The Obama-era is nearly over. President Barack Obama was the first president I voted for with great enthusiasm and confidence. Eight years ago I’d argue that he came at the perfect time for me to vote for him, my political consciousness was developed and I had a candidate I can vote for which matched my political consciousness. In November of 2008, Obama was elected, the country was elated. It was a historic election, the first black president. He was going to bring great change to our country. In the euphoria of post election – some even forgot that we are in the deepest recession the country has ever seen since the Great Depression in the 1930s. The economy was something Obama can wave a magic wand and fix too.
His signature piece of legislation was of course Obamacare passed in 2010. It was to be his signature achievement in domestic policy. It was what he wanted to be remembered for. He passed this bill while Republicans in both houses were kicking and screaming. There were other serious problems in the country at the time, namely the recession, high unemployment rate, but he kept his laser focus on healthcare reform. It had been on his agenda since he was a presidential candidate. He wanted to overhaul and reform the broken, cost prohibitive healthcare system in America, where you’ve either got to be very poor, very rich or past the age of 65 to get decent healthcare. He wanted to do what the Clintons couldn’t do. The most obvious fix is the single-payer system or convert the current medicare system to cover everyone, not just people over 65.
He started out the reform proposing a single-payer system, but when the insurance companies lobbies came calling, harassing and threatening Democratic legislators, one by one they caved. What we ended up with was a hybrid between a single-payer system with the market system. State medicaid was expanded to cover those earning in the bottom 25th percentiles, but that was subject to the discretion of the states. So governors in Red states one by one, decided to cut their noses to spite their faces, many rejected the expanded Medicaid. Yet as each one rejected the expansion, they had no alternative plans to keep the most vulnerable (usually women or PoC) covered, in fact some even cut aid to state Medicaid – such as the state of Texas under governor Rick Perry. The states that needed the expansion of Medicaid the most, rejected it, and those are states with high population of people living in poverty.
For the rest of the people that fell in the middle, we were stuck with an impossibly difficult, time consuming, byzantine process while trying to apply for health coverage for the family. Where if you ticked the wrong box by mistake can screw up your whole family’s application. Every year, come renewal time, you’ve got to check and make sure all of the doctors your family sees are still in the network you are on – if they are, then you can continue with your coverage, if not, you have to find a new insurance plan to include them. More than half the time, the doctors of your choice are no longer in ‘your network’ because they found another ‘network’ which offers higher reimbursements.
While it’s nice the federal government provide generous subsidies upfront, even up to families of 4 making $125,000 per year and the demand side of the equation is solved, the supply side of the equation (the insurance companies and health service providers) presents new problems. While it’s illegal to do, many doctors, because of the hassle involved simply refuse to accept anyone who purchased health insurance from state or federal exchanges. Meaning to say, if two patients had the exact same health insurance, but one patient purchased it privately (off exchange or through employer) and the other patient purchased the coverage on the exchange (with federal subsidy), the doctor will take the patient who purchased it privately. The doctor will attempt to work out a cheaper ‘cash’ deal with the patient who purchased their coverage on exchange just to avoid the extra hassle and paperwork they must do for patients who purchased their insurance on the exchange with federal subsidies. The insurance plans with federal subsidies reimburse slower so no doctor or healthcare provider likes them and one can’t blame them. It creates extra work for their office staff which would then raise cost of wages. I was told this practice was illegal, but many doctors are doing it on the sly.
A lot of doctors, in the face of Obamacare decided to ‘go private’. Our children’s pediatrician did this. He didn’t want to bother with insurance companies at all. So what he did instead was he charged a flat fee per child per month and that flat fee would include wellness visits, immunization shots and sick visits too. Amazingly, he was able to keep over 50% of his patients and through word of mouth recommendation, was able to get new patients. So, if we wanted to keep our pediatrician, whom we love because he has an alternative and flexible immunization schedule and give my children lots of stickers at each visit, we have to pay his monthly fees and health insurance on top of that. Then you have the in-network and out-of-network issue, in non-emergencies, it’s fairly easy to arrange to see all in-network providers. But what if there was an emergency and an ambulance was called and you are unconscious or bleeding profusely, are you meant to tell your ambulance driver to make sure to take you to Hospital A instead of Hospital B or else you’ll be stuck with a $10,000 deductible – which would really render your insurance useless?
And for those who are on Medicaid, you can forget about seeing the doctor ‘of your choice’. Most doctors with established practices stay away from Medicaid, reimbursement is low and slow and involves a ton of paperwork, a trifecta no well reputable doctor wants to touch. So, doctors who tend to accept medicaid are doctors in not-so-good parts of town, in dingy buildings where the waiting room is full of coughing, puking, screaming children and their exhausted mothers. This is not a slight on those doctors or nurses, those are great doctors who care deeply about their patients, but they are overwhelmed, with too many patients and not enough reimbursement, forced to practice in bad parts of town, in old buildings and most of those patients are women and children of color or undocumented immigrants. Many community doctors in California treat undocumented immigrants for free or for very cheaply. These are great doctors who perform their Hippocratic oath with very little reward in end.
That Obamacare allowed 90% of Americans to be covered by health insurance is an often touted statistic to prove the success of the program. Yes, 10% fell through the gaps and it’s the most vulnerable 10% of the population, but that’s becaues their states refused to expand medicaid and then you have the few lazy people who just can’t be bothered with applying for insurance. However, being ‘covered’ doesn’t mean anything if that coverage is restricting, cost prohibitive in the deductible and co-pay side. That’s no different than having just the basic coverage, just in case of a major medical catastrophe or accident happens – you will be covered, but for those with chronic conditions that require frequent doctor’s visits, or those with children who catch colds and viruses from other children. The cost of healthcare is still prohibitive.
I don’t want to go on a rant about Obamacare and not point out the great benefits that came with the law. Pre-existing condition is no longer a reason why anyone can be denied coverage, it was nice for once while applying for insurance, your insurance agent doesn’t even ask you about any pre-existing conditions you have. Children get to stay on their parents insurance until age 26. There are no more lifetime maximums for coverage, so those with serious chronic conditions who need a lot of medical care don’t ever have to worry about their insurance limit running out while they are still alive. Children’s policies immediately include a dental policy, so parents don’t have to purchase additional dental policies for their children. Children born with serious conditions are immediately covered on their parents health insurance plan without new ‘underwriting’ to determine eligibility or to raise their parent’s insurance premiums more. All of these are great improvements – but it doesn’t address the cost side. Those with a known pre-existing condition while can’t be denied coverage, can be charged higher premiums. Women of childbearing age are charged higher premiums – even if those said women have taken permanent measures to not have any more children. People over the age of 60 but not yet eligible for Medicare are charged sky-high premiums. This was the trade off or deal Obama made with insurance companies. This is where they ‘got’ us. Right now, some insurance companies such as Humana and Unitedhealthcare have chosen to exit the federal and state exchange business as they are losing money and they can’t do what they want with their plans and how they spend their money. If exchanges keeps losing insurance providers, then the ‘competition’ side of the exchange will weaken, with less competition, premiums will begin to rise anyway.
Which brings me back to the single-payer system, a beautifully simple, wonderful solution to the mess of choosing the right insurance and making sure the network includes your favorite doctors. There will only be one network, in which all licensed practicing doctors and health practitioners and providers belong. Very much like Medicare, it’s a single-payer plan for people over the age of 65. Incidentally, most of the people I know who work in the medical field love Medicare. Reimbursement is prompt, without much paperwork fuss and the amount is adequate. The patient is happy and the doctor is happy to treat the patient and provide them with great care. Most seniors also love their Medicare. The doctor’s practice is a business, their income has to exceed expenses for it remain a going concern. Perhaps a single-payer system can introduce method of reimbursement that not only reimburses doctors on a per patient basis, but subsidize the doctor on his overhead expenses as well. Since it is a single payer system – market based competition won’t apply, the government needs to make sure that each doctor’s practice, practicing in the single network of the healthcare system is well looked after and maintained. The area of healthcare, on principle and just on human decency should not be one that is based on ‘profit’. An insurance company making a ‘profit’ off of the illness of other people is grotesque. Their business model of hopefully having enough ‘healthy’ people who rarely visit the doctor but dutifully pays their monthly premiums to compensate for those who aren’t healthy is Orwellian and dystopian.
A person’s health is their wealth. It’s not a old cliche but a simple fact of life. That without your health, nothing else in the world matters. Billionaires will gladly give over their whole fortunes if someone can cure them of an incurable illness. I am willing to bet all I have that Steve Jobs would give over significant amounts of his fortune if someone could cure his incurable cancer that ultimately claimed his life prematurely. It took me having my mother who became critically ill, but thankfully was in a country that had universal health care that provided her with lifesaving surgery and brought her back to full health and not costing her a dime for me to appreciate this old ‘cliche’. I shudder to think what would have happened to her if she was in the United States when her health crisis happened and she was inadequately covered.