The health care reform dissatisfaction taboo

Thank you, Helaine Olen.

For some time now, especially throughout the past couple of months, I have been stewing in dissatisfaction with the progress/prospects of health care reform from my individual perspective. I have nonetheless been reluctant to complain because the issue has become so absolutely binary. Either “Obamacare” represents the ruination of all that is good, is the source of every problem with anything, anywhere, and must be erased from the Earth… or, the good news just keeps on coming, millions more Americans insured, it’s the dawn of a “get more pay less” era in health care, etc., etc.

The former is just hysterical revanchist psychosis. The latter is very possibly all true, as far as it goes, and I want very much to believe that it’s going to go further, that I just need to be patient and give it another year or two or five. I can’t say for certain that this won’t happen, but so far I sure don’t have enough evidence to be confident.*

So I appreciate Helaine Olen stepping forward to say, at Slate, that “Those Protesting Harvard Professors Have a Point: We’re all still paying too much for our health care.” Basically, she has nailed almost every one of my concerns, concerns that I have been reluctant to voice, worrying that “I support the goal of reform and don’t want to lend any support to its absolutist opponents,” and “maybe it’s just me, maybe I’m being too selfish dwelling on my personal and perhaps atypical circumstances when so many people are getting help with greater needs.”

Maybe I am, but for what it’s worth, without hearing it from me someone else has now pointed out just every dissatisfaction I have identified…

“Almost everyone who has health insurance now has a deductible. And those deductibles are soaring.” Oh, heavens, this ship sailed years ago for me.

“A family of four can pay hundreds of dollars a month in insurance premiums and still find itself on the hook for several thousand dollars’ worth of medical bills annually.” So can an individual, actually. This I have concluded is the problem with insurance-based health care, or at least a big potential weakness: the system hits a big reset button every January 1. Even with a high deductible, insurance can still be a godsend for a major, concentrated medical “event,” e.g. if you get cancer and have six-figure hospital expenses. But if you have ongoing expenses, e.g. an incurable condition like I do, then they can cumulatively bleed you dry over the long term, and none of that counts because expenses in a given calendar year don’t exceed the “out of pocket” limit. Under the ACA this is effectively several thousand dollars. Six-thousand some is the formal maximum; you can get plans with lower limits but so far as I can tell the premiums rise accordingly.

“…take a pill not on the approved formulary… you are on your own…” Oh, like my prescription. It’s only available as a brand-name product, at present, and it’s incredibly expensive. Yet it works well, with no bad effects, and the marginal cost of making more of these pills is probably similar to the marginal cost of the main alternative, an older drug that’s available as a generic but would entail significant ongoing health risks. How would society as a whole be better off by pushing me to take the generic drug and its attendant risks? It wouldn’t, obviously. But under the US system, the newer drug is nonetheless priced vastly higher, so insurers either relegate it to a “nonpreferred” tier with high deductibles and copays, or just don’t cover it at all.

I was not familiar with the term “balance billing,” but Olen’s definition is yet another precise explanation of my worries: “That’s the difference between what the insurer will pay for a service, and what an out-of-network doctor or laboratory bills you. Just because a hospital performing a surgery is in network, does not mean, say, that the anesthesiologist assigned to your case is as well.” Exactly. I’m not against “narrow networks” in theory, but as usual with health care there’s an information problem. I can (with much tedious effort) look up whether or not my gastroenterologist is in-network for a plan, but what about all the other resources she deploys, the laboratories, the anesthesiologist, etc.? It’s easy and perhaps natural to assume that “well, within a given facility or hospital system, if one provider is in-network then everyone else involved in treatment presumably is as well.” Easy, natural, but wrong. Ooops.

So… what? Olen argues that “It might be one thing if ACA defenders began to acknowledge that these issues are almost certainly behind a decent proportion of people’s unhappiness with Obamacare, and began demanding meaningful change.” I would suggest dumping the section I’ve highlighted in gray; I think one could easily get lost in a thicket of “real reason” arguments, and they’re beside the point. Whether or not people are right to be dissatisfied for the right reason or for the wrong reason, they are right to be dissatisfied with how things stand at present. Likewise, ideally we could sidestep the inevitable blame game; “The Affordable Care Act, after all, didn’t [create these problems.]” As I can and will tell anyone, it didn’t; I’ve lived with these festering issues since before anyone imagined that we would be discussing something called “Obamacare.”

But “it didn’t do much of anything to discourage any of this either.” Maybe it wasn’t supposed to. Here again we can argue until the cows come home about whether the ACA was mostly meant to expand “coverage,” or to reduce costs also; what we should be doing instead is recognizing that we needed to reduce costs, and still do, and that trying to promote cost reduction into existence through accentuating the positive may not really do it. Maybe it will, I could yet be wrong, but at this point I don’t believe it falls into the category of things that we should take for granted.

Unfortunately, I also don’t know what else gets done or when. The Republican party still shows zero sign of useful engagement with any of this. Barring a total implosion, I’m not sure where further legislative reforms will come from any time in the next five years. I suppose that one can imagine a Republican president taking office in 2017, the revanchist fever cooling a bit, and something helpful winning GOP votes in Congress… I think the complete implosion seems more likely, and I’m not expecting either one. Nor am I expecting another “executive action” measure to impose price controls, or some other “Obamacare Part 2” without congressional involvement. This may be hypothetically possible for all I know, but for all the empty burbling about a president that’s “got his groove back,” I don’t see an exhausted term-limited president grabbing the third rail all over again.

For the time being, I expect that the bleeding will simply continue. Steven Brill can declare that “We cannot pay for this,” and Olen can agree, and both may be right, but that doesn’t mean that relief must be imminent. It could also mean doing without. I hope they’re both wrong, meanwhile, and that something emerges, somewhere, to save me from the broken system that’s devouring almost every spare dollar I have and still looking hungry… I expect that some kind of renegotiated terms are in the future, at some point, somehow.

But I expect it will be a painful wait of years before we get there.

* Update, Jan. 26: Vox publishes a story headlined “Obamacare 2.0.” The actual story, by the indefatigable Ms. Kliff, does not use this term but it does seem like the administration saying basically “yes, we know, and we have been working and continue working to put more downward pressure on prices, as best we can without congressional involvement.” So, that’s something. After reading this I do wish they were communicating a bit more about such activities, not because I think it would shift broader opinion but because it might make me just slightly less morose… But, then, maybe quiet background efforts are the one, only way “an exhausted term-limited president” would do anything further with this issue.

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