On the right flank, there are the ever-ready health insurance companies (and all their employees), drug and medical supply and equipment manufacturers/distributors (and all their employees) and the dregs of the venal GOP has its standing army. Straight ahead are the AMA and Blue Dog Democrats. If necessary, AARP can be mobilized. And on the left flank are the unions that understand all too well that part of their strength derives from getting their members expensive health care insurance.
Tbhe rabble taking on those foes are the uninsured – low income and/or considered too unhealthy to qualify for health insurance - that portion of medical providers that don't want to spend their time and money on billings and getting authorizations for their patients, and those who are choking on the cost of their health insurance, deductibles, and/or co-pays and don't want any change other than reduced costs. The poorest non-disabled, non-elderly 25 milliondon't figure in the fight because they get Medicaid. No surprise that single-payer was defeated before the foes fired a single-shot.
(Full disclosure before I get accused of being a heartless, right-winger, if it were up to me, I'd nationalize health care. Bring our national health care costs in line with other industrialized countries. Unfortunately, the word "socialism" induces fear and loathing in too many Americans because that's how we've been socialized. If one is going to be labeled a socialist, might as well advocate for, you know, socialism.)
In one way or another, they'll defeat any public insurance option as well. Possibly by handing single-payer advocates a hollow victory: a public option that is guaranteed to fail because it costs too much or brings so few new insured individuals into the fold that it doesn't change the medical-industrial-complex.
The rub in this battle is that at some level all the combatants recognize that a significant portion of the US population gets too little care and that leads to higher total costs for everybody in the long-term. And at Atul Gawande detailed in The Cost Conundrum many get too much and not particularly good, but expensive, care. Skirmishes on common ground can be won. Make gains in that territory and future battles will be ever so much easier.
One of Gawande's most important observations needs more focus:
To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician.
That was reiterated in by Walecia Konrad in the NYTimes IS your medical insurance bad for your health? "If you have a high-deductible plan, the answer may be yes. ..."
As any doctor will tell you, small health problems left untreated can become big problems, warns Kathleen Stoll, director of health policy at the health care advocacy group Families USA. "This is just one of the many high-deductible pitfalls consumers need to watch out for," Ms. Stoll said.
Consumer pitfall according to Ms. Stoll. That's rot. It's a matter of national health. And we all pay for this ignorance, the insured and uninsured alike. As reported in the LATimes,Families USA also tells us
The question refers specifically to the amount passed along via healthcare premiums, not less tangible factors. And the answer is: $1,017 a year for family coverage and $368 for an individual policy.
Those are the figures in a new report from healthcare advocacy group Families USA. The introduction states:
"As the number of Americans without health insurance continues to rise, so too do the costs borne by those who have coverage, who face what might be called a 'hidden health tax.' Private health insurance premiums are higher, at least in part, because uninsured people who receive health care often cannot afford to pay the full amount themselves. The costs of this uncompensated care are shifted to those who have insurance, ultimately resulting in higher insurance premiums for businesses and families.
Too bad they can't tell us how much of the additional $1,017 or $368 cost to the insured is because the uninsured are forced to use hospital emergency rooms for primary care and untreated minor problems that became major problems. (Or is that an intended omission because the number wouldn't be significant in the overall health care costs of those with insurance?) The truth – if it could be determined – is immaterial when a "fact" is so naturally and symbolically rich. Everybody would be happy if hospital emergency room weren't burdened with providing primary health care to poor people.
Can we all agree that primary and preventative health and dental care is the most cost effective component in national health care? (Even the evil health and dental insurance companies agree with that.) Don't we all agree that primary and preventative health and dental care is a right? (If not, why do local/state governments bother funding any public clinics for the uninsured? Why do we allow the uninsured to use hospital emergency rooms for primary care? Why do we fund and administer Medicaid for the poorest of the poor? Fund S-Chip for lower income children?) What we can't seem to do is shoehorn that into our private, "free market" health care delivery system. Insured and uninsured alike too frequently skip preventative care because it comes packaged with deductibles and/or co-pays that they either can't afford, they don't have easy access to, or they assume isn't worth the money when they are well.
Can we all agree that employers that provide no health insurance benefits to their employees are getting a free ride? That those employees are forced to take advantage of Medicaid, use whatever underfunded public health clinic is available, or show up in hospital emergency rooms? Can we all agree that billing third parties for low-cost services rendered adds a disproportionate cost component to that care? Can we agree that doctors and nurse practitioners need no instruction in providing good primary/preventive care? Can we agree that a major component to patient satisfaction is both time and quality of the patient's interaction with the physician?
Build It and They Will Come
That's exactly what Rural Area Medical – RAM - "Pioneers in No-Cost Health Care" has done. As reported almost two years ago in the NYTimes:
And so each summer, shortly after the Virginia-Kentucky District Fair and Horse Show wraps up at the fairgrounds, members of Virginia Lions Clubs start bleaching the premises, readying them for RAM’s volunteers, who, working in animal stalls and beneath makeshift tents, provide everything from teeth cleaning and free eyeglasses to radiology and minor surgery. The problem, says RAM’s founder, Stan Brock, is always in the numbers, with the patients’ needs far outstripping what his team can supply. In Wise County, when the sun rose and the fairground gates opened at 5:30 on Friday morning, more than 800 people already were waiting in line. Over the next three days, some 2,500 patients would receive care, but at least several hundred, Brock estimates, would be turned away. He adds: "There comes a point where the doctors say: ‘Hey, I gotta go. It’s Sunday evening, and I have to go to work tomorrow.’ "
Virginia is in the US – the country with the finest health care in the world – and people have to line up at fairgrounds for once a year basic health and dental care. Care that a "public option" isn't going to give them because they are too poor for that. And this situation isn't limited to rural America. It exists everywhere.
No, I'm not suggesting that we run a national primary and preventative health care system with donations and volunteers. Health care providers should be paid just like teachers, police, and firefighters are paid. Nor am I suggesting that such a system is a panacea to the health care crisis in this country. I am suggesting that everybody could have have the option for at least this level of care for "free." It could be accomplished three times faster than it would take to implement a "public option" that merely cuts the ranks of the uninsured in half. As it will cut costs, without cutting revenues, for the health insurance companies, they might become advocates instead of foes.
-- Later – details on how to get from here to there and how there greatly expands the range of possible future courses from the cramped current debate over health insurance. --