Thursday, February 25, 2010

Why the Republicans are Wrong on Healthcare

Just a brief note on the president's health care care summit that is taking place today. First of all, I agree with David Gergen on CNN this afternoon that this represents everything good about our country and our way of government. Sure, nothing will come directly from the interaction today, but it shows the American people that beyond all the electioneering rhetoric and silliness of "death panels" and "socialism", our elected officials are thinking about health care and that solutions exists. Very few nations in human history could have such a substantive discussion.

A couple days ago, Sen Orrin Hatch was on CNBC and said that requiring people to acquire health insurance is unconstitutional-- and it may be. Sen John Kyl, another Republican, re-iterated the meme against universal coverage with the argument that it would increase the average premium by 10-15%. President Obama retorted with the fact that this is a comparison between apples and oranges, since the Democratic bill requires a more comprehensive insurance coverage as opposed to the cheaper catastrophic policies that a lot of marginally insured folks have now. Obama made the point that such catastrophic policies are not health insurance but rather home insurance since it only protects someone from losing their home in the event that a major health issue drains their finances. It does not insure health since it covers no preventive care or regular visits.

Sure, some wealthier folks do not need anything more than a catastrophic policy and could pay out of pocket for most expenses, but that is the exception and not the norm. Even so, I see no problem with individuals doing their own analysis as to how much coverage they need or desire... but remember the consequences if their analysis is wrong.

Rep. Clyburn, a South Carolina Democrat, gave an example of a local hospital telling him that their Emergency visits increased by 31% over the past 3 years and that most of those people were uninsured or under-insured. The reason that folks are using the ER is because physicians offices do not accept their (under)insurance-- such as Medicaid-- and the people do not have cash to pay upfront. Clyburn never mentioned why these folks end up in the ER-- the reason is because acute care hospitals are required by law to see them. Clyburn never mentions that the hospitals and the doctors on staff do not get paid for seeing these people. Even if someone has cheap insurance-- a catastrophic policy-- the deductible may be $1500 or $2000, and these people have no intention of paying anything, that is why they go to the Emergency room.

This goes back to my same old thesis: if you believe in the free market and people making their own decisions, then repeal the Emergency Medical Treatment and Active Labor Act (EMTALA) that compels hospitals and affiliated physicians to treat everyone regardless of their willingness to pay. This will revolutionize medical care finances. The Republicans keep saying we should allow individuals to make their own choices, but yet they do not have any intention of allowing individual physicians or individual hospitals to choose not to see Medicaid patients or nonpaying patients. At least the Democrats realize that the mandate should be funded somehow.

Without EMTALA laws individuals-- doctors and patients-- can have all the choice they want. If their kid has a fever of 105 degrees and all they have is Medicaid... oh well, they can try to convince someone to get up at 3:00 AM and see him for $25. Senator Kyl is from a big square state (Arizona) and they have this fetish about people being in charge of their own destiny. Great. But if he wants to live in a world red in tooth and claw, then he should stop telling doctors and hospitals that they must see people for free.

Some conservative thinkers do not feel that EMTALA is a driver of increased costs. John Graham says that "uncompensated care" is a small fraction of the ER load. Sure, but what about "under" compensated care? Medicaid pays only 18 cents on the dollar. Furthermore, Graham concentrates on hospitals reimbursement and argues that non-profit hospitals should shut up and absorb the costs. Okay, but "hospitals" don't treat patients, doctors do. EMTALA compels physicians affiliated with acute care hospitals to take turns seeing patients regardless of the payment.

EMTALA was signed in 1986 by Ronald Reagan, and both Democrats and Republicans have strengthened this mandate over the last 20 years. My belief is that this is a primary driver of health costs since the loss of funds from under-insured ER visits is simply passed onto private paying customers. And the ER is the most costly department in the hospital. Furthermore, poor folks without insurance will wait for a small problem to become a big problem before going to the ER for "free" care. Not only are we all paying, but we are paying for a bigger problem that it would have been otherwise. Pay doctors a fair wage and that poor family's kid would have been seen in the office last week and the fever never would have been 105.

Also, the Republicans authored, championed and passed the Medicare Part D prescription drug benefit in 2003 which President George W. Bush signed into law. This is a huge entitlement, funded with borrowed capital, that did three wonderful things for the Republican party: 1) it gave a large entitlement to their primary voting block, seniors, whether those seniors needed it or not, 2) it promised to pay drug companies 100% of the retail cost of all drugs for seniors with no negotiating, thus paying off their industry overlords, and 3) pretty much required any senior on medication to sign up for a privately administered Medicare Advantage plan, thus paying off their other block of industry overlords. Cost of Medicare Part D is projected to be $727.3 billion over 10 years.

So the Republicans are hypocrites. Yes, one could argue for a free market health care system. Consumer information is available and perhaps we should open up health care to all the vagaries and vicissitudes of the free market. If that's preferred, then why didn't the GOP do that with Medicare Part D? If we are to do this with health care in general, then let's engage is full disclosure: people will die from preventable illness. If they try to game the system or are hoodwinked into a crappy policy by a slimy insurance agent, then their care may not be covered. Physicians should be able to demand payment upfront-- just like grocery stores and gas stations-- and all of a sudden the lack of financial acumen can lead to some one's death. One morning you wake up with the world by the tail, and by evening you're dead from acute appendicitis-- all because you didn't read the fine print on your insurance policy.

Another thought I had was when Kyl or someone said that our nation is too diverse for a comprehensive health care policy. Maybe so. It occurs to me that other western nations have populations of between 40 and 80 million folks. Perhaps we should split the nation into 5 regions-- Northeast, Southeast, North, Midwest, West-- since each share various political leanings and each region can decide how comprehensive their health care should be. Again, be warned, if you have crappy insurance from South Carolina or Oklahoma, and you end up in my Emergency Room, then you better have cash my friend.

I'll have Senator Kyl's office number handy to give to patients.

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