Friday, June 29, 2012

As For Me

One Kaiser Plaza, Oakland, CA. Headquarters of Kaiser Permanente.

I think I posted a while back that today is the last day I will have comprehensive health care coverage. For a little over a year when I am eligible for Medicare, I'll be on my own. 

I have been covered through Kaiser Permanente for the last 25 years or so, very rarely using their services but comforted by the knowledge that it was there if I needed it. I didn't realize how costly it had become until the COBRA statement came saying that to maintain the coverage we have would cost close to $3,000 per month. Oh really. Isn't that something. At Kaiser??? Eeek.

Well, after considering the risks/benefits, the costs, and the fact that we would soon not be anywhere near a Kaiser facility, the answer was "No thanks." Other COBRA plans were available at $1,500 a month and up, but they didn't seem worthwhile either -- high deductibles, limited coverage, rather pointless, really.

Thankfully, while I've faced some life-threatening illnesses, I don't have a chronic condition that requires continual treatment and care -- at least not yet. The debilities of age do seem to be creeping up on me, but I've been able to manage them on my own well enough up to this point... let's hope it stays that way.

Interestingly, while medical coverage was hyper-expensive (I have no clue how older workers -- or ex-workers as the case may be -- are supposed to manage such huge COBRA bills to maintain coverage), dental and vision coverage were made available at no cost. So there's that.

I don't know that the ACA would actually have any positive effect on this situation. COBRA would still be available, but it would still be out of reach financially -- at least so far as I've been able to puzzle out the limited information I've seen. If there really is a 6% of gross income limit on health care insurance costs to households, then that actually would make a big difference, but nothing is in stone until it is graven there, and nothing will be graven until after Decision 2012 concludes.

The notion that the First Thing President Romney Will Do is "Repeal Obamacare" is patently absurd, of course. Having seen this man's ways for a while, what he will do First is to sell the rubes on the kabuki that he will be conducting from day one. He has no intention of repealing Obamacare -- it's too lucrative to his owners and sponsors. Besides, despite his August Pretensions, even he doesn't have the power to "repeal" it. Not that he would want to. He might be inclined to suggest changes to the program that increase costs and limits coverage to individuals and households, but otherwise he will leave it pretty much alone. The Industry won't let him muck with it very much.

On the other hand, if Obama receives another term -- which is looking more likely, his political instincts are still astonishing -- he would probably be inclined to tweak it in a similar direction, simply because that's what he does. If an R suggests "improvements" he's right there. So. ACA or nothing, that's what the nation is going to be stuck with.

I've dealt with Medicare and Medicaid on behalf of others in the past, and as long as you can get care, they're fine. The problem is getting care prior to a crisis -- or even in a crisis in some cases. I've spent up to 12 hours in an ER waiting room with a Medicare patient before any sort of treatment at all was offered; and of course once she was seen and treatment was begun, she was in dire shape.
Who would have thought.

There was no cost to the patient for Medicaid treatment, though now there are small co-pays for doctor visits and much higher ones for ER visits (of course, when the doctor refers you to the ER, what are you supposed to do?)  Medicare co-pays are still something of a mystery to me. At no time was anything out of pocket demanded, but costs beyond what Medicare reimbursed would be billed to the patient up to certain limits. I still don't quite understand how it worked, though. Nevertheless, I am well aware of all kinds of shady billing practices by providers. Rick Scott is only the tip of the iceberg. It seems like every provider engages in bill-padding at the very least, frequently much worse.

 There are nowhere near enough providers and facilities to accommodate a large influx of new patients, and it has long been my impression that the basic idea of the ACA is to get payment now for future medical care -- that quite likely will not be available. It certainly won't be in the short term. This will mean that people will be "covered" for treatment they can't get. Brilliant!

As I understand it, money for more community care clinics is being fervently stripped out of the ACA. These clinics are an important step in expanding access to care, but if the money is being stripped out as we speak, it's patently obvious that expanding access is not on the agenda, not that it truly ever was. If I recall correctly, Bernie Sanders was the one who demanded the clinics, and he was bought off with promises that have been relatively meaningless ever since. If there is little or no access to care due to lack of personnel and facilities, regardless of coverage and subsidies and all the rest of it, then it's pretty obvious that the whole Rube Goldberg contraption of the ACA was never meant to do much more than keep the insurance cartels and the medical industrial complex in profits forever.

Yes, I'm cynical about these things.

From the beginning the correct solution to America's medical care crisis was expanding and improving something like Medicare for All. This is not rocket science, this is obvious, and it was obvious when the correct solution was never on the table let alone considered that the point of the ACA was profit for the medical cartels. Period. If somebody gets medical treatment they otherwise wouldn't, oh well!

The correct solution was to remove the middle-man cost and inconvenience burden of insurance companies, simplify, streamline, make care available, tax to fund it, aggressively expand professional training, and provide an extensive network of primary care facilities. The correct solution was to put all of this in the public sphere, as a public health matter, rather than expanding private, for profit health care.

This has all been known for decades.

And yet the Health Care Reform panels never even heard let alone considered the correct solution.

Ah, but ACA is better than nothing!

The question is for whom?


  1. Medicare for All is a must. But it's not enough in and of itself. The real problem is capitalism, and I don't say that to be glib or partisan. I mean that in a mathematical way.

    The real problem with our health care system is that it's for-profit and it's too damn lucrative for so many parties along the way, incentives for exploiting this system are vast.

    Amazingly enough, even private insurance companies get ripped off. Medicare a bit less, because it's tougher. But it gets ripped off too. Costs for procedures and drugs are patently absurd, and doctors and hospitals knowingly charge more when there is an insurance company to pick up the tab.

    They often charge a boatload more.

    A typical round of chemo for me costs roughly 28K. One month. Four sessions. The insurance company picks up about 25K. I pay three grand out of pocket. According to some investigative reports, dealing with Californian hospitals, the non-insurance price would probably be in the neighborhood of three grand total. The hospital would still be making a profit at that, but because an insurance company is willing to pay many times more -- even after they've crammed down the price a bit -- they get what they can.

    And this is not due to covering for the indigent, though that is a small factor. This is really about making a ton of money on medical procedures. For shareholders, doctors, etc.

    Insurers, of course, make a ton of money for executives and shareholders as well. Their costs are inflated by health care delivery, but they more than make up for that by charging ridiculously high premiums and copays. Of course, they make their money via young and healthy people who pay in and don't take out. Either way, it's all screwed up.

    Obviously, a rational system would be a direct payment of some kind for services rendered, with no profit in the picture. Good salaries for doctors, nurses, et al. But no shareholders involved, and no killings made by equipment folks, etc.

    Basically, people should know going in that if you want to be in the medical field, you can make a nice living, but you won't make a killing. Figuratively speaking, of course.

  2. Your point is excellent and well-made. Sorry you still have to endure chemo-therapy and its associated costs but it's a good thing you're around to write about it!

    The basic problems of the American health care system are to be found in its for-profit operating principles and organization. Even the remaining supposedly non-profit private health care institutions operate on a for-profit model (and some of them are extraordinarily profitable, too.)

    I'm old enough to recall when it wasn't like this, and I can distinctly recall the transformation to a for-profit model as my mother was in the middle of it as a medical professional.

    Hospitals were not operated to make money but to serve the public health care needs of their communities. Doctors were well-compensated to be sure, but their primary focus was on public health not on making money (at least that was the case with most of them; then as now there were exceptions.) Costs were contained all up and down the line, and there was little need or use for health care insurance. Hard to believe, I know, but most patients paid out of pocket for treatment and hospitalization as well as medications -- all of which were relatively affordable. Those who couldn't pay were taken care of at "County" -- the public hospital that was in practically every county -- which provided essentially the same care everyone else got at little or no cost to the patient. (Again, there were exceptions.)

    This system had its faults to be sure, one of them being limited access to healthcare for many. The other was fairly limited treatment options -- many of the treatments and drugs we take for granted now didn't exist and were not even on the horizon.

    All that began to change in the late 1960's and early 1970's when a whole cohort of business administrators were brought in to transform hospitals and health care into profit centers. The focus shifted from patient care which was perhaps primitive by modern standards, but was actually very good all in all, to making money.

    One after another hospitals were taken over by business administrators and their public service function was abandoned. They no longer existed for the public and the health of the public, they existed to enrich a cadre of investors (often doctors, but not always.) It was a major transformation that was strenuously resisted by health care professionals at the time (futilely as it turned out.)


  3. Ron Paul's romantic notion of what the practice of medicine used to be like is based partially in fact. He blames the transformation that took place in the '60's and '70's on Medicare, which is absurd. The advent of Medicare was actually seen as a boon by all but the fringes of the medical profession (like Ron Paul) at the time because it was a matter of extending the public health care mandate to old folks who otherwise might have a hard time affording the extensive and expensive treatments they often needed. Medicare was seen as a good model for eventual "Universal Health Care" -- by which everyone would be entitled to good health care by competent professionals throughout their lives, without worries over costs. This was all considered to be part of the public health care mandate of the field.

    The VA and IHS among a few other public health providers still operate on the model that was intended to include everyone eventually.

    And Kaiser was a pioneer in providing efficient mass health care at were once considered reasonable costs.

    The business model transformation of doctors' practices and hospitals was a separate matter that seemed almost like a fad at first. Some doctors and investors discovered they could buy community and nonprofit hospitals at a discount and turn them into money makers relatively quickly. Sometimes they wouldn't even have to buy them. They'd just insert an administrator or two. Then hospitals and doctors' practices started transforming themselves before they were bought up and transformation was thrust upon them.

    Eventually, the entire health care system was put on a for-profit business footing, which leads directly to where we are now.

    The insurance cartels found they could make a bundle without doing anything simply by promising to cover most health care costs (which were rising exponentially on the New Model business plans) at reasonable costs.

    It wasn't Medicare that did it.

    There were efforts to counter some of the worst abuses of the for profit model, but they have mostly been absorbed or eliminated by now.

    My own belief is that the public health, public benefit, public service model is the one that should replace the for-profit health care business model. But that will require the public demand it and medical professionals back it - which to a surprising degree they already do.

    Wresting the system out of the hands of the parasites and exploiters is made more difficult by such things as the ACA -- which is intended to keep health care matters where they are.

    But it will either happen or the system will collapse.