Friday, February 25, 2011

Promises Promises

When is a contract a contract? When is a promise a promise? The answer in 2011 is “It Depends”.

Public employees have contracts. Some of their contracts promised adequate wages with really good fringe benefits and generous retirements. Almost all of their contracts guaranteed stability. Governments; cities, states and the feds, and public institutions such as schools, often took the easy route. Our leaders and elected officials pushed these payroll costs back twenty or thirty years when funding would be someone else’s problem. This strategy was so popular at the steel mills and the auto plants that it had to be a good idea.

The future is now.

Vice-President Dick Cheney once said the deficits don’t matter. And they didn’t. To him. In 2011, after ten years of unfunded wars, unregulated banking, and reckless spending, we are in a real mess. We could reassess our priorities and then align our income (taxes) to pay our bills, but that would be difficult. That would take courage. Instead, we tear up contracts, de-certify unions, and cut heating oil subsidies for the poor.

What does all of this have to do with the delivery of health care? After all, this is Health Insurance Issues With Dave. In a word, everything.

The recent election gave us Republican governors in Wisconsin, Ohio, etc… Elected to create jobs and right their ships of state, these new governors have chosen a different path. They have decided to target their public employees and to eliminate the unions that represent them. We are being told that these contracts are too expensive to honor. We don’t have the money. Their jobs, and the incomes that paid their bills, will disappear. The pensions they were promised may be gone.

Why is this different than government’s promise of health care? We haven’t properly funded the health care we have promised to the poor and the elderly. We have deferred the expenses and punted every time a difficult decision has been on the table. A quick example is the Medicare Doc Fix.

In an effort to make a dent in the fiscal mess that is Medicare, a decision was made in 1997 to control the escalating costs of medical care. The Sustainable Growth Rate was a payment formula designed to keep doctors’ rates in check. Unfortunately, the formula didn’t work in the real world. The adjusted payment rates would have forced a large number of doctors to not accept Medicare and to leave the system. One option would have been to correct the formula. Another option would have been to scrap the Sustainable Growth Rate and start over. Congress, Republicans and Democrats, chose a third option. They passed periodic fixes to the bill and pushed the tough decisions back for someone else to handle. The Sustainable Growth Rate was passed in 1997. How much have we saved to date? Nothing. The implementation is still getting postponed every month.

Is the Doc Fix a good idea? Would the Doc Fix solve Medicare’s problems? Probably not. But if Congress doesn’t get Medicare’s costs and funding under control, we will eventually be facing the same problems, and the same decisions, that the states are grappling with today.

Can the federal government be entrusted with more responsibility for our health care? What promises are too important to break?


Wednesday, February 9, 2011

Are We Serious About Change?

I wasn’t expecting a letter from State Farm. Of course, the news wasn’t good. My insurer regretted to inform me that I was never going to be reimbursed. Hit by an uninsured motorist (Mr. Popularity – March 6, 2009), I was forced to pick up my deductible and part of the car rental expenses. That money was gone. In a final act of irresponsibility, Ms. P. had her debts discharged through bankruptcy.

Ms. P. was driving illegally. She did not have insurance. Had she followed the law, she either wouldn’t have been on the road, thus not hitting me, or her insurance would have paid for the repair of my car. Her insurance. Instead, State Farm spent thousands and I lost about $800. Since bankruptcy is a matter of public record, I could, if I was a glutton for punishment, learn who else got screwed by Ms. P. Banks? Retail stores? Did she go on a shopping trip before she ran to the courts for relief?

Why should you care? Her refusal to follow the law and to pay her debts costs you money. We are covering her debts. And there will be more.

1 o’clock. No Oliver. No surprise.

Oliver may be the poster child for the uninsured. He is in his late fifties, disabled from an accident, and officially under-employed. He gets by through the kindness of his family members. One has him working part-time in a small business. Another helps with the rent. Insurance was to be paid by his little sister. All he has to do is show up for our appointment and give her the bill when it arrives with the policy.

Oliver was covered, briefly, last year, but he was too busy to get the bill to his sister. He has been too busy to get here to my office. He is just busy. Odd how much time it takes to do nothing.

Oliver’s family can’t force him to have free insurance. Who will pay when Oliver seeks medical care? Who will cover his next surgery? YOU, of course.

There is much to dislike about President Obama’s Patient Protection and Affordable Care Act. It was poorly designed and even more poorly explained. But, it is the individual mandate that is being attacked by Republican judges. And without a legal requirement to be in the system, to be responsible, we can not move forward. We can not improve the delivery of health care, guarantee universal access, and control costs if we don’t require everyone to participate.

Federal District Judge Roger Vinson recently ruled that the PPACA is unconstitutional. He wrote that Congress couldn’t require Americans to buy insurance. He also determined that this provision, the individual mandate, could not be severed from the rest of the law. The second part of his ruling strikes down the entire bill.

As a non-attorney, I will not discuss the merits of Judge Vinson’s ruling. Is he right? Will he be upheld or reversed on appeal? What will the Supreme Court decide? It is important to remember that all rulings are subjective and reflect the Court and their time. Previous Supreme Court decisions have, in retrospect, been all over the map.

So let’s skip the law for a second and talk about people. There are lots and lots of Ms. P.’s and Olivers, far more than any of us might want to admit. I encounter the intentionally uninsured daily. They are healthy young people who are convinced that they are incapable of getting sick or injured, even though they ski, ride motorcycles, or engage in other hazardous activities. Some are just selfish people who have never pulled their own weight and never will until forced. And some are simply weak-willed who can’t walk past shiny new things.

We also have the unintentionally uninsured. We have 50 and 60 year olds who have lost their jobs and group health insurance and can’t afford food, much less insurance. There are any number of sick and disabled who need our help. Helping the unintentionally uninsured was supposed to be the goal of the PPACA.

Ms. P. chose to drive a car without insurance. Almost all of us will one day need health care. It won’t be a choice. U.S. hospitals are not going to deny care. We aren’t going to barricade the Emergency Room doors to keep out the uninsured. So what we are discussing is money. How are we going to pay for care? How do we pay for doctors, hospitals and prescriptions?

We understand, or least most of us do, why drivers must be forced to carry insurance. Requiring people to be responsible for a portion of their health care expenses is just as reasonable. We will never have 100% participation. Just as there are a small but dangerous group of uninsured motorists, there will always be people who evade the system. They will fly under the radar right up to the moment that they need care.

Don’t like the individual mandate? OK. Tell us how you will improve our system without it.