Monthly Archives: October 2013

Why I <3 ObamaCare, and You Should Too.

This grew out of a comment on a friend’s Facebook timeline, and I figured if I was going to spend as much time as I have this past week tediously typing parts of this with my thumbs, I might as well get it all down in one place, and then I can point people to it instead of having to try to explain it over and over in bits and pieces. So here goes:

I spent a great deal of time over the past 10 years digging into the issues with our health care system. It was not entirely voluntary, so don’t start thinking I’m some kind of super-duper truth-seeking zealot. I was in school for much of that time, and the health care system is, not surprisingly, a pretty important thing to know about when you’re in a health care profession, and I had to do a lot of analyzing and writing about all of this stuff in order to graduate, and convince my master’s committee I had achieved the level of knowledge and expertise required in order to be awarded my degree. As a result, I got pretty intimately acquainted with what the problems are and where we were headed, and why things needed to change, radically, if we wanted the system to stay around much longer. I read the original proposed healthcare bill in its entirety, and let me tell you, that was NOT fun. I waded through pages and pages of congressional testimony, and mountains of data, and…well, just take my word for it. You’re about to profit from years of mental pain and anguish on my part, at absolutely no charge. You’re welcome.

Along the way, both during my years in school and since entering the health care work force full time, I’ve also spent a lot of time getting up close and personal with the issues affecting our uninsured population, the barriers they face, and the impact that not having access to adequate health care has on them, their lives, and the rest of us. And I’ve had to let go of a whole lifetime of erroneous thinking and preconceived notions.

Before any of that happened, however, I lost a 6-figure job to the tech industry crash, and got an intense first-hand crash-course education in just exactly how little difference there really is between any of us and those people standing on street corners with cardboard signs. We were frighteningly close to ending up there ourselves, for a while. At the same time that we were trying to figure out how to keep one step ahead of having to fight for a spot to sleep under an overpass somewhere and scrounge up a piece of cardboard for our own panhandling sign, I also had to face the sudden and very uncomfortable realization that I had done a lot of judging in the past, toward people whose lives and circumstances I had made a lot of assumptions about but that it turned out I knew absolutely nothing about. I had, like so many others who have lived lives blessedly free of real hardship, the stupid notion that I somehow deserved my comfortable middle-class upbringing, when I really did nothing at all to earn it. It was just a random coin toss of fate that let me be born into the family I was born into, rather than into a poor, lower-class family where I would not have had the opportunities life had given me. I was no better or more deserving than the homeless guy on the corner. I had just been more lucky. But that’s a whole ‘nother story that’s already been documented elsewhere. Finish reading this one, for now, and then if you’re interested, I’ll give you the link to the other one. There’s even a movie to go with it. For real!

Anyway, here is a very simplified (as much as I can, anyway) explanation of why ACA (“ObamaCare”) was implemented and why is is absolutely essential that it go forward, and why it is actually a GOOD thing for our country and for us as individuals:

Since EMTALA, the law that says emergency care must be provided regardless of ability to pay, was enacted, but with no provision for funding it, medical costs have skyrocketed. Hospitals have to eat those unpaid bills. In order to stay afloat, that means they have to charge everyone else more to cover the costs they have to absorb. And emergency department things are much more expensive than things elsewhere in the hospital, so everything ends up costing a whole bunch more in order to make sure the hospital can afford to keep operating.

Also, when someone doesn’t have access to health care except via the ED, that means they can’t just go on in when they start to notice a problem. They have to wait until it’s bad enough to actually be considered an emergency. So, for example, instead of having their diabetes diagnosed early enough to treat it and keep it from progressing, they end up in the ED with a gangrenous foot ulcer that results in weeks in the hospital, possibly culminating in an amputation, then months of rehab, followed by disability, because now they have lost their leg and can’t work. And all of the costs for all those weeks/months of hospitalization, surgery, and care gets eaten by the hospital. Oh, they’ll bill the poor newly disabled person, of course, and the person will end up having to go bankrupt, and now their health is gone, their leg is gone, their job is gone, and so is their home, if they had one, and everything else.

Oh, yeah. All those millions of uninsured Americans out there? Over 2/3 of them are hard working people with full-time jobs, not the deadbeat freeloaders your far-right political leaders would like you to think they are. The disabled unemployed ones you probably picture when you think of “uninsured” are actually quite likely to already be covered by Medicaid. So take a moment to try and readjust the mistaken impression you’ve had so carefully implanted in your brain.

Got it? Okay. Let’s continue:

Let’s go back to the skyrocketing medical costs for a moment. They’re the highest in the world, by a huge margin, despite pretty mediocre results when you look at markers of population health. It’s a pretty sad state of affairs. Our infant mortality rate, one of the primary measures of the quality of a nation’s health care, is abysmal. Even some third world countries have better infant survival rates than we do.

Despite the huge inflation of medical costs in order to try to cover all the unpaid stuff, and cutting back staff so much that it impacts quality of care and threatens patient safety, a scary percentage per capita of hospitals have closed their doors over the past 20 years. I won’t try to quote the statistics, because I’m not sure I remember them correctly now, but it’s pretty staggering. An even larger percentage of emergency departments have shut down, since if a hospital doesn’t have an ED, they aren’t subject to EMTALA. Often, though, by the time they resort to such extreme measures it’s already too late, and the hospital goes under anyway. The most realistic projections, based on the rates of increasing medical costs, the economy, the increasing numbers of uninsured Americans and chronic illnesses, and the rate of hospital closures, are that we’d probably lose our last emergency department by the year 2020. And most of our hospitals.

That’s scary, boys and girls. Because no matter HOW rich you are, and no matter how stellar your health care insurance plan may be, if there’s nowhere for you to go for medical care when you have a massive heart attack in the middle of the night, you ARE going to die, and all your money won’t do you a bit of good.

Okay, try to stay with me. I’ve simplified this as much as I can, but there are still a lot of contributing factors you have to comprehend in order to get it.

Higher medical costs result in higher insurance costs. We all know how insurance works. It’s based on a very informed statistical prediction of what the likelihood is of a thing actually happening. Some of us pay homeowner’s insurance for years, for example, and never have anything happen that the insurance company has to cough up for. And, unless you’re fabulously wealthy and can afford to pay cash for your home, you are required to buy homeowner’s insurance in order to get a mortgage loan. So the insurance company is able to stay in existence and make a profit because they are collecting insurance premiums from far more people than they’re having to pay out on.

With medical insurance, however, there’s traditionally been little incentive to pay for it if you are a healthy person, and the more expensive it gets, the fewer people can afford it, until pretty much the only people who have it are the sick people, who are actually going to USE it. That makes medical insurance a risky business. For the insurance companies to stay afloat, they have to find ways to collect more money than they pay out. They’ve had to charge even higher premiums, as well as find any excuse they could NOT to pay as many claims as possible. Which, naturally, has not made them very popular, except with the book and movie industries who’ve profited from the resulting drama potential.

Here’s another important issue: Since our country has traditionally relied on employer-based healthcare, it impacts our industry, and our nation’s economy, too. (And this part I’ve oversimplified to a degree that borders on criminal, because economics hurts my brain.) It’s more and more expensive to employ Americans, because it costs so much to insure them, and that makes our goods and services more expensive, and makes it harder to compete in the world market. That’s why many companies have taken to moving their manufacturing overseas. Here’s a thing that really surprised me, though: if you looked at a graph of corporate and individual income levels over the past few decades, you’d notice that for the most part corporate profits have continued to rise pretty much at the same rate as they always have. Cost of living has also continued to increase. Individual income, however, which used to keep pace with the rise of corporate profits (and for reasons I have trouble comprehending, is supposed to do so, to keep the economy healthy), has flatlined. Are you getting that? Corporations are still making money and getting richer. Individuals, however, are getting poorer, because a dollar in today’s economy is not worth as much as a dollar was a few years ago. So when our salaries don’t increase, but everything else does, we’re actually getting poorer, even though we’re the ones making it possible for the corporations to get richer.

So why is this happening?

Well, employers aren’t going to give up their profits to cover the ever-increasing cost of providing healthcare. Sorry to break this to you, but your employer really doesn’t love you. You are a commodity. If they have a choice between making themselves poorer or making you poorer, guess who’s going to get poorer? So the way they pay for the increasing cost of providing you with employer-based healthcare is by continuing to pay you the same salary, instead of giving you the periodic increases you should have gotten to match the company’s growth. Companies keep getting richer, while their employees keep getting poorer as the cost of living goes up and their salaries don’t. That healthcare your employers have been “providing” you, you’ve really been paying for yourself. Part of the cost is deducted from your existing paycheck. That’s the part you can see, but it’s not really all you’re paying; it’s only a fraction. The rest comes in the form of the paychecks you might have gotten, if medical costs and therefore insurance costs hadn’t increased so much more rapidly than everything else.

But Americans don’t realize this is happening, because Americans only believe what they can see. And the raises they aren’t getting are invisible to them, so they just don’t exist, even though from an economic standpoint, they really do.

Stop again for a moment, because you need to let that sink in. Your money is being taken from you before you even get it, and diverted to pay for the cost of health care for the millions of uninsured people in this country. It’s like in the old west, when the bandits would rob the stagecoach before it got to the bank. That money belongs to you; you just don’t know it yet. And they think what you don’t know won’t hurt you, but it’s hurting all of us.

A few years back there was an experimental project in California that put some hard numbers to the difference between providing emergency care or primary care. This project focused on the homeless population, because they tend to be one of the most expensive populations for hospitals to provide medical care for. On average, it costs us (in that invisible money that gets stolen from us before we get to even enjoy the thought of getting it) $100,000 per homeless individual per year. So this one hospital identified their most expensive “frequent flyer” homeless emergency department patrons. They provided them with housing, food, and basic primary medical care. And then at the end of a year (it may have been longer; the details are fuzzy now) they took an accounting. I can’t remember the final per-person cost for certain now; I want to say it was like $12,000, but just to be safe, let’s call it “under $20,000.” They went from paying more than $100,000 in medical care for each of these individuals to paying only $20,000 (or less) per year, and that was for not just their medical care, but also their housing and food.

Okay. So if I came along and told you that you were going to have to do your part in making sure everyone in this country has health care, but I gave you a choice: You can have the equivalent of $100 per paycheck deducted from your annual salary before you ever see it, or you can have $20 per paycheck deducted and shown on your paystub, which would you choose? Seriously, if you would actually prefer the $100 option, email me, because I’ve got this bridge I’d love to sell you…

Are you getting the picture yet? ACA doesn’t mean we’re going to START paying for other people’s health care. ACA means we’re finally going to get to reduce what we’re paying to a much more reasonable amount, AND get better health care coverage for all of us in the bargain. Well, all of us who don’t live in states whose governors turned down the Medicaid expansion, that is. But that’s another post, and plenty of people have already written that one, so I’ll get back to the one I’m writing…

So, along comes ACA, with a way to shift the costs. If everyone is insured, then there’s more money available for insurance companies to pay for medical things for those who need them. Hospitals don’t have to eat the cost of providing care to as many people, because everyone has insurance, and the insurance companies will pay for their care. And the insurance companies can do this, because the pool of money now isn’t just coming from the few people who are actually going to need payouts. It’s now like the homeowner’s insurance; a lot of people are paying into the system for care they won’t end up actually needing. And yet, the amount they’re paying is far less than the invisible amount they were paying before without knowing about it.

And, and this is HUGE, people can get treated BEFORE their illness gets so bad it becomes an emergency, or a chronic condition requiring repeated trips to the ED. That guy before with the diabetes? Instead of paying for his amputation and rehab and taking care of him for the rest of his life? You’ll only be paying for his primary care doctor to teach him how to change his diet, and prescribe him some medication to keep his blood sugar under control. Guess how much cheaper that is than doing it the other way?

Hospitals will stop being broke because they will get paid for services, and medical costs will even out over time. Not all at once, because this mess has taken a long time to make, and it’s going to take time to fix it. But it will happen.

They’ll also be able to actually hire adequate numbers of staff, so care and safety will improve. Nurses can take care of patients again, instead of having to also do secretarial and housekeeping duties. People will be able to work and continue being contributing members of society and be healthy instead of being chronically ill and miserable and going on disability. Insurance costs will level out as medical costs do. Employers will be able to raise salaries appropriately without cutting into their profit margins, and people will be able to afford to live because their income will better keep up with increased cost of living. The economy will improve.

And, 10 or 20 years from now when that heart attack hits? You’ll be able to go to an emergency department and get the care you need. And you probably won’t have to wait 4 hours or be treated by overworked doctors and nurses trying to juggle more patients than is really safe. And you’ll recover, and go home, and see your grandchildren grow up. And so will a lot of other people who would have died years earlier if we stuck with the status quo.

Change is hard. It’s uncomfortable. It’s upsetting. But things that don’t change stagnate and die. Change is how we grow, and get better.  Think of it as an investment. Pay now, profit over the long term as the system rights itself. And have the peace of mind of knowing your children and grandchildren will not die for lack of emergency medical services if their appendixes rupture, or they fall out of the neighbor’s tree and break their arms and legs, or get hit in the head with a baseball.

It’s win-win for America. Period.

Oh, yeah. If you still want the link to that other story (and the movie to go with it), you’ll find it here: The Accidental Op-Ed

Posted in Deep Thoughts, Nursing | Tagged | 4 Comments