21 February 2012

Why the ACA Matters, Part 18 - Beyond the Mandate

Science Blogger Kevin Zelnio writes about his six year-old son's bout with pneumonia:

My family includes four of the 49.1 million uninsured people in the United States. I’ve comforted myself that we couldn’t afford private insurance, which we can’t, but at least we were all relatively healthy and never seemed to have problems. [...] 
But recently my mindset has become affected by our position. I tell my kids not to do things that I certainly enjoyed doing as a kid, like don’t climb high on trees, run a little slower on the trail, watch out for roots and stones! It’s not just the usual parental concern either. I’m consciously thinking “oh my god, I cannot afford to fix them if they get broke!”. 
This is the luxury gap between the between the 20% of nonelderly americans who are uninsured and the rest. The luxury is, of course, being able to just walk into a doctor’s office and see them at the appropriate times. It is easy to discount this minority since most are at or near the poverty line. But many of the uninsured are like myself and just can’t seem to make the numbers work for a family of four each month by adding on private individual (i.e. non-group discounted) health insurance.  [...] 
By Tuesday we weren’t left with any choice. My son had just gotten out of a bath and though he wasn’t cold, his hand and his feet were blue. I’d never seen it like that before. My wife laid it down and we were going to the Urgent Care. We all got dressed and heading over there early. He was miserable, crying in pain cause he couldn’t get enough oxygen. We were scared that we might have waited too long. [...] 
Most of the uninsured in this country aren’t lazy, freeloading hobos who don’t wanna work. They span a wide variety of demographics. As a 30 something, white male with advanced college degree who works full time as a self-employed consultant and writer are you surprised that I cannot afford health insurance for my family? In fact, the majority of uninsured are in my age range and are full or part time workers earning incomes above 100% the federal poverty level.
The good news is that his son got better. The bad news is that his care was a couple of orders of magnitude more expensive than it might have been if they'd had better access to care, and that his son's life was put into jeopardy by their necessary reluctance to seek out care. Adding insult to injury is that this family will probably have any financial reserve they possess wiped out by what should have been a minor illness.

And these aren't dirty cigarette-smoking, cell-phone buying scumbag poor people who deserve their fate (the caricature of the uninsured found most typically on libertarian blogs). This guy holds an advanced science degree and this family is firmly in the middle class. They're just unlucky enough to have to buy non-group plan insurance in the pre-ACA marketplace.

And this shouldn't be surprising, but it is: 12% of families making more than $90,000 a year (that's 4x the federal poverty level for family of four) went uninsured for at least some of the time in a given year, and that number is much higher the closer to the FPL you get, with 15-40% of those affected remaining uninsured for an entire year or longer. And when they are uninsured, they skip screenings and preventative care and also skip necessary care when they get ill. All of which adds up to increased cost, sickness, and death.

The ACA — if it goes into effect — will mitigate this. The health insurance exchanges will regulate individual health insurance plans, guarantee that no person or family will be rejected due to prior history, and make it easier for families to shop for and purchase insurance. The subsidies will make insurance more affordable on a sliding-scale basis. Bringing everybody (or nearly so) into the system will make insurance cheaper for all of us.

The ACA isn't perfect. At best it's a start. There may not be death panels, but there's plenty there not to like. You've got the mandate (for the record, I'd be fine with ditching the mandate if there were another effective method to encourage healthy people to buy in — lock-out periods or late-entry penalties or what have you). There's no public option to force insurers to compete honestly. ACOs may not do anything to bring down costs. But for Kevin Zelnio and his family and the many other families in similar situations, who desperately want insurance but cannot afford it, ObamaCare provides them with a ticket to enter into the system. It's a pity that it's gotten so polarized that we can't move on and get to work on fixing deficiencies, improving what we've got, rather than refighting the scorched earth campaigns of 2009.


  1. I simply do not understand your support for the ACA.

    Consider your blog essay, "Washington Medicaid vs Prudent Layperson" not too long ago (January-ish) in which the 'HCA' a local government body overseeing health care, was acting foolishly.

    Fundamental to the issue you described there was the limited recourse trying to confront a do-gooder government entity acting stupidly. There just aren't many avenues for redress. And government oversight bodies routinely act "sub-optimally."

    There's fewer avenues for recourse if/where the Feds take charge & act on something--and they're notoriously worse than lower-level governments.

    Sure, the CONCEPT behind the ACA sure sounds good, but when has the Federal (or any) government managed anything of a complicated nature well for any sustained length of time???

    Expecting ACA to deliver on its promises AND not have untold adverse unintended consequences is to be in thrall to a CONCEPT at the price of willfull ignorance of history, namely the government's uninterrupted history of managing complex programs badly.

    Just remember when things don't work out & other problems manifest (if its not deemed unconstitutional) -- you asked for it & supported it....so don't insult us by complaining it isn't working as you thought, or as it should, or whatever....

  2. Ken,

    You seem to be ignorant of the difference between emergency medicine and the rest of medicine. Emergency medicine is the only specialty that by law (given participation in Medicare/Medicaid) must provide some level of service to everybody that walks in the door.

    If an orthopedist doesn't like what Medicaid pays for an arthroscopy, he doesn't have to do it. Practitioners of emergency medicine have to provide a minimum level of care, even if the payment for that care is zero.

  3. I hope you're right about how much the ACA will benefit the currently un and underinsured. But in the meantime, Republican radicals, with the possible help of the SCOTUS, are busy undermining and dismantling "Obamacare." If the individual mandate goes, the whole house of cards will collapse, which will put us back at square one (i.e., a primitive and grossly unjust system of care). I'm not optimistic. Republicans hate spending, unless said spending is couched in macho terms of global hegemony (eg. state-building in Afghanistan and "liberating" Iraq).

  4. As a Canadian, in a system flirting with privatization of care so very interested in this, it is really difficult to figure out the situation of the middle class but un-insured.

    Is the issue that these people truly cannot afford insurance, or is it that they have made a financial risk calculation and choose not to buy insurance, and are left in a terrible predicament when that gamble is lost to the house?

    Here in Canada somewhere between 35 and 40% of total government spending is related to healthcare. On a family income of $90,000 the marginal tax rate in British Columbia is about 38.5% (There is also a 12% VAT, and provincial healthcare premiums but lets ignore that for simplicity) so total income taxes are about $22,500 on that $90,000. 40% of that total tax is $9000 per year.

    So for a pretty middle class family here in Canada, making $90,000 per year we are looking at something like $9000 a year (or 10% of pre-tax income) contributed to healthcare. Now if that were optional certainly a group of youngish and generally healthy people would opt to take the gamble of not paying, a gamble which some would win and some would loose. I imagine that most people would feel that 10% of pre-tax income for healthcare was unaffordable if they were generally healthy and using very limited medical resources.

    So are these middle class but uninsured people in the US having an affordability problem, or are they having a risk taking problem? From the outside it is really difficult to figure out which it is, and clearly they are 2 different problems with 2 different solutions..

    Dr. J

  5. We pay around 900.00 a month for our health insurance for a family of 4. We also pay 5000.00 deductible. Our insurance limits what medications we can receive and the dosage. Many things we have had to pay out of pocket, and this an employer sponsored health plan through a major health insurer.

    This weekend we sat down and sifted through our receipts. We spent over 20,000. on medical last year. We make 80,000 a year.

    If Obama care isn't overthrown, it is likely our insurance will be canceled through employer-it is far cheaper for them to drop their insurance.

    Then we will be forced to buy privately- it will be years and years before private insurance will provide the same at the same cost as our employer sponsored insurance.

    Can we afford 30,000 a year? Or even 40? a full half of our income for our chronic health needs?

  6. Hi Dr. J,

    As a British Columbian who lived in California for a few years, all I can say is $9,000 is *cheap*. We paid $1,000 per month for health insurance for my daughter and I when we lived in CA. My husband was fully paid for by his company.

    I think our insurance was cheap in comparison to others. In some families they were paying $2,000 per month.

    What really got us though was that when we actually compared our take-home pay between BC and CA (the salaries here and there were essentially the same), there wasn't much difference between the two --- except that we were paying the $1,000 per month for our health insurance on top of our CA taxes. I can see why some families forgo insurance and hope for the best.


  7. The problem with this post is that the assumption that once someone is insured, the insurance will cover whatever they say it is going to. This is so outside my own experience of having insurance, where they decide not to cover procedures months after the initial okay and then throw it in the deductible or some other teeny clause or try to wriggle around the Mental Health Parity Act, I almost can't fathom going to the doctor and not having to pay and pay and pay.

  8. My family too is firmly in the middle class, and until a couple years ago we paid for our own insurance through Regence. We had medical expenses that far exceed what this family had, including a NICU baby whose diagnosis and brief care involved doctors in three countries. We reached our our of pocket maximum more than once.

    We would never consider delaying needed care. What we did then, and do now with a group plan, is to use our health care dollars wisely.

    We go to our doctors offices or to a walk in clinic rather than going to an ER.

    We talk with out doctors about the costs of medications and usually find workable alternatives to the expensive stuff. My two blood pressure medications cost us $8 a month and work fine.

    I'm a big fan of personal responsibility. If this father, who is better educated and likely smarter than me, and probably makes more money than me as well. delayed care for his child, it is his fault, not the system's fault.

    There are good arguments on both sides of this issue, and more in favor of the ACA than against it I think, but this blogger's anecdote isn't one of them.

  9. The ACA would sure take care of this irresponsible, poor choice making excuse for a father. The government will collect his premium, no matter if he can afford it or not. The Daddy State will protect Zelnio's kids from his self-centered risk taking - and Zelnio will pay what the State says is fair, not what he feels he can afford.

    Children often suffer for the sins (omissions)of the father and this sad case is no different.

    McDonald's Managers make $20 - 90K per year with benefits. Once you are a parent, YOUR desires (job, education, hobby) are subordinate to the needs of your family. It would SUCK to be a Marine Biologist at McD's but it sucks even worse to bury a child.

    Our nation has become largely a bunch of whiny post adolescents with self-interested priorities. Zelnio made many choices - few prudent ones and none that put his family first - he is not alone by far; he is simply the most literate.

    Other options include a 2nd or 3rd job (done it myself), selling a 2nd car, moving in with parents...admittedly none are pleasant and all are humbling but that beats having your wife delay treatment for an early cancer or having your kid die.

  10. I'm a nurse in the ER of the local county hospital. The county also funds almost 20 clinics throughout the area. SO MANY of our patients come in because of the 3 week wait times for appointments at the clinics. That's not for specialists--that's for the NPs and PAs. Almost out of insulin? An insured person goes to the doctor. An uninsured person in my county can't wait 3 weeks and goes into DKA.

    Even more of our patients come in because EMTALA only requires emergency stabilization. If you break your arm and go to any other local hospital (even the non-profits), you'll get a splint and a follow up appointment for a cast in 3-5 days, but the ortho won't see you without payment. You're almost out of vicodin so you can't wait 3 weeks to see the clinic doctor, so you end up back at my ER for a re-evaluation and a new ortho appointment (within our system) in 3-5 days. Hope you didn't actually need to use that arm at work.

    Dr. J, I'm pretty sure most families would LOVE to pay $9000 a year in health insurance. I make $50,000/year and have good benefits. If I had kids (one or twenty, my premium is the same), I'd be paying $5600 a year in premiums with a $2000 deductible, $35 copays and $20 generics. I could easily see myself going over $9000 with all the normal childhood illnesses. Keep in mind--I have GOOD benefits. My husband's insurance would have premiums over $10,000 and a $5,000 deductible.

  11. Note carefully Dr. J's comment -

    "On a family income of $90,000 the marginal tax rate in British Columbia is about 38.5% (There is also a 12% VAT, and provincial healthcare premiums)."

    Romney a with a multi-million dollar income paid 42% last year; half of all Americans PAY ZERO. With the additional costs of ACA, "the other half" has to be tagged for their share - after all, they get sick too.

    So tighten your belt, nothing is free, not even healthcare.

  12. The ACA is an inevitable path to "medicaid for all". Be prepared for much more of the nonsense such as what is happening with Washington State medicaid and ER visits

  13. ACA is an example of government intrusiont into a service area where government's performance is notoriously poor; the blogger's essay, quoted in the first comment, is just an example of how little recourse one gets in such situations .... and has nothing to do with any distinction in the type of care provided, or not provided.

    As for care not being provided, Canada's system is a good example of how governments fail at the expense of their citizens:

    Chaoulli v Quebec: Decided at Canada's Supreme Court was that the goverment (Province) failed in its duty to provide health care; failure was measured in part in corpses. Result: private health had to be made legal as an alternative. That was in 2005; now Lindsay McCreith of Ontario has a similar claim/challenge there stemming from his inability to get needed care and resorting to the USA to get treatment for a life-threatening brain tumor. Good for him the USA was available, otherwise he'd be dead too. http://www.canadianconstitutionfoundation.ca/article.php/52

    Kirby Report -- This Canadian Govt report from about a decade ago encompassess hundreds upon hundreds of pages regarding what was perceived as an imminent (by govt responsiveness) threat to the viability of Canada's health care system. As a result some changes were made.

    Fraser Institute -- this Canadian think tank has done numerous studies on Canada's health care; bottom line: availabilty is poor, many cannot get a regular doctor at all, wait times are long, and the situation is worsening by all major measures. Their website & research reports are readily accessible. For those of you who can get there, stop by a few veterinary clinics & see how easy it is to get your pet an MRI...then compare that for a human with a real need (ask L. McCreith of Ontario, for example).

    Canada's care is expensive, poorly provided, with particularly long wait times for specialists and the elderly.

    In addition to Fraser Inst.'s data, Timely Medical Associates--a medical broker, has similar info. If Canada's was so good, why is a profession such as Medical Broker even viable!?!?!?

    Sure, government-provided health care "sounds" good...until one considers government's poor efficiency, etc. (true in every country)...then one must consider that fighting the government is the hardest battle possible--much worse than insurance companies, etc.

    The only way govt health care appears good is to project one's wishes on the concept in self-imposed willful ignorance of very significant realities about the more or less continuous inefficiencies government programs inevitably have, and, their inability to be resolved. Government programs do not improve in quality, they invariably decline, and then persist with tenacious resilience.

  14. I'm going to weigh in on this from a British perspective, because it's where I'm living, and it's where I was born. My grandmother died a few days ago, may she rest in peace, and there were nurses there every single day from the NHS (the National Health Service). It made her death as pain-free as possible, and as dignified as it could be. There is nothing, and I mean NOTHING that could convince me that the USAs private medical industry is better than ours, because at the end of the day, even if the NHS isn't perfect (nothing is), women in this country can give birth without worrying about the cost, people can die peacefully, and the notion that a family is bankrupted by an illness is hard to fathom. It's a place where every student has access to medical care. There are no cashiers in doctor's offices, and no money changes hands, and there's a lot of emphasis on preventative medicine. My meds, which I take every day, would cost hundreds of dollars a month without the NHS, but right now it costs about $10 every 6 weeks. The fact is that the leading cause of bankruptcy in the States is due to medical costs. And that's a shame. To us, it's only common decency that your neighbor, whether he's a drug dealer or a saint, shouldn't have to watch his son or wife or mother suffer because there's not enough money around. I take it upon myself to give a damn about what happens to them, all of us should, because one day that IS going to be you, or someone you love, and the last thing you want to be thinking about it money. It's hard enough being sick as it is, but having to struggle to pay the bill makes it so much harder. The hard facts are this:

    - The USA has a lower life expectancy than countries as economically developed
    - Americans pay double what other developed countries spend on health care
    - There are 33 countries with a lower infant mortality rate than the Americans. And one of those is Cuba.

    You should be ashamed of yourselves. It doesn't cost that much to give a s**t, and actually, a public health system, contrary to what some stupid think tank or other might think, costs far less to anyone who ever has to worry about money. Yes, it's not perfect. And yes, there are queues. And it's true that people die sometimes and we blame the NHS. But it falls short so much less often than you think.

    And the reality is that the biggest change that needs to happen is that people need to realize this: government is not, should not be a hegemonic, far-off entity that controls our lives regardless of our will. It is the name for the things that we choose to do together.

  15. The ACA is actually unavoidable path to "medicaid for all". Generally be prepared for more of the nonsense including what is in progress with Washington State medicaid as well as ER visits


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