Health Insurance and employers

Paul Krugman offered up this data set last week in The New York Times. 

Sobering facts. 

For years I've wondered how long American corporations and business can continue to foot the bill for the nation's health care strategy.  The time is coming when thoughtful business leaders will join with consumers to drive forward a more comprehensive, sane plan for providing the health care benefits we all need. 

The Collapse of Employment-Based Coverage

Reed Abelson at Economix points us to a startling study on the effects of the Great Recession on health insurance. You can see similar trends in the Census data, but for whatever reason this survey — carried out by a highly reputable group — is even stronger. Here’s the key picture:

What this says is that the system that has provided workable insurance coverage to many (but not enough) Americans is coming apart at the seams. And this in turn means that if health reform goes down, we’re going to be looking at a wave of misery spreading across the land.

Evidenced-based care

On Thanksgiving day, while walking down a very uneven sidewalk toward the park with the grandchildren, Brenda tripped and fell.  She broke her fall by stiff-arming the sidewalk.  She bumped and scratched her face and badly bruised her hand.  She shook off her injury and went on to the park! 

The next day, after a short visit with her doctor, she went to a local hospital emergency room to have her hand checked out.  After a lengthy wait and a couple of rounds of X-rays, she learned that no bones were broken.  During the exam, the examining nurse practitioner (she never saw a physician) questioned her about the scratch on her face, finally suggesting an MRI to make sure there were no broken bones in her face.  Brenda assured her that such a procedure was not necessary and that another X-ray would suffice, if even was really necessary. 

She left glad to know that there were no broken bones and with her hand and arm wrapped up to the elbow.  She also wondered if the attending staff was guilty of over prescribing treatment. 

In a "fee for service" health care system like we now experience, her suspicions make a lot of sense. 

Then, on Sunday morning, The Dallas Morning News carried a front page story on evidence-based medicine and cost sharing and the move of the Baylor Health Care System to such a strategy for providing care to its patients (by the way, the ER Brenda visited was not a Baylor hospital!). 

No one wants to talk rationally about health care realities these days.  But, in view of rising costs and our return in health and wellness benefits for what we pay, the time has come for serious discussions.  From the report it sounds as if Baylor will lead the way in that much-needed conversation.  Good for them! 

Be sure and read the story, "Baylor will try new Rx," by clicking here.

Thoughtful comment on Medicaid and its improvement

Dr. James Baker is the CEO of Metrocare Services here in Dallas, Texas.

Metrocare Services, formerly known as the Dallas County Mental Health Mental Retardation (MHMR) Center, has served Dallas County for over 40 years by providing first rate clinical and social services to persons with mental illness, developmental disability, or severe emotional problems.


Jim is an expert on mental health care delivery among the poor and, thus, an expert on Medicaid.

Click here to refresh your memory on my previous post that addressed what I considered an outrageous comment about Medicaid made by Senator Lamar Alexander (TN-R).   Be sure and read the comments on that post. 

Here's what Dr. Baker left in the comment box on that earlier post: 

I want to go back to the original question by c hand: Why do "so few physicians...accept patients covered by the ... very good plan?" and why do patients with these plans have to wait for care?


Medicaid IS a very good plans from the perspective of its benefits, that is, what it will pay for. It is very generous in that respect.


The reason docs dont "accept patients" (actually it is the insurance that many dont accept...) is that Medicaid's reimbursement does not even cover most docs' costs for the services.


And if Congress doesnt repeal a Medicare reimbursement cut of 21% that is set for Jan 1st, the same access problems will worsen for the elderly that already happen for the poor.


The fix is counter-intuitive: increase both the number of people covered and the doc rates for both programs, so that access is easier and happens sooner in the course of a disease, so that the cost of each episode goes way down -- and therefore so does the total cost to taxpayers...


Unfortunately since it is counter-intuitive, many policymakers have a hard time grasping this reality...


Wednesday, November 25, 2009 3:30:00 PM CST

Jim, thanks for the clear and rational explanation. 

Ever consider a run for Congress?

"Medical ghetto"?

Even though I expect this post will set off a firestorm of comments, many or most of which will be very negative, I cannot find the words to properly express just how offensive I find the words of Senator Lamar Alexander (R-TN) during a speech he delivered in the current Senate health care debate.

Give him your attention.



In the first place, Medicaid represents the only health care option available to a portion, and only a portion, of the very poor in America. The major negative associated with Medicaid relates directly to the fact that so few physicians will accept patients covered by the otherwise very good plan.

As a result, my poorest neighbors must wait for care, and not only in long lines or in crowded clinic and ER waiting rooms, but for weeks at a time for scheduled treatment. This would be remedied if we had the benefit of a comprehensive, national health care plan.

But second, and even more offensive, if the good Senator feels that Medicaid is a "health care ghetto." doesn't he have a moral responsibility to improve it? Doesn't he have a fiscal responsibility to the nation to reform it, extend it and promote it? Hasn't he signed on as a national leader with the responsibilities that accompany such a decision? 

Never mind the obvious race baiting here. Let's talk quality, equity and health care justice, not to mention improving the nation's wellness and health outcomes across a broad array of health measures.

Senator, please!

My young friends and "health insurance"

On Thursday, October 15, my young friend, David Null appeared before a U. S. House of Representatives committee considering health care reform.  David, Sherry and little Tatum experienced the failure of our current system of caring for one another's health as a people.  I decided to post David's comments in their entirety. 

United States House of Representatives
Committee on Energy and Commerce
Subcommittee on Oversight and Investigations

Testimony of David Null

My name is David Null and my family’s insurance story begins in 1999. My best friend and I finally came to realize what we considered the American dream; we started our own company together. Our baby, Tatum, was now two and my wonderful wife, Sherry, quit her job teaching so we could raise our family at home.

We employed 12 and had group health coverage sponsored by the company. We were doing well, life was good. But like many Americans, 9/11/2001 hit our company hard. Contracts got cancelled, our business plummeted and we were forced to discontinue our group coverage within 6 months. That’s when we had toswitch to the individual policy market. Business was bad but we knew the value of insurance and didn’t want to go without, although sometimes we did. Three times in 5 years we were unable to continue coverage without lapse because of decreased business in the 9/11 aftermath. We’d lose coverage for a few months and then we’d get a good contract and get a new policy.

January of 2005 I found myself shopping for health insurance again. We had been without insurance for about 3 months when our youngest daughter, Hannah, fell in the bathtub and split her chin. A quick trip to the ER for a liquid bandage cost us almost $800. It served as an excellent but costly reminder for the need to be insured. So I began the search for another policy.

Sherry and I spoke at length to an insurance agent at our dining room table. I explained an event in detail to the agent when my mother had become deathly ill suddenly. Her intensive care had cost nearly $200,000. I explained to the gent, “I don’t mind paying for the doctor’s visit for the head cold. We can handle that out of pocket. It’s the big “Oh, no!” like what happened to my mother that I need to protect my family from financially. Something like that could bankrupt us.” The agent told us, “You’re a very savvy shopper and this is the policy for you. By the time you factor our negotiated rates and what the policy pays out, you’ll hardly have to pay anything.” The way he explained it, it sounded like we were getting what we asked for, protection from being bankrupted by the $200,000 example I gave him. Our premiums were affordable at $320 a month, about $100 less than what we paid just before for insurance. I was under the impression my savings were due to not having significant office visit coverage like I asked. We felt relieved to be protected again.

March of 2005, just three months later. We started out for Sea World for Tatum’s first spring break, she was seven. Tatum had been sick to her stomach a little but we left thinking she’d be better the next day. She was a quick healer and always the picture of health. We had been in the hotel only hours when she looked at us with canary yellow eyes. We knew something was very wrong and immediately headed home to see the doctor the next morning. We didn’t realize until we arrived home that Tatum’s condition had deteriorated so much that her peaceful sleep in the truck was actually her slipping into a coma. We rushed her to the hospital and before the sunset that day we were told she would require a liver transplant within days to possibly save her life, if they can keep her alive that long.

Tatum laid in the ICU clinging to life. Her brain swelling from the poisons accumulating that her liver normally removes. The doctors told us she was the sickest kid in the hospital and they struggled constantly just to keep her alive. She had only days at best to live. In the midst of all this, the transplant department administrator came to me and said we needed to talk about insurance and walked me to a council room. As we walked I thought to myself, “Aren’t I glad we picked up that policy when we did. Wonder what he wants to talk about”. We sat down and he proceeded to explain that my insurance had a 25,000 max and Tatum had reached that after the first night. She had no more insurance from this point forward and its hospital policy to collect a $200,000 deposit to proceed. I couldn’t believe this was happening. Could this be true? Surely it’s a mistake because this is the big oh no I was buying protection from. Now my precious child lies just down the hall struggling for her life. Suddenly, not only were we facing the possible death of our child but now the financial death of our family at the same time. How could this be happening to us when we have insurance for this?

Thankfully, the hospital CEO agreed to proceed without any guarantee of payment. Tatum’s life is most important to the hospital and we’re grateful for that humanity. Miraculously, within two days a donor had been located. A loving family, who lost their daughter Angela, graciously donated her liver to Tatum so she could keep living. Tatum received her transplant with probably less than 48 hours to live.

Once Tatum was stabilized, the hospital helped me apply for Medicaid and we were narrowly approved. The coverage was retro active so they covered the entire transplant. Tatum’s bill for the first stay of 21 days approached $600,000 and our so-called hospitalization policy only covered about 1/10th of that cost.

Even with insurance, this left a balance we could never bear to payback, it would have bankrupted us. Our insurance had failed us. We were clearly relieved that Medicaid covered the entire cost. Tatum and our finances both had near death experiences. Although, we didn’t know at the time what going on Medicaid was going to mean to our family. Our daughter had been on total life support for a week and now our finances would be going on life support for the next two years.

Post transplant is also medically expensive. Her blood labs were $4,000- 6,000 a month. Her medicine over $1,000. CT scans and liver biopsies were the norm. The first sign of rejection was cause for 3 days inpatient for IV treatment. Nine months post she developed a complication of the anti-rejection medicine and developed a cancerous like infection. That required 7 weeks in the hospital with IV treatments daily. That treatment caused her to need another monthly IV treatment that was several thousand dollars for each bag. We never knew what the next day would bring but we knew for sure we can’t afford even one day without insurance.

We began to look for insurance that would help cover her post transplant expenses so we could get off Medicaid. We thought Medicaid was there to help people who couldn’t afford insurance or their medical bills. Then I was told by insurance agents to “not waste the time, paper or ink filling out an application with Tatum on it because they won’t even accept it.” We were learning Tatum was blacklisted from individual policies. Getting a corporate sales job for group coverage didn’t seem like an option for me. I’d make too much during the waiting period for company insurance and we’d get dropped by Medicaid, leaving a gap we couldn’t cover. Sherry is a teacher and schools do most their hiring just once a year. Additionally, our family was instructed by the hospital to self quarantine from public for infectious reasons. Teaching is a sure way to bring home a virus that could put Tatum’s life at risk due to high immuno-suppression. We now had no where to turn. We were somehow stuck on Medicaid. Not because we couldn’t afford insurance, we thought we had insurance when this started. It was simply that the insurance industry would not make a policy available to us in the individual market.

So, in order to keep receiving health care for Tatum we had to voluntarily drop our income to near poverty to satisfy Medicaid requirements. The allowed monthly income limit on Medicaid was a shocking $1,613 a month for a family of 4. This barely allowed us to cover our mortgage, most utilities and some food bills. That’s under $20,000 a year. This meant I would frequently have to pass on work because I’d make too much for Medicaid. It was even suggested that we might fair better financially if we got a divorce.

Those were tough times and we found ourselves in the red every month. Many expenses went on credit waiting for a day when we could afford to make the money to pay it back. Interestingly, with Medicaid we never incurred any cost for her healthcare. We’re very lucky; we actually have no debt related directly to medical bills. The high cost of staying on Medicaid is on the backside, trying to survive financially on less than $20K a year. We took on tremendous debt, eliminated our savings and retirement and put our growth on hold trying to survive while she got the healthcare she needed. All because we didn’t get the insurance coverage we specifically asked to have.

After two years Tatum began to reclaim her new normal life. Her immune system and new liver were getting along much better and she was on a bare minimum of immuno-suppression. There were now more good days than bad so her mother could return to teaching, group health coverage and an entirely different insurance experience.

I found it interesting when we transitioned to group coverage; Tatum was accepted with open arms and without question. They wouldn’t give us the individual application and yet on the group application, all we had to do different was check a couple ‘yes’ boxes and write ‘liver transplant’ in a blank. Next thing we knew we had insurance cards in hand. The insurance cost deducted from Sherry’s paycheck is actually reasonable and identical to other co-teachers. Our rates have remained that way for three years now. Under group coverage we’re treated like we don’t have a preexisting. It would appear individual policies and group policies exist in completely different universes.

Her mother and I are thankful Tatum’s physical recovery is quicker than our finances. She’s growing, thriving and giving back. She regularly appears on behalf of Children’s Medical Center, the Southwest Transplant Alliance and is active in supporting her favorite charity, Make-A-Wish. Her life has been a joy and inspiration to many. We’d do it again for her sake. We’re thankful Medicaid was there for us to provide the protection that nobody else would. We’re equally thankful to be off Medicaid.

We do hope our testimony illustrates for you how the Hospitalization and Surgical policy in question here today was obviously worthless at actually protecting anyone from financial disaster with its ridiculously low maximum caps. Through all this, we’ve learned the languages of policies and agents can be confusing. In spite of both being college educated, we didn’t recognize or understand at the time that $25,000 maximum for “Misc Hospital Expenses” meant the total of the medical bill. We thought it literally meant misc hospital expenses. Even today we still find the wording a little counter-intuitive and misleading.

While policy language can be confusing, we asked in very simple terms, for a policy that would protect us from the big “Oh, no!” We ended up with a policy that would do no such thing. We trusted the agent was matching our needs to his product. He was not. His policy was saving us only 25% compared to our last policy but the $25,000 cap was 1/40th the coverage ($1million). No college degree is needed to see that’s not a good deal. Obviously not a policy with the consumer in mind.

While our testimony should be labeled “Grossly Under-insured”, we’ve since learned that even traditional $1 million policies are sometimes no challenge for long-term life threatening illnesses. Maybe 10 years ago it was sufficient. Today it’s very possible that $1 million will still leave you under-insured. They estimate that transplants, nationally, average somewhere in the ¾ million dollar range, plus post transplant expenses. Had we started our experience with a million dollar policy, we’d be close to maxing it out now, if not already. If that ever happens, my wife will be forced to move to another school district with a different insurance
provider or I must give up self-employment and take a corporate job. Only time will tell.

Most importantly, we’ve learned that being under-insured really is the same as being uninsured. They both lead to the same end. Unfortunately, we’ve learned that if your American dream is to be self-employed, the insurance companies can make it your nightmare. Under-insurance certainly impacted our lives. God has carried us through and we trust He will continue to do so, and we’re glad. We’ve certainly learned from this experience and are trying to move on.

It would seem like the story ends here but it’s actually just the beginning for Tatum.

Under-insurance isn’t the biggest tragedy of our story if you ask me. Tatum’s story encompasses another shortcoming of the health care system that you need to do something about so people like Tatum can be truly free. Without health care reform from Capitol Hill there will be more challenges for a grown up Tatum and those like her.

What will continue to sadden Sherry and me is the issue of blacklisting on the individual market, for life. That carries a lot of ramification behind it that most of us never consider. We’re lucky because Sherry’s dream has always been to teach and with that career choice we have access to group coverage. But that’s not every bodies dream. Does this mean Tatum and those like her, will be required to dream of corporate work for group coverage or marry into it. What if they get laid off? Small companies will certainly find reason to not hire her, or her husband, if they find out she’s transplanted because it will torpedo their insurance rates. Will
Tatum and her husband be forced into the Medicaid trap too, not because of finances but because of policy unavailability? Her career options to access affordable health care in the future are tremendously effected simply because the industry has designed it. Is that really fair? Is that American?

Consider this. When Tatum was four, she and her mother went to New York City. Tatum visited Ellis Island and stood transfixed on Lady Liberty, our American symbol of freedom and beacon to the world. Tatum even got herself a Lady Liberty costume. She was told Lady Liberty stands and invites the world to come to the land of opportunity, where anyone can follow their dreams. And yet Tatum, a born and bred American citizen, might not get to share in this dream through no fault of her own. Simply because the insurance industry has developed a system that won’t allow it. Our Tatum has so much potential, but for now, she doesn’t have full access to Lady Liberty’s promise to pursue her dreams. She can’t pursue little girl dreams to be an artist, or have a dress shop, a restaurant or self-employed in any fashion that requires individual coverage.

When she asks me what she should be when she grows up, I can’t tell her the same thing you probably told your kids. Right now I can’t tell her she can be anything she wants and you need to fix that. Do I tell her Lady Liberty does not stand for her too because the insurance industry has made it so with underinsurance and preexistings? Do I tell her the government before her today, a government for the people, by the people, refuses to take the steps to also protect her rights to life, liberty and the pursuit of happiness?

What do we tell her? Tomorrow our family plans to see with our very own eyes our Declaration, Constitution and Bill of Rights. A true privilege and honor as an American. These documents were bought and upheld with the blood of men for all of us. What do we tell about her place in those? What do we tell her?

In closing, while my purpose today is to testify and answer your questions as an American citizen, I also come to pose just one question to the very distinguished committee as a father. Which of you, will commit yourself today to be able to look Tatum in the eyes and tell her, that you will be helping lead the way and you will see to it that when she grows up she’ll have affordable access to adequate healthcare, regardless of her occupation, and that today she too can start pursuing all her American Dreams?

We sincerely pray that God bless you and guide you. And God bless America.
Thank you.

To read a story on David and Tatum's powerfrul testimony click here.
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Health care reform and faith

Here's the first section of Jim Wallis' recent essay, A Faith Declaration for Health-Care Reform. I believe the statement is very important.

Over the course of the health-care debate, voices of faith have been raised about the moral values at stake beneath the policy discussions. As bills are finalized and moved through both chambers of Congress, now more than ever we need to remind ourselves of the values that move us to reform. From the Bill of Rights to the abolition of slavery, from women’s suffrage to the civil rights movement, those who have raised the question of values have often changed our country for the better. Change can be scary in uncertain times, but it always comes when a nation chooses hope over fear.

Unfortunately, God sent Moses down from the mountain with only the Ten Commandments, and not a health-care bill ready to be passed out of committee. There is no one “right” religious position on how health care should be provided. But I believe there are some fundamental moral and biblical principles on which to evaluate any final legislative agreement, principles on which many people of faith -- even politically diverse people -- might agree. After the heat of the summer’s confrontations over health care, it’s time for a cooler fall debate. It’s time for a re-set of the health-care debate, and a return to some basic principles could help.

To read his "Five Principles of Faith for Health-Care Reform" and his entire statement click here.

Reactions welcome.

Cover everyone or worry about donations???

Here's a really great essay by E. J. Dionne, Jr., "Uncharitable Charities" from today's edition of The Washington Post.

Thoughts?

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Sugar tax for improved national health outcomes?

Sidebar poll from The New England Journal of Medicine:

Do you favor taxing sugar-sweetened beverages as a way of helping to finance health care reform and improving public health?

No (26.0%, 493 Votes)

Yes (74.0%, 1,419 Votes)

Total Voters: 1,912 (as of 9/17/09)

Your vote???

The "public option"

Last week I spoke with a young woman who works for a large non-profit company in Dallas.

She graduated from the University of Missouri and earned a masters degree from the University of Texas at Dallas.

Her current job is a seasonal, part-time position.

She is looking for a full-time job.

But today, she does not have the benefit of health insurance.

She cannot afford it.

I thought of her when I received the link to this piece on the so-called "public option."

Watch it and tell me what you think?

What doctors think. . .

The website for The New England Journal of Medicine (September 14, 2009) reported on a national survey of the attitudes and opinions of physicians when it comes to a plan to provide health coverage for all Americans.

The article, "Doctors on Coverage — Physicians’ Views on a New Public Insurance Option and Medicare Expansion" reports important findings, or so it seems to me.

Here's a taste of the content:

In the past few months, a key point of contention in the health care reform debate has been whether a public health insurance option should be included in the final legislation. Although polls have shown that 52 to 69% of Americans support such an option,1 the views of physicians are unclear. Physicians are critical stakeholders in health care reform and have been influential in shaping health policy throughout the history of organized medicine in the United States.2

The voices of physicians in the current debate have emanated almost exclusively from national physicians’ groups and societies. Like any special-interest group, these organizations claim to represent their members (and often nonmembers as well). The result is a well-established understanding of the interests of physicians’ societies but little, if any, understanding of views among physicians in general. Faced with this absence of empirical data, we conducted a national survey of physicians to inform federal policymakers about physicians’ views of proposed expansions of health care coverage. . . .

Overall, a majority of physicians (62.9%) supported public and private options. . . . Only 27.3% supported offering private options only. Respondents — across all demographic subgroups, specialties, practice locations, and practice types — showed majority support (>57.4%) for the inclusion of a public option. . . Primary care providers were the most likely to support a public option (65.2%); among the other specialty groups, the “other” physicians — those in fields that generally have less regular direct contact with patients, such as radiology, anesthesiology, and nuclear medicine — were the least likely to support a public option, though 57.4% did so. Physicians in every census region showed majority support for a public option, with percentages in favor ranging from 58.9% in the South to 69.7% in the Northeast. Practice owners were less likely than nonowners to support a public option (59.7% vs. 67.1%, P<0.001),>

To read the entire report, with charts and graphs, click here.

Interesting stuff, huh?
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The Moral Code of the Health Care Debate

Thoughts to ponder, especially for people of faith:

With all of the shouting, the fear, and now what often looks like hatred -- we are in danger of losing the moral “core” of this health-care debate. That core, quite simply, is that many people are hurting from a broken health-care system. They include the 46 million who have no health insurance, but also the many who do but don’t get what they need and simply can’t afford good health...

People of faith need to be the steady, moral drumbeat driving the debate and keeping our politicians accountable. This is a critical and long-overdue opportunity to fix a broken and inequitable system, which must not be derailed either by powerful special interests or by those, on any side, who just want to score political points. It is up to all of us to make sure that doesn’t happen.

Jim Wallis
Sojourners

Read the entire text of Wallis' comments from 8-20-09 here.

Central Dallas Ministries, along with a number of other organizations and churches in the Dallas Metroplex, will be sponsoring the Justice Revival with Jim Wallis, November 10-12, 2009 in Market Hall. Watch for more details!

Health Care Crisis

The health care "debate" rages on, fueled at times by hysterical fears and plenty of outright falsehood.

What seems lost to many is the growing need among millions of Americans for basic health care.

Take a look at the video. It first aired on "60 Minutes" in 2008 before the Presidential election.



Sustainability and scale are the key challenges facing "free clinics" like the ones featured in the report. We need to find a way to care for one another, and that means everyone.

Reactions?
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