposing would have made the difference for Josh. Under Hillary's plan, he would have been covered.(And I'm quite sure he would be covered under Obama's plan too.)
If he didn't choose a private sector plan, he
would be automatically enrolled in the public sector plan (though he could switch to private later. If it hadn't already happened, it would have happened the night he went to the hospital-- at the first hospital.)
Under Hillary's proposal both the public sector plan and the plans private insurers offer would have to offer benefits at least equal to what Medicare offers. So it's not likley that hte hospital would have kicked him out while waiting for the surgery.
Would Josh be able to afford the insurance? Using the Mass plan as a rough model of who would get subsidies, a single person like Josh would get a subsidy if he earned less than $31,000.
And in his case, it sounds like he probably earns little enough that he would qualify for a 100% subsidy.
At the very worst, under Hillary's plan, no one could not be charged more than 5% of their adjusted gross income.
As Paul Starr has pointed out, the assertion that Hillary's plan would force low-income people to buy insurance that they cannot afford with money they do not have is a canard. The government cannot mandate that individuals do something without providing subidies that make it possible.
The Feds can mandate that the States do something without giving them the funds to do it--that's what we mean when we talk about an unfunded mandate. (The logic is that the states can always raise taxes, float bonds whatever to raise the funds. EVeryone understands that individuals cannot do that.)
That's why in Mass., (where the economics were not well thought-out from the beginning, where the mandate has no teeth, amd where there is no public sector alternative) the state has exempted 20 percent of the population from the so-called "mandate" --recognizing that they just don't have the money to afford the insurance that is out there.
And Mass doesn't have the money to raise subsidies in part because many affluent people have figured out that they would rather pay a modest fine than be forced to buy insurance.
Some are young healthy "immortals"; others are very
wealthy people who can self-insure using an HSA and a high-deductible catastrophic policy.
It is rather fancy that we want the best medical care and we want it cheap. In fact, in my own experiences working as a public health worker in countries with mandated public medical insurances: Canada, Japan, and Taiwan, the truth is still that you got what you pay for. It is also true that more medical care does not mean better health. Medicalization of our society has been creating more sickness to be managed if anyone ever be cured.