Tuesday, August 8, 2017

The "Death" of Obamacare?

Well, the summer's now at it's slackest moment: It's August and all the representatives are home for the rest of the summer...after having failed to "repeal and replace" the Affordable Care Act of 2010. It's common knowledge now that conservative politicians consistently ran on promises to do so. Now that their caucus hasn't been able to come up with a passable plan, Obamacare remains in place while the states and the President try to figure out ways to sabotage it.

Meanwhile, the ACA is more popular than it's ever been!

There's way too much to say about the ACA and the tortuous process of getting from what came before to what we have now. There's been so much written and said about it: It's good. It's bad. It's merely an insurance market reform law. It's socilism. It's "imploding"...or it isn't. With that said, I will focus on here is what the symbol of the ACA says about how our society is evolving.

A few general facts (1):

  • Despite our ardent love for a "market-based" private health care system, Medicare remains extremely popular among those older Americans likely to vote against changes in the health care system, and for the repeal of the ACA.
  • Despite spending more money per-capita on health care than any other country (Switzerland is a distant 2nd place), many of our health care outcomes (e.g., life expectancy) lag behind our lesser-spending neighbors in the developed world.
  • Americans pay more for medical technology and prescription drugs than citizens of any other country.
  • It's not all bad: we have a lower cancer death rate than most countries. We visit the doctor less often than people in developed countries (so why is insurance so expensive?)

So in the 2000s it became apparent that having tens of millions of people uninsured was both a drain on our economy, and a kind of shadow tax on people with insurance, since the payees--doctors, hospitals, and medical products services--weren't simply going to accept non-payment from those uninsured people. The costs were "shared" by charging higher premiums to insurance holders.

Although many developed countries have a single health care payer system--Canada and Britain are the common examples--not all do. Moreover, as President Obama said at a press conference prior to the ACA becoming law, health care is about 1/6th of the American economy. You can't just change that overnight. Fair enough.

But it seems that, in spite of all the protest against the ACA (it was never worse off than about 47% popularity), now that it is threatened, a lot of people are speaking in favor of it. It's funny, I still routinely hear from some patients, and many nurses and doctors that "Obamacare" is what's causing all the problems in health care. Truth is, some of those problems are caused by Congress not fixing some of the problems that cropped up with it as it rolled out. Republican congressmen were too busy trying to repeal it entirely to take the time to fix it. Besides, if they fixed it, then they couldn't use it as foil against Democrats.

If to some this sounds like an editorial, it isn't. I'm just stating the facts (and by the way, none of these facts pay any tribute to Democrats, so I'm not writing a nakedly partisan essay here).

So this is where we are. Why?

Ok, now I'll editorialize!

For a long time, we were a frontier culture in a vast land. While we've always had differences, some severe (anyone remember something called the Civil War?) we've always had this sense of optimism, that just over the horizon, there lies a new land that offers a hope for a new day. Over the course of the 20th century, that frontier came to an end, and now even Alaska is settled all the way to the North Slope. Yes, there are still broad tracts of empty land. There are still new tomorrows to the west (or the east, if you're already out west). But by and large, we feel each other, our neighbors and our nemeses, people we know and people who seem strange and foreign to us, and there's no place to go.

So we've become more tribal, and this has been abetted by the internet. Demographic studies have shown we are tending to move to be with those "like us." Political districts reflect this as well, and a growing number of congressional districts are essentially uncontested. Wealth disparity continues to grow--America has a high disparity between the rich and the rest of us, higher than Europe and Canada, and even higher than much of northern Africa; we're better in that respect than South America and China, but roughly equivalent with Russia (of all places!)--so many of us feel a pinch.

A social conversation has begun to arise about this. What do we do now that we have nowhere else to go, nowhere else to conquer? How should society regulate itself? Am I responsible for my neighbor? One of the recent issues debated in the attempt to repeal the ACA concerned private buyers of insurance on the exchanges who didn't like paying for a basic menu of health care services that they might not ever use--like a man paying for a policy that must include maternity care.

On the face of it, it does seem kinda stupid...until one factors in the relatively low fraction of the cost of that care as it is distributed among many thousands of ratepayers, versus the much smaller fraction of ratepayers who actually use it (women of childbearing age) who would be charged much more without those non-user contributors. Funny, I think was a guy named Jesus who said something about loving our neighbors--what did he mean?

Am I responsible for my neighbors?

If one teases out the scenario, the sense of it sharpens. The man, paying a fractional cost for maternity care, actually gains benefit in unseen ways, like the fact that affordable maternity care lessens infant sickness and death and thus removes hidden costs from society at large--and thus from him as well, at least incrementally. Treating health care costs like an a la carte menu pays homage to our rugged American individualism, but it neglects the complexity of a society whose frontier safety valve shut off nearly 100 years ago. In the end, we all pay anyway.

How should society regulate itself?

In the past doctors were private agents, and so were hospitals (where they even existed). Insurance companies often operate on a for-profit basis, as do ambulances, some hospitals, many nursing homes, drug companies, and the list goes on. But that profit is made on goods and services that an increasing number of Americans see as a "public good", or a "right". Recently-convicted investor Martin Shkreli raised the price of dapsone, a very old and very generic (but also very necessary) drug by 5000% before public shaming caused him to dial it back a bit (it's still unnecessarily expensive)--because he could. It's no crime to price gouge, even when it comes to a matter as serious and as necessary as medical care. Capitalism is king. Or is it?

I have no issue with people getting paid, and I have no issue with private concerns existing to develop and provide unique and valuable services to the sick--heck I'm one of those people who do so! But I think one has to also be aware that the massive scale of some enterprises in health care, the importance of some of its products (like dapsone, or Epi-Pens, or Narcan), and the interconnectedness of that industry, combined with emerging expectations of Americans, has caused us to begin to entertain the possibility that rampant health care capitalism may not be the solution that many believe it is. Maybe it isn't especially moral to get as rich as possible on the backs of sick people.

Finally, I think it is dawning on people that we struggle with an essentially human, and especially American, sense of privilege. We want the best; who doesn't? But when does the "best" begin to come at the direct cost of another, and when--because of that interconnectedness I spoke of earlier--does it actually begins to incur indirect costs to us? 

People say they don't want the high taxes that come with single payer health care, but studies have shown we're essentially paying a "tax" anyway, in the form of high premiums. But instead of that money going to the common good, it goes into the pockets of dirtbags like Martin Shkreli! How is that better?

People say they don't want their health care "rationed"--and yet they seem to have accepted exactly that from heath insurers, who deny unneeded MRIs, CAT scans, new drugs, and unproven therapies. Is that rationing, or is it rationality? In the latter case, people seem to be willing to pay a "tax" to have their care rationed (or rational)--and give a nice extra bit that goes to corporate profit, or to the multimillion-dollar salary of a non-profit executive. (2)

Personally, I'd rather pay a tax I know is going to make my health care easy and portable, and keep the "extra bit" in my own pocket!

But hey, I'm fine. I have good insurance and a job unlikely to end abruptly. But I guess bad things could happen to me too, so I have a stake in this I guess. People need to start thinking more like this in order to hedge against the inevitable--and needing health care is pretty much inevitable, even if for reasons political, religious, or personal one were to choose not to use it. (3) So we better start having this conversation more explicitly. It needs to stop being about Republicans and Democrats, liberals and conservatives and greens and libertarians. The conversation needs to be about "real" things. How can we talk about the utility of a "free market" when that market is clearly opaque? (pardon the pun) What are the real, if indirect, costs to each of us when millions go uninsured or underinsured? Whay are we really paying so much for medicines? (Hint: it ain't research and development.)

Next time you're ill, try pricing the estimated total cost of the affair beforehand. The answer you'll get: "We can't know that until we see you." Show up and ask, and they'll say "We have to run some tests." Inquire on the price of those, and you'll find no answer forthcoming. Being sick isn't what it was. Like our former frontier landscape, health care in America has modernized: it can do a lot, and there's a reasoned approach to doing it. Maybe it's time we stopped treating ourselves like we're living in the 19th century. Maybe we need to start talking about how we're going to deal with reality and stop talking about if we'll deal with it.

(1) For the sake of time, I didn't cite these, but the facts can be verified easily with Google searches on the relevant terms. Or you can take my word for it.
(2) The CEO of Blue Shield of California was paid over $3,500,000 in 2015.
(3) Wake up at 3 AM with appendicitis, and see if you still feel like health care is a "choice" you can opt to not use!

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