Ken’s Take on the World


Healthcare: Privilege or Right?

As Republicans struggle to obtain enough votes in the US Senate to pass their version of a bill (Better Care Reconciliation Act) that was originally brought forward to repeal, and replace, the Affordable Care Act (ACA) much focus has been placed upon the economic costs and the personal costs to those who would be affected should this legislation become enacted into law.  As one who has paid attention to the debate over healthcare access for the past three decades, I have been thinking of a much deeper question that we should be asking of ourselves as it would, perhaps, better drive the debate over this legislation.  The question that each of us should ask is this:  Should healthcare be considered a privilege, a commodity, that should be available only to those who can afford such care or, should it be considered a necessary right for every person that must be protected, and assured by government?

 

When I have posed this question to those who express opposition to the ACA, the most common response that I receive is that healthcare should be treated as any other service that a person would seek out.  The most common support offered for this position is that every person receiving services should be required to pay for such services.  To bolster this claim, these critics argue that it is not fair to expect others to pay for services that they receive.  On its face this appears to be a reasonable argument that must be considered.  After all, you wouldn’t take your car to a mechanic and not be expected to pay for repairs or maintenance on your vehicle.  You don’t take your family to a restaurant and expect to receive free food, do you?  You wouldn’t call an air conditioning repair person and expect to not receive a bill for the parts and services provided, would you?  These criticisms appear to suggest that healthcare services and products are no different than whether or not your vehicle or your heating and cooling systems at home are functional.  This is a false and illogical argument.

 

When one dines out at a restaurant, one knows what they can afford and if they are unable to afford to dine at a certain establishment they simply eat dinner at home or at a less expensive restaurant.  When your air conditioner is on the fritz, if you do not have the money available for repairs, you will need to open your windows, use fans, or other methods of staying cool.  For those with underlying health conditions in which extreme heat is dangerous, communities provide cooling centers, or family and friends are often able to step in to provide temporary shelter until the air conditioning is repaired.  Even if a new central air system must be installed, the cost is almost always going to be less than $5,000 USD.  Many heating and cooling companies will also finance this amount to keep costs manageable.  Similarly, if you need repairs on your automobile, you can determine what are the most crucial and pay for those and defer other repairs until later.  Or, your community may have decent public transportation available.  Or, you may be able to car-pool to work or use a ride-sharing service.

 

Healthcare, unlike these other services, is not a commodity that can simply be delayed in many cases.  I have frequently likened the provision of healthcare as an essential service that must be available to every single person.  Similar to a community that provides fire departments and trained personnel to operate this life-saving equipment.  Or, law enforcement agencies that respond to safety or criminal complaints.  Or, military agencies like the Coast Guard who respond to emergencies on our nation’s waterways.  We don’t bat an eye when we are asked to fund these critical services.  As a society, we have come to realize these are critical pieces of infrastructure that exist for the benefit of each of us even if we never need to directly use these services.  Why, then, do we look at healthcare differently?

When I have attempted to discern how so-called conservatives continue to maintain the position that healthcare is a commodity, and not a right, in addition to the arguments about paying for services and the burdens of having to pay for those who cannot afford these services, they remind me that healthcare services are already provided to people in the nation’s Emergency Departments (ED) regardless of one’s ability to pay for such care.  This, then, implies there is, in fact, some existential right to healthcare.  When I point out this inconsistency in logic, one person actually mentioned that fewer (uninsured) people seek medical care as if this implies lower costs to taxpayers.  The problem with this (il)logic is that while uninsured individuals are far less likely to present to a primary care physician in the community setting, they are far more likely to present to an ED for treatment of conditions that can be much more effectively, and economically, managed in a community setting by a primary care physician.  This translates into significantly increased healthcare costs for all of us.  The average cost of an ED visit in the United States is nearly $2,200 based on a study described in “The Atlantic.”  Compare this to the average cost to a primary care provider (PCP) in the US which is only $100 based on an Agency for Healthcare Research and Quality (ARHQ) study by the Department of Health and Human Services (HHS).

 

A review of multiple studies has demonstrated that access to health insurance is correlated with significantly improved health outcomes.  The review, published recently in the “New England Journal of Medicine” (NEJM), documents that improved healthcare outcomes are especially notable among pediatric patients.  Further, this review notes that not only are healthcare outcomes improved, but other measures of quality of life, including educational achievement, are improved with access to health insurance.  Other studies have demonstrated the significant economic consequences associated with illness.  I am not only speaking of the direct costs associated with providing medically-necessary care, but the impacts that illness and preventable injury have on individual and societal economic stability and growth.

 

I believe we must frame the debate over access to health insurance as one of a necessary right that must be protected by government actions.  Only then, will we be able to determine the most effective means of financing healthcare in the United States.



Hear ye, hear ye

Within the next two weeks the United States Supreme Court will issue its ruling on the Affordable Care Act (ACA). There is much speculation as to what the Court has decided (yes, the case has already been decided) when it issues its ruling on the Constitutional questions raised by the Affordable Care Act. Some think it will be completely struck down while others (you have to love dreamers) believe it will be completely upheld. Most of us who have actually read the Act, believe it is quite likely that the Justices have decided that parts of it fail to pass Constitutional muster and must be struck down while leaving large portions of the ACA intact. In any event, the ruling of the nine men and women who comprise the highest court in our land, will have far reaching effects on the lives of everyday Americans. Not only will their decision(s) affect average folks, the impact will be felt by healthcare providers, insurance companies, pharmaceutical companies, and medical device manufacturers.

For the President, the ideal situation would be for the Justices to decide that the entire Act is Constitutional, thus bouncing any attempts to modify or repeal all, or part, of it to Congress which is unlikely to muster the support for doing so. I, personally, think this scenario is unlikely for two reasons. First, I can see a lack of Constitutional backing for the individual mandate that is a key provision of the Act. Second, given the current make-up of the Court, I do not see a majority of its respected members agreeing that this provision is Constitutional. Certain members of the Court are not especially keen on having the Government require individuals to do certain things. In many ways, this is a very good thing.

For Congressional Republicans, an ideal scenario would be for the Court to strike down the entire Act. This would allow them to put forth legislation addressing the provisions of the Act that a majority of Americans have repeatedly identified are quite acceptable to them. This would allow Republicans, with very broad bipartisan support, claim they support meaningful healthcare reform. I also do not believe this scenario is very likely because precedent shows that the Court has supported the right of Congress to enact laws that address interstate commerce. The issue the Court must grapple with here is that there is no specific severability clause that would permit the Justices to only strike portions of the Act. Not that there is no precedent for allowing this, it is, however, interesting that no such clause was included in the final legislation that was sent to the President in March of 2010.

Personally, I am inclined to believe that the Justices have decided that the Act can survive with the removal of the individual mandate. It is not up to the Court to decide that the hardship forced on corporations resulting from a loss of revenue as this is not a question posed by this case. So, what happens if the individual mandate is struck down and the remainder of the Act survives intact?

Medical insurances companies will, initially, face the greatest financial burden. They will (continue to) be forced to provide coverage to anyone regardless of medical condition. Further, they will (still) not be able to drop people when they become ill. These are both extremely important issues for individuals who, inevitably, will require healthcare services at some point in their lives. Pharmaceutical companies are also on the hook for reducing the cost of medications to some groups and this would not change with or without the individual mandate. Hospitals and other healthcare providers will be hurt with the loss of an individual mandate as Medicare and Medicaid reimbursement rates are slated to be kept under a tight rein under provisions of the Act. With otherwise healthy folks showing up in Emergency Rooms, reduced reimbursement and increased volume will make it a challenge to continue to provide high-quality care.

The impact on businesses and individual purchasers of health insurance will become very noticeable without an individual mandate. These folks can expect their premiums for health insurance to rise significantly especially for those who have pre-existing conditions or who work in inherently dangerous fields. Without the guarantee of a large, relatively low-risk, pool of people purchasing insurance, companies that sell insurance will be forced to raise rates on everyone who does buy in order to maintain a healthy profit-margin and in light of the fact that individuals cannot be denied insurance. Businesses and corporations will likely decide that it may be cheaper to self-insure thus drawing even more customers out of the health insurance marketplace. As this begins to happen health insurance providers will begin to go into bankruptcy leaving millions with insurance policies that are worthless. This is the worst case scenario, however, it is what will ultimately lead to something I have recommended for more than a decade. As insurers fail, healthcare providers become sucked in by a staggering loss of revenue, and they, too become bankrupt. The Government, belatedly, recognizing that healthcare is not a commodity that cannot be satisfied by the traditional laws of supply and demand, will have to take action and a form of Universal Healthcare will be implemented.

Could this be avoided? Not likely. America has the greatest medical technology in the world. The healthcare industry in the United States makes up about 1/6 of our Gross Domestic Product (GDP). The costs associated with the development of new drugs and medical devices that are designed to improve the quantity, or quality, of life are, well, quite costly. Healthcare in this country is, literally and figuratively, too big to fail. Unfortunately, finding a way to pay for this is an issue. For far too long America and its leaders have acted as though healthcare, and access to it, is a commodity that is to be financed based on free-market principles alone with very limited regulation. American citizens have become so insulated from the actual costs associated with healthcare through employer-provided insurance benefits. We have come to expect the very best in medical innovation even though it is not always necessary. We demand the newest drugs. We know we will receive tests performed on the latest diagnostic machines and that a robotic system can be used for almost every surgical procedure. This is neither cost-effective nor wise. However, when the Affordable Care Act was introduced, critics called attempts to look at the feasibility or appropriateness of care, people balked and critics derided this, quite incorrectly, as the implementation of, “death panels.”

Instead of implementing a Universal Healthcare system, or at least the framework of such a system, when they had the opportunity, Congress attempted to circumvent the inevitable. Healthcare has become a major burden on businesses and individuals. A uniquely American model based on the healthcare systems of every other industrialized, and a significant number of developing, nations should have been seriously discussed and implemented. We had the chance to do this in 2009 (and a number of times in the century prior) and we failed. We were provided legislation that, despite its length, failed to ensure that every citizen had insurance. The final bill failed to provide sufficient cost-containment mechanisms. The expansion portions of the bill were challenged by Attorneys’ General, allegedly, acting in the best interests of their citizens. And this is why we eagerly, and anxiously, await the opinion of nine folks in black robes.

One other prediction. Whatever the ruling(s) that are presented, they will be nearly unanimous. The Court will have considered its own integrity and, realizing the view of the Court in recent years as more in lockstep with their Presidential nominator’s political affiliations, will make sure that whatever conclusion has been reached is supported by a near-unanimous Court.