Monday, January 25, 2010

Health Care = Big Government

No shit.

Bill O'Reilly, despite his Masters degree in Public Administration, never has a solution to any problem. He's a smart guy who can find the festering purulent ulcer emanating from the diabetic's leg, and he may even know how to debride and dress it, but he won't.

Here's the deal: there are two possible solutions--- and only two. One, we can provide health care for everyone and fund it with consumption taxes, ie, clean up the wound, or two, we can amputate the leg, by stopping all mandates for hospitals and doctors to provide free or below-market care. Both will work equally well, but very different in their level of difficulty and pain and outcome. I'll start with the second choice.

Choice #1 : Amputate the leg (= Repeal EMTALA)

First of all, this is not a call for ending old folks' Medicare, far from it. This is a call for the right wing approach of allowing the free market to call the shots and getting "Big Government" out of health care. The metaphorical "leg" in this scenario is the EMTALA statute (Emergency Medical Transfer and Active Labor Act) that requires all acute care hospitals that accept Medicare to also accept everyone regardless of the ability to pay for services. Repeal that law and let the "free" market sort it out. No more Big Government.

When I was an intern on the general surgery rotation, the chief resident handed me the giggly saw for an above-knee amputation. Exciting as it was, even I understood that his thought was that even a first year gynecology resident can do this.

Sounds simple, and it is, but amputating EMTALA would completely revolutionize health care in this country. EMTALA is the primary driver of rising health care costs because hospitals and physicians must shift costs for underpaid and free care over to the paying customers. If Needy Ned comes in with an acute appendicitis, he has to get treated-- by law-- and only later does he decide if he's going to pay. The hospital is not allowed to require payment at the time of service and cannot transfer him to another facility under penalty of law.

What does this mean? This means that the ER doctor, the surgeon, the radiologist who reads the x-ray, and the pathologist who prepares and reads the surgical specimen, all work for free. The hospital must provide nurses, technicians, operating room personnel, housekeepers, patient transporters and pay all their salaries. Then we have the overhead expenses: electricity, heat, rent and liability insurance. All fixed and variable costs provided for free. And these costs are met by shifting them to the person in the next gurney who does have insurance... which is the largest reason why health insurance premiums are rising so dramatically.

And Bill O'Reilly, with his Harvard degree, knows all this, remember that.

Likewise, Medicaid does not cover costs, so it's barely better than nonpayment. It pays 18 cents on the dollar of private carriers and about one-third of Medicare. Physicians are not required to take these patients in their offices, but hospitals must accept them for urgent and emergent care. As part of EMTALA, hospitals must make available certain specialists as well as primary care for 30 days following an ER visit. Most acute care hospitals make physician privileges contingent on covering the emergency room patients so this is a form of endenturement. If they cannot coerce physicians, then they often pay a stipend to local private doctors or they hire an entire staff of doctors and nurses for indigent care. Expensive.

As the economy falters and people lose their jobs, and thus their health insurance, more and more folks will qualify for Medicaid or go without insurance. If hospitals could require fair payment for services and turn non-payers and under-payers away, then Medicaid would have to increase reimbursement to something closer to Medicare fees.

Will increasing Medicaid reimbursement increase health care costs? Answer: No. The costs are already high and are already being paid since they are merely shifted to paying patients. The problem is that since outpatient access for Medicaid patients is so low-- because very few doctors voluntarily accept their payment-- these patients over-utilize the emergency rooms and this pushes up costs astronomically. Pay primary care docs a fair wage to see them in their offices and they could prevent many of these expensive ER visits. Penny wise versus pound foolish.

Without EMTALA, people will die; that's the painful part. But the free market is brutal and guys like Bill O'Reilly and Eric Cantor and Mitch McConnell and Glenn Beck are hypocrites to blabber on about the benefits of the free market but then conveniently leave out the down side. I have heard not one pundit or politician or tea-bagger broach the repeal of EMTALA because they know that people will die. It's easy for these assholes to compel doctors by law to take care of people for free. Furthermore, I have not heard of one left-winger bring this up-- and I think this is the crux of the issue. Shame on all of them.

The Supreme Court just ruled that corporations have personhood rights when it comes to financing elections, so why don't hospital corporations have personhood rights to refuse low reimbursement for services? Food is necessary for life, yet grocery stores are not required to hand out free food to nonpayers. My plumber isn't required to fix my leaking hot water heater without payment.

But in the long view, costs will be saved. Private insurance premiums will decrease as hospitals and physicians stop shifting costs around. Free marketers can set up charities to provide insurance for poor people if they are so inclined, or not. If not, then society will be relieved of the burden of all these irresponsible and poverty-stricken freeloaders. Whatever.

Sure, do all the other free market stuff, too, to get "Big Government" out of health care: allow insurance to be sold across state lines, provide for health savings accounts, require doctors and hospitals to post prices for shoppers, give private citizens who purchase insurance the same tax breaks as employers, or better, do away with tax breaks altogether for health insurance. NO mandates for insurance, no price fixing, no opacity. But the repeal of EMTALA is part and required parcel of any free market renovation of the health care industry.

After ten years of Republican control of Congress, they had only made EMTALA more restrictive which only decreased the influence of the invisible hand on health care. Also, Medicare Part D, a Republican baby, is a biggest cost-plus government boondoggle since the stealth B-2 bomber. They know all the buzz words for free market, except for the most important one: EMTALA-- yet the GOP has no intention of ever making health care, or anything else for that matter, an actual free market.

Choice: #2: Debride and Dress the wound (= fix the system)

Actually, we have no "system" per se in health care in this country, only a patchwork of plans, facilities, and payers without any rhyme or reason. Each insurance payer has different standards and fee schedules. Some pay more for primary care and less for specialty care, and others the opposite. Some pay for screening exams, others don't. The only consistency is that all the private payers vie vociferously for the healthiest and wealthiest patients. And the rest go on Medicare and Medicaid, or go without insurance.

Does Medicare lose money? Sure, but maybe it's because they take the oldest, sickest and most disabled of the citizens while the private companies have all the younger and healthier ones. This is yet another case of privatizing the profits and socializing the risks. I think Medicare does a better job than any other payer in managing the huge risks at relatively low cost. Of course, it's impossible to compare Medicare with private companies head-to-head because we have no public option or Medicare-for-all plan.

My suspicion is that the most important issue for Aetna, Wellpoint, United Health, etc during this recent health care tirade was to strike the public option from the legislation. They could live with any other provision as long as they were not compared head-to-head with Medicare-- then we would all know how inefficient and egregious these private payers really are. If Medicare were allowed to take on healthy working folks who pay private premium rates, my guess is that it would compete very well with Aetna, et al, and Medicare would actually flourish.

In the current set up, if one of the healthy and wealthy gets sick, there is a better than even chance that they will be dropped by their insurance and never qualify again. One person I know has an infant born with a congenital medical problem, so he can never quit his job or he will lose his insurance forever. Forever.

So here's what the progressive Democrats have to do: submit two bills to Congress. The first restricts private insurance from using pre-existing illness as a criterion for disallowing benefits. The second bill prohibits insurance companies from dropping enrollees when they get sick or lose their job. That's it.

Nobody would dare argue with these simple requirements. Polling shows that a vast majority of voters agree with these two restrictions. If Republicans argue or want to add other provisions, remind them loudly that they were the ones who wanted line item votes on every single aspect of health care-- no huge omnibus bills, no "Big Government". And these bills will pass with only 51 votes.

The next sound we would hear is the plaintive screams from private insurance executives whining about how unfair this all is. They can't be required to insure sick people! How will they ever be profitable!? How will their executives ever be able to afford yachts and Swiss ski vacations!? They will plead for an insurance mandate, a law requiring every healthy 25 year-old to purchase one their insurance products (which, by the way adds no value to health care.) This, they will argue, is the only way to ensure a large enough risk pool to enable the above restrictions.

Okay, the progressives say, we have mercy on you; you can have your mandate to go along with the pre-exiting illness and loss of job restrictions.... BUT, then we have to add the public option AND an expansion of Medicare to 55 year-olds, for no other reason than to allow a trial period of head-to-head comparison to see how costs flesh out. If they balk, then fine, we'll just institute the popular restrictions and move on, and they can whine to themselves.

The other free market stuff like fee transparency, selling policies across state lines, health savings accounts, tort reform, etc., can be added later, or not-- none would have a material effect on either health costs or access and they merely serve as pet projects for specific interest groups. So go for it.

My surmise is that the eventual finding would be that publicly administered health care, ie, Medicare, would become the most popular choice as costs are saved with economies of scale and premiums become more affordable. Buying drugs, billing, authorizing treatments would all be done on such a huge scale that costs would be slashed. The added value would be the huge data base that could be assembled to look at treatment outcomes, cost analysis and ways to improve access.

And if the federal program isn't efficient, then private payers would garner a larger and larger niche and the experiment would end.

Similar to postal service, where the federal government competes with private carriers, the health field would have true choice. The post office has the added mandate to provide home service to every rural outpost and domicile, and despite this constraint, they operate with very similar profit/loss numbers as Federal Express. Can it be improved? Probably, but it's in the ball park and I know of nobody that doesn't hesitate to use the US Post office to pay bills and send important mail-- all cheaper than private carriers.

After a few years, my guess is that Medicare-for-all would become a popular request as people find that their 55 year-old relatives are not dying in droves and they often see the same physicians and go to the same hospitals as their privately insured relatives do. Sure, some would eschew federally operated health care, and that would be fine. And we would no longer need EMTALA laws since everyone would have decent insurance.

Likely, we would continue like France and England with public and private systems operating side by side, competing and improving outcomes.


Either one of these plans would work, but ignoring the problem would be a mistake. If the Republicans hope that the recent negation of health care reform will table it for another 16 years, I would like to think the Democrats will disabuse them of this notion. We cannot afford to spend 18% or 20% of our GDP on health care. The lousy access is literally killing people and this is not appropriate for an advanced society. Whining about who is going to pay for all this health care is outrageously idiotic: you are already paying for it, and then some. To delay reform is only more expensive.

Everyone is covered already, we treat health health care as a de facto right in this country-- that's why nobody is rushing to repeal EMTALA. The next time some teabag troglodyte or Fox News 'tard rails on about "the free market", remind them that we haven't had a free market in health care for a long time, if ever.

1 comment:

tgutwald said...

Thoroughly enjoyed the post. I will excuse some people for not talking about repealing EMTALA as long as they support an insurance mandate which would render EMTALA moot.