The walking dead: the uninsured in the USA

I don’t normally comment on politics here, it isn’t the point of this blog but sometimes I probably won’t be able to stop myself. I worked in San Diego for 4 years, and I saw a lot of the good in US health care, as we were treating newborn infants we rarely had to worry about insurance, and it never intruded into acute care of the babies in our NICU. It affected the UCSD bottom line, but that was for someone else to deal with. I worked with a great group of neonatologists, dedicated to the babies in their care, and the infants got anything they needed for their acute care.

We did sometimes get communications from insurance companies, informing us that they would stop paying for a hospitalization, so we would hustle to discharge the baby quickly. This is one pressure that leads to an increase in home O2 in the USA compared to our use here, which might even be a good thing in some ways if you get babies back with their family sooner.

Every now and then, though, I came across something that would stop me in my tracks. There was one mother with metastatic breast cancer who had not had a full evaluation and treatment because she was not eligible for state supported care, and had no health insurance herself, so to avoid bankrupting her family se did not return to see the surgeon after her initial diagnosis (it turned out he had offered to do the surgery for no fee, but she would still have had many costs that she could not afford). Especially as she was pregnant. When she delivered at 28 weeks, it was too late for anything other than palliation.

This story was brought back to my mind by a perspective article in the PNEJM: ‘Dead Man Walking’. (open access) A story of a man who died because of lack of insurance. Stories such as this brings home the reality of the uninsured and the underinsured in the USA.

‘Obamacare’ is a half-baked solution which was gutted by special interest groups, but at least it stands a good chance of reducing the numbers of people who end up in the situation of the man whose story is told in this article, as long as it doesn’t completely get destroyed. One commentator even suggested on TV recently that the big problem with the US system was ‘too much insurance’! I don’t think he was talking about the excessive profits and lobbying ability of the insurance industry, either.

About keithbarrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
This entry was posted in Not neonatology and tagged . Bookmark the permalink.

3 Responses to The walking dead: the uninsured in the USA

  1. Becca says:

    I try not to write about insurance as well. Much like I never thought I would be a preemie mom, I did not think I would be in an insurance nightmare. Long story short, I got lucky with timing so the nightmare was minimal. My pregnancy was saved.

    As a mom, it’s frustrating to have to learn every nuisance of policies, appeal automatic denials, and battle with companies just to receive the coverage our premiums are supposed to provide.

  2. Marty says:

    Keith,

    I’ll politely disagree. Obamacare’s intent is not to improve healthcare. The lack of attention even to developing a workable website, the clear deficiencies of Obamacare aside, should make that clear to anyone who believed promises from the Obama WH. We are repeatedly told by advocates of state health care that we have 30 or 40 or 60 million uninsured. The numbers continued to increase as the political chatter for passage of the bill heightened. Of the supposed “uninsured” (uninsured…we are legally bound to deliver emergency healthcare unlike any other country in the world), when reasonably examined, approximately 12-16M are the folks who may not be eligible for insurance or have severe pre-existing conditions that made it difficult or impossible for them to get insurance. The remainder were/are either already eligible for Medicaid and never applied, have money to buy insurance but decided they didn’t want it or are illegal aliens.

    The solution offered by Obamacare supporters was to take a wrecking ball to the current healthcare system, lie about in order to get the minority support they got and then propose a healthcare solution that would treat 30-50M more people while saving the average family $2500 annually.

    As for the bad guys in all this. There is blame for the insurance industry. They saw an opportunity to survive and supported this disaster as long as Obamacare would push millions of relatively healthy Americans into the system to pay and the government (taxpayers) would start further subsidizing a whole new group of citizens who had previously been willing to pay for their self-selected policies but would now be forced to pay for much more comprehensive policies (maternity, substance abuse etc). These policies would be more expensive, have higher deductibles but meet the standard that Obamacare demands for a “good” policy.

    I have little sympathy for insurers who sold out rather than try to stop this train wreck. The government also has enormous interest here. As opposed to some elsewhere, there is a tradition in the US that views government as having a limited role in our lives. Obamacare is the march for government to fully take over 1/6th of the US economy. The EASIEST thing for government engineers should have been the website. They didn’t even care enough to get that right before setting deadlines for folks to have insurance cancelled. Simply incredible.

    The unspoken conspirators in all this are large healthcare systems. When ios the last time anyone has heard of a US healthcare merger being challenged. Never. The silent partners in this effort are big hospital systems. As the competition in an area decreases, we know well what happens to prices. The free market dissolves and hospital systems can set any price they want…and they do. More about this issue here. http://www.forbes.com/sites/theapothecary/2012/03/01/how-hospital-mergers-increase-health-costs-and-what-to-do-about-it/

    So I agree that the US healthcare system could be even better Keith. We have 15M or so that need a solution. The answer is not more US government intervention. We are in the mess we are in because of such intervention. Through Medicare, Medicaid, VA and Tricare, the government already controls 60% of the payer market. Why do health insurance companies charge so much? That’s because hospitals want to stay afloat and the 60% from the government will not keep the lights on and allow a profit (and remember non-profit only means you don’t pay shareholders, it does not mean you don’t make money and put it into more infrastructure, salaries etc). So hospitals can charge insurers what they want, the private insurers/payers subsidize the pitiful government payment rates and so private insurance costs money. For the record, the year over year profit margin for US insurers is 6-7%. Anyone worried about Google’s profit margin?

    We can take care of the 15M or so. If we opened up insurance markets across state lines 20 somethings could buy policies that don’t require the massive coverage mandated by some states and Obamacare. Take away the tax exemption given to employers and give it to individuals buying their own insurance. This would open up totally new frontiers in healthcare for Americans. This would bring in, at a reasonable rate, many of the non holders of insurance policies. This would also open up the opportunity for insurers to create and support high risk pools that would support the 15M. If necessary, we could build in government subsidies for these folks.

    As you know there are nightmares in the Canadian and UK systems. These stories are generally not shared by our mainstream media which is an arm of the Democratic Party. Visiting http://www.waittimealliance.com is chilling to me. You remark on individuals not getting tx, in Canada many are left to die on waiting lists, guaranteed treatment eventually when there is a doctor taking new patients or a spot on the MRI list opens in 3 months.

    The Obamacare nightmare has just begun. As developers well knew, first goal is get everyone off their private insurance. There will be 50M more cancellations coming over the next months. That is happening for self-insured and will happen for employee insured next year. In the midst of this people are being told to go to a website that doesn’t work in order to sign up for an insurance product which will cost more or force many to take a government subsidy. This may not seem like a problem for some comfortable with socialism, but as our plumber told us this week on a house call, “I have a decent business and self-insure. I was told my new ACA policy will be 325% more a month. I can’t afford that Marty. BCBS told me that I should go to the Ocare website, that I would probably qualify for governement support. I have never done that, I can’t do that.” This 6’4″ 250 lb behemoth was in tears. And these citizens haven’t even started to experience what healthcare would be like under Obamacare. Doctors have been leaving medicine in the US, shortages are predicted and we have 30-50M new folks to care for? Maybe the WH architects of Obamacare will put up a website like Wait Time Alliance that will at least offer Americans the hope of some day, months or years down the road, getting the care they were promised.

    • Thanks for the comment Marty,
      I think your response points out some of the major issues in this (US) debate. Why would anyone have bothered introducing Obamacare if they did not want to improve health care? Of course that was the intent. Even if they messed it up, to suppose that it was done for other reasons is evidence of the lack of respect across the debate fracture lines. Even people like you with your dedication to good health care seem to believe that this was done because democrats want to control your life.
      I must object to the idea that the USA is the only country in the world where there is a legal obligation to provide emergency care. That just is not true. In any country in the world with universal health care, and there are many (I have worked in 2 of them, Canada and the UK) there are such legal obligations, we don’t have a law forcing us to evaluate patients who present to emergency rooms even if they don’t have insurance, BECAUSE WE DON’T NEED ONE! The laws in the USA were put in place because patients were being sent away to die, or shipped to another ER, if they couldn’t pay. There is in Quebec a clear obligation to provide emergency care to everyone who needs it, both in the laws which control our health care system, and in the rules which regulate our professional practice.

      I think it is interesting, Marty, and you are someone for whom I have a great deal of respect, that you worked in one of the best health care systems in the world. The military system in the US provides ultra-high quality health care to all of the military and their families, and they are all covered, even the lowliest employee or soldier. Regardless of rank or ability to pay.
      If you are poor working class in the US, you are more likely to die than if you are wealthy. If you can only afford the cheapest insurance then you might well end up with a policy which is as bad as worthless, with high co-pay, enormous deductibles, and an insurance company which tries to avoid paying even the small amounts that it is supposed to pay. Allowing insurance purchase across state lines will allow the working poor to buy crappy insurance from other states with lower standards, will it do anything to reduce the impact of health care disparities, unlikely.

      I am proud to be a Canadian, to have a health care system which is funded our taxes, which treats everyone regardless of ability to pay. A health care system which as a result leads to much better health care outcomes in every domain, much better in every domain than the richest country in the world, and which has health care outcome disparities which are very much lower across social groups. No-one in Canada or the US risks bankrupting their family if they get sick, my families in the UK and in Canada have all had to face health care issues, chronic and acute, over the past couple of years. They have all received care of equally high quality as anyone in the USA (not necessarily in fancy private rooms with WiFi access and Netflix) and have never had to give one moments thought about how to pay for it.

      No patients do not die on waiting lists. Waiting lists exist mostly for hip replacements, cataracts etc, and we need to work to reduce them, but acute care in Canada and the UK is of equally high quality and there are no waiting lists for things which are life saving. Access to oncology services for example is not affected by waiting lists, and certainly not by the size of your wallet.

      I think it is informative that the one area in which health care outcomes in the USA approach those in Canada, is among those over 65 years of age. At which point everyone in the US is eligible for ‘socialized medicine’.

      You need more government intervention in health care, not less. The elimination of the public option was the major failing during the painful development of Obamacare, if it could be re-introduced, then maybe you could have a system which one day might be as effective as ours!

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