Osama bin Laden's dead. Is it OK to focus on something else now, like maybe something I care about? I'm obsessed with health care and I think temp body shops should be outlawed. The issues are closely linked.
I haven't posted to this diary in a while now. My excuse is that I've been ill, very ill, largely incapacitated and very close to requiring hospitalization. How I got to that point before securing medical attention has become the all-too-common American experience. Minor afflictions go untended until it becomes obvious that the condition is progressively getting worse and that further delay might mean permanent disability or even death. All of us, except the very, very wealthy have a point up to which we will hold off seeking treatment, speculating that it's something small that it would be more trouble to see a doctor about than to "tough it out" and make do with home remedies and over-the-counter medicine.
All over the world, people resist going to a doctor when they ought to for various reasons. I can be a cultural bias, as in, "I don't like doctors and I don't trust them!" In the developing world, it might boil down to the perception that doctors kill you because people go to them when they become so ill that the local curandero or other traditional practitioner can't help them. The ill person goes to the nearest clinic far too late and dies. Availability plays an important role as well. If the clinic is a two-day donkey ride down the mountain, one is likely to hold off for a while in having that bad cough seen to before undergoing the ordeal of making the trek to the doctor. But, by far, the greatest disincentive, world-wide, to seeking medical attention in a timely manner is out-of-pocket cost.
Ah, there's the nub of it! If it costs you anything at all to see a doctor, one does a cost/benefit analysis on the probability that the condition might be serious enough to cost you a lot more money if left untreated. How serious it has to be depends entirely on one's personal finances. For the uninsured, paycheck-to-paycheck worker, going to the doctor often means not only foregoing a day's pay, but being fired as well. If you miss work, they discharge you immediately because there's always someone in the reserve army of the unemployed ready to step in and replace you. This is why workers will drag their aching bodies to work until their boss ejects them from the workplace saying, "You're too sick work. When you get back on your feet, and you're no longer a hazard to yourself and your co-workers, come in and I'll see what I can do. Of course, I can't guarantee you a job. I need healthy, productive workers, not people who are out sick."
The truth is that the worker has been penalized for being sick. His or her personal well-being is irrelevant to the employer because there is no incentive to make it worthwhile for that particular worker to recover and return to work. Employers take their pick of the most able and productive workers as often as they care to, which mostly depends on the amount of training and ramp-up time required to make a replacement worker fully productive. If it takes 15 minutes to teach you your job, then one too many coughs during the course of an hour, or just a little too much sweating and indications of being dizzy, means that you get the sack. Poof. You're gone. Next! If you've never read The Jungle by Upton Sinclair, do so at your first opportunity. For those of you who have, note that the paradigm of the worker selection at the slaughterhouse gate still exists today, pretty much intact, for low-wage, low-skilled workers. For those of who have not read the book, ponder the similarity between that scenario when you read it, depicting the state of labor a century ago, and the day labor lineup of mostly undocumented workers in home improvement store parking lots.
Being a disposable worker, discarded like a used tissue when you become just slightly less profitable than another, is not solely the province of the underclass. "Temps", or contingency workers, are hired by business entities who do not directly use the worker's labor. The "body shop" recruits and selects workers to fill job orders from operative firms. The worker is presented to the hiring manager of the client firm to be interviewed and assessed. Once the worker is approved, he or she is hired by the temp firm and farmed out to the client firm on an employment-at-will basis. That means that the firm where you actually work can dismiss you at the drop of a hat, and will do so when it sees fit. The worker can quit any time, too, but this rarely happens because workers generally want to work and earn a living. Even if work conditions are bad, the pay is low and you dislike your co-workers, the alternative of not having a job at all is probably worse. Thus, you get brought in when they want you and chucked out like trash as soon as they don't.
When you get sacked by your workplace supervisor, you are escorted out of the building at once by your handler, the temp shop's liaison with the client firm. You may not communicate with the work boss or other workers inside your former workplace again. They're done with you and do not want to waste any more time and money on you. You prudently abide by this constraint because you agreed to it in your contract with the temp shop.
The client firm pays a steep price for this flexibility; it's billed by the temp shop at an hourly rate about three times the hourly rate received by the worker. In exchange for 2/3 of the money, the temp shop cuts your paycheck, makes the deductions for SSI, medicare and income tax withholding, kicks in the employer share of SSI and medicare and remits the total amount due to the government. At the end of the year, they issue a W-2, just like a real employer. The difference is that unlike a real employee of a firm, a temp has no right to redress of grievances, no security, no career path, no opportunity to learn in the workplace and become expert in a job, and no benefits of any kind. All the laws we have about unjustified termination, retirement plans, health insurance, equal opportunity in the workplace and issues of common decency about which an employee might sue are all neatly bypassed. You've got no rights, but they offer cash money in exchange for work, so you take what you can get, buckle down and put your nose to the grindstone.
Most importantly for you, being terminated by your work boss means that you also immediately cease to be an employee of the temp shop. The cute part is that all the responsibilities of the temp shop as your de facto employer are conveniently vacated. They don't need to do anything for you at all. If you're enrolled in the crappy 401(k) plan they offer, you can cash it in, roll it over into something else, or let it ride and resume making contributions if and when that same temp shop gets you another gig. Actually, they try to do this as soon as they can because having been hired before means that you can get hired again. And, as your employer of record, they don't have to kick in for unemployment compensation benefits if they offer you employment and you refuse it. The state stops the checks, so they don't dun the temp shop for their share.
You don't get stupider just because someone doesn't like your work; it only means that they were not getting their money's worth out of you. The worker's labor has value, but businesses prefer to avail themselves of it on their own terms. Dealing with human beings as individuals with rights to security, an expectation of advancement and a modicum of dignity is seen as a distraction and an impediment to efficient operation. Unions are anathema to this model and are deftly cut out of having any role in the workplace by the temp shop. One cannot be prohibited from joining a union if one should exist because of federal labor laws, but the union has absolutely no power to intercede on the worker's behalf in the workplace. The temp shop, as the worker's employer, bears sole responsibility for the legal obligations of an employer to an employee. But, the temp shop never sticks up for a worker who has been wronged in the workplace. It's in the business of funneling labor into its client firms and cleanly shutting off the client firm's obligations to the worker when it doesn't want the worker. Most of this is accomplished by discharging the worker as an employee of the temp shop as soon as the workplace manager dismisses the worker. Thus, regardless of seniority, the amount of time the worker has been working in the field, level of formal education, experience, professional development, loyal service or any other quality for which one might expect compensation and recognition, any temp worker is just a body who can fill a slot and generate revenue. You're not a human being, but a disposable, interchangeable part of a machine. If you ever aspire to being a real person, with goals, aspirations and hopes, forget it. You're just one of the cattle, and you're brutally reminded of that whenever you step out of line, hold up your empty porridge bowl and beg, "Please, sir, may I have some more?"
Up until now, if you're not familiar with the temp shop labor market, you may have assumed that the temps I'm discussing here are mostly low-level workers. True, there are a lot of receptionists and copy machine operators working as temps who have little or no chance of ever getting hired as a direct employee for their job. But, mainly I've been talking about well-educated, highly skilled IT professionals, graphic artists, designers and documentalists (technical writers and editors) who get caught up in the temp shop treadmill and can't get out. The choice often is to accept reasonably good pay from the temp shop, switch jobs every few months and endure frequent periods of unemployment and to forgo all benefits and worker's rights, or to just not work or be underemployed, working for much less money at a job for which you are grossly overqualified.
Corporate downsizing, economic contraction, exporting of jobs abroad and systematic elimination of older workers all act to dislodge highly experienced workers from jobs they have done for a long time, are expert at doing, and for which they expect to be compensated appropriately as well receive benefits generally expected by long term employees. For every high-cost worker edged out, the firm can probably get a temp to do the same job for less money in terms of total overhead. They pay the temp shop's inflated billing rate, but have no other costs associated with maintaining the worker. The more skilled a worker must be to do the job, the more likely the worker selected will be someone who has done a similar job somewhere else. There are even cases of workers being sacked and then hired back as temps to do the same job.
I once interviewed for a job that I had created for myself at an avionics firm. I had been laid off with half the work force on the first day another firm formally took control after buying and splitting off a division of the parent corporation. A few years later, they sold the company to another corporate conglomerate. A few years that, the successor corporation put out a job order for a position whose description was eerily almost the same, word-for-word, as the paragraph in my résumé describing my work at the original firm. That job description was on file and had remain unchanged since I wrote it at my manager's request so he could give it to me and secure an increase in salary for me. During the interview in the manager's office, I explained how I had worked in the same building and pointed into the bay of cubicles where I had sat for nearly four years. This set him back on his heels a bit when I related it to him, especially the part about inventing the job, but he still felt that my work experience wasn't adequate to merit getting hired to do my old job. It had been almost ten years since I had worked there and he stated that their procedures and development tools had changed too much in that time such that my skills might be out of date. I countered that I had been working steadily at several high-tech firms in the area like Microsoft, Adobe and Asymetrix, and that I had kept abreast of advances in software engineering. He shook his head and remained unpersuaded, citing the fact that I had not worked in the avionics industry for nearly a decade and concluding that I couldn't possibly be effective in an industry I no longer knew anything about. It didn't matter the I had never known much about avionics per se. I'm not an engineer and the job I had done was entirely a software development position. This was different than the job for which I had been originally hired, being an embedded systems firmware developer, which wasn't really an engineering job either, but was largely performed by engineers at that firm. The fact is that he didn't want me; I was too old. He wanted a young me, a bright, eager lad willing to serve up his prime working years for a pittance and then be replaced as soon as the cost/benefit ratio of my labor became too high. You see, this was a direct hire position, a career job, not a temp gig. He may have been told, "No one over 40." It was clear to us both that he was making excuses for blatant age discrimination.
Regardless of the root cause for a worker's displacement from their last "real job", anyone thrust into the pool of workers who can only get work in their field as a temp automatically becomes an itinerant, pickup laborer without benefits or prospects for a career. As such, the contingency worker, temp shop system is an abomination that destroys people's jobs, strips them of all rights, denies them any security and permanently blocks advancement. Temp shops should be outlawed and all firms who want a worker to do a job should be forced to actually hire one, not bring them in as a temp. If a firm chooses to contract with another firm for ancillary services like building maintenance, janitorial service or food service, and the work is done by the contracted firm's employees, that's fine. Those workers still have real jobs with their firm where they are free to organize and bargain for security and benefits. What needs to stop is allowing a fake, substitute employer to act as a front to bypass existing laws and regulations that protect workers. This crap has got to stop. It's killing the middle class and does nothing other than generate misery.
The tie-in with health care is that useful health insurance coverage is very difficult to maintain as a temp. The one I worked for the most had a plan that cost about $38 a week, the rest of the cost being picked up by the employer, the temp shop. It seemed like a fairly good deal, so I signed up for it. There was a spouse and dependent add-on that could be purchased for an additional premium roughly four times the price of the employee-only premium. It had a flat rate, the same for a spouse and no children, the one child of a single parent, or a Mormon with a wife and a dozen children. It was a ripoff for most people, so they didn't purchase the dependent add-on very often. I didn't because it wasn't clear that they would even agree to cover my two young children who did not reside with me because primary custody of them had been awarded to my ex-wife who received generous child support payments from me due to my reasonably high earnings prior to the dissolution of our marriage. They flat out excluded covering my former wife under any circumstances because she wasn't my spouse and didn't live with me. Working as a regular employee, I had always been able to get reasonably priced health insurance for myself and for my dependents. But now, as a temp, I couldn't.
Even the employee coverage turned out to be not as good a deal as it seemed to be at first. I soon realized that if I took time off from work to visit a doctor, I wouldn't get paid for that time unless I made up the hours by coming in early or staying late. The temp shop could only bill for hours actually worked. If I were too sick to go to work, I could choose to not get paid and visit my predesignated doctor from the preferred provider list. I would have to make a co-payment out of pocket for the visit and additional services were subject to an annual deductible amount for which I would receive no reimbursement at all until I spent that much out of pocket. Then, I only got 80% reimbursement for additional expenses up to the annual benefit limit or the total lifetime cap, whichever was least. The worst part, though, was that missing work for more than two successive days would probably result in my being dropped by the work manager who wanted my ass in the seat cutting code and not at home trying to recuperate and get well enough to return to work.
The end of a temp assignment, regardless of its cause, also meant immediate termination by my employer, the temp shop. This meant that my health insurance coverage would end immediately at the end of the current calendar month. So, if they chucked me on the last day of the month, I was done and off the books as soon as I walked out the door of my workplace. The next month, I could continue being covered for up to six months under the government-mandated COBRA program where the worker pays the full premium for the same coverage, which is between four and five times what an active employee pays through payroll deductions. The temp shop further discourages COBRA coverage by delaying sending you the papers for enrollment until very close to the 90-day retroactive enrollment period. Unless you pressure them to sign you up immediately after being terminated, you get mailed a statement where you are instructed to immediately pay the outrageous premium for the two months fully past, the current month, and the next month's premium in advance. That's four months' premiums, up front, in cash, right away. Then, you must pay the remaining two months' premiums before the first of the month or your coverage is immediately terminated at the end of the preceding month. They take great pains to assure you that paying for retroactive coverage means that you can be reimbursed for expenses already incurred and allowable under the plan. Swell.
It's highly unlikely that anyone could come out ahead buying into that deal. Even if you did spend a lot of money already and would recoup close to the amount of your premiums, you would only be able to maintain the coverage for another three months, and it's not cheap. Needless to say, most people pass on this offer. If you have had little or no medical expenses since termination, it's clearly pouring a lot of money down the drain for nothing. You are not allowed to delay COBRA enrollment, even if it is done retroactively. You must pay for coverage for all months since eligibility for the active employee plan ended. For those who hadn't spent any money yet, you would have to pay six months' premiums for just another three months of coverage. I've never paid that! It's extortion.
COBRA is clearly a means to extract even more money from an unemployed worker who gets little or no benefit from paying the inflated premiums. The active employee plan is a ripoff, too, but not as obviously. Health insurance plans for temps are largely scams where they collect a lot of premiums and pay out much less in "medical losses", that is, payments to health care providers for services provided to insured persons.
All health insurance is a scam because the prevailing medical loss ratio for major health insurers is around 70%. That means that the insurer takes 30% off the top and parsimoniously doles out the rest, scrambling to deny claims and weaseling out of making good on coverage purchased in good faith. The medical loss ratio is lower, surely much less than 70%, for temp employee coverage. Insurance is only worthwhile when it is sustained over the long term. It's nearly worthless when it starts and stops every few months, and especially when the end of coverage is precipitated by an illness or injury that would most likely call for the insurer to incur a medical loss by paying out for care provided to the insured party. Crappy health insurance plans for temps serve only to deny health care services to workers who should be able to afford real coverage. Decreased access to health care drives people out of the middle class and into the ranks of the working poor. The working poor are pauperized and left completely at risk, having no access to health beyond what they can pay for out of pocket.
Temp health plans are nearly perfect scams where premiums are collected and very little is paid out in benefits. It may not be the most lucrative market niche, though. Health insurance for college students has the lowest medical loss ratio, around 10%. That's right. The insurance company keeps about 90% of everything it takes in insuring college students, who are by and large, young, active and healthy.
I should have smelled a rat because the health insurance provider at my temp shop was United Healthcare, the outfit that paid CEO Bill McGuire $1.78 billion for three years' work. It sickened me to realize that a substantial portion of my premiums had gone directly into his pocket and I had never, even once, received a dime in benefits from my health insurance plan. You see, that was back in the old days, up until about three years ago, when I was still a fairly robust, healthy person.
I quit working soon after I turned 59-1/2 and could withdraw retirement funds without penalty. After a few months of relaxing and assessing myself, it occurred to me that I had several complaints and needed to have them checked out by a doctor. I went in with my list of health issues, but quickly learned that there was a whole lot of other things wrong with me of which I was entirely unaware. These included (but were not restricted to) hypertension, risk of diabetes, excessive cholesterol and early indicators of kidney problems. I was a wreck and needed attention. Being either unemployed or desperately trying to hold onto a succession of temp jobs for the preceding seven years, I had not had a checkup or received any health care services during that entire period of time.
The clinic accepted me, albeit reluctantly, as a "self pay" patient. I pay up front for office visits and am billed the full cost of tests and other services. My doctor is freaked out and somewhat aghast that I have no health insurance. To help me out, he works diligently to minimize the number of office visits, carefully orders only tests that are likely to provide significant information and searches for low cost drugs to treat what ails me. We keep in touch via the internet using a system of web pages they call "eCare". This costs nothing and I don't need an office visit for the doctor to monitor my progress. I send him messages and he replies with comments like, "You seem to be responding to treatment. Keep taking those pills and sending me updates. Schedule an appointment if you think there's something wrong."
After I first sought treatment three years ago, I looked around for individual health insurance plans that might be worth having. I was stunned to find out that I would probably have to pay between $700 and $1000 a month for individual plans that didn't pay out much. Worse yet, all of my newly diagnosed ailments would be excluded as pre-existing conditions. In other words, I could shell out to be covered for the unlikely occurrence of an event I couldn't foresee, and still be entirely responsible for paying for treatment of everything that was most likely to afflict me. What kind of a deal is that?
I found out that "going naked", as health insurance companies like to put it, wasn't all that bad. I pay no premiums and only pay for the care I receive. There is no 30% being drained off of my premiums because the insurers never get a cent from me. Another bonus is that my pharmacy offers discounted pricing for most drugs to those who do not have prescription drug insurance coverage. Sweet!
While I have gotten off easy for the most part so far, I have been penalized for being sick. When I don't feel right, I know that it will cost me $125 to get it checked out, and more if I require tests, treatment or medicine. My mental cost/benefit calculator kicks in and I assess the probability and expected value of shelling out that kind of money and being told something other than, "Rest, drink plenty of fluids, take aspirin or Tylenol and schedule another appointment if you're not any better in three days."
I didn't seek treatment for my current illness for two weeks because my symptoms closely resembled a sports injury, a torn rotator cuff, that I had suffered in my right shoulder 18 years before. That time, I "toughed it out", treating myself for pain with ibuprofen, taking hot showers, sitting in the sauna and massaging the shoulder with the opposite hand. It hurt to drive, and for a couple of days, even to type at a keyboard. I gritted my teeth and worked through the pain. I didn't want to take time off from work to be told to rest and put ice on it. I was already doing that.
This time, the pain was in my left shoulder. I had gone swimming the day before I experienced any discomfort and assumed that I had injured my left shoulder the same way I had munged up my right shoulder 18 years before. Things got worse for a couple of days, but I clung to my erroneous self-diagnosis. After a week, I seemed to start improving, so I didn't get an appointment and continued expecting to recover on my own. A few days later, though, the lower back muscles on the right side and the buttock muscle just below that that began to ache and throb. The shoulder began to hurt worse and the area of pain and swelling around it was expanding. It was clear that I was getting worse by the day, so I made an appointment to see my doctor. Two days later I went in and the doctor drew fluid samples from the joint and the bursa. Both had large amounts of pus, dead white blood cells. He didn't buy my sports injury idea at all and thought it most likely that I had a bacterial infection. By putting off treatment for so long, he said that I was perilously close to needing hospitalization. He bit his lip when he said that because he knew that putting me in a hospital bed would really cost me a lot of money. Instead, he prescribed an antibiotic and a potent pain reliever. I had my driver take me to the pharmacy where I got the discounted drugs and took my first dose of each immediately.
Over the next couple of days, my shoulder improved markedly, but my leg and buttock got worse. The doctor advised me with the eCare setup to schedule another appointment. I went in and he ordered some X-rays and had more blood drawn to see if the test results showed any improvement. The chest X-ray showed a spot on my lung that suggested the infection had spread there. The radiographer suggested having a CT (computed tomography) scan done, but my doctor dismissed this because even if it told us more than we currently knew, the cost was outrageous and wouldn't change the treatment he had prescribed. The hip X-ray showed nothing abnormal in my skeleton, so he concluded that the infection was spreading through my blood stream to other areas. He added on a sulfa drug, a medicine decades old and very reasonably priced. I got those pills and started taking them too.
Since the second visit I've been gradually improving. I can move my left arm around and do things with it instead of holding it next to my body like someone who has had a stroke and lost the use of one side of his body. It still hurts to bear weight, but I can drive again, using mostly my right arm to turn the wheel as well as shift the manual transmission. My injured right leg has improved enough to allow me to operate the gas pedal and the brake without pain. I can walk again, without a cane, but it's a slow shuffle. A trip to the grocery store exhausts me. I use the cart like a walker, moving very slowly while whoever is assisting me scurries around getting items and placing them in the cart.
The significant point about the amount of time it took for me to seek medical attention is that I thought I had it under control and that a $125 office visit wasn't necessary. If it had been $50, I might have gone in a little sooner. If it had been free, I might have gone in the third day when it was clear that I was badly hurt. If I had gone in at that time, the infection would have been treated sooner and I would have been closer to full recovery than I am now. But, I gambled, just as nearly everyone does in this godforsaken, pestilent wasteland of a nation. I tried to do a cost/benefit analysis on my anticipated out-of-pocket expenses. They don't need to do that in civilized countries, like every other industrialized nation except this one. Many third world countries, notably Cuba, have excellent universal health care systems. We're messed up here and our fee-for-service medical care system creates unnecessary misery, suffering and death. Why can't I have, or even buy insurance for health care as good as any Cuban peasant can have?