The Dark Side of Healthcare

The present wisdom being circulated — that the healthcare reform passed on Sunday night is “a step in the right direction” — blindly assumes that a public option bill rectifying HMO avarice (among other consolidations of power working against the commonweal) is forthcoming. It assumes that healthcare costs will remain the same between now and 2014 — the year in which all individuals who can’t get healthcare from their employers (including the unemployed, the self-employed, and those working for a business with less than 50 employees) will be required by law to purchase healthcare. (By 2016, those who fail to purchase healthcare will take either an annual tax hit of $695 or 2.5% of household income, whichever sum is greater.)

But the new legislation doesn’t require businesses with less than 50 employees to offer healthcare for its workers. Which means that, for these small businesses, the onus will fall upon the worker to bankroll her own healthcare. And while it is true that federal subsidies (i.e., affordability credits, which will run out in 2019, a little-observed issue among some progressives) will exist, through a graduated scale, to help any individual making less than $44,000 a year ($88,000 for a family of four) pay for her own insurance (at least over the course of a six year period), there remains an army of elephants in the room that nobody wants to talk about.

Beyond the misplaced definition of “neutralizing” industries identified by Glenn Greenwald, there’s the uncertain future of whether premiums can even be stabilized to fit a healthcare organization’s for-profit disposition. The Los Angeles Times‘s Duke Hefland couldn’t seem to get any prognostication from the experts. But if there’s anything just as certain as death and taxes, a for-profit corporation will find a way to make more money, stopping at nothing to squeeze out the vulnerable. While the bill does put a stop to the deadly practice of denying healthcare applicants coverage because of pre-existing conditions (this is arguably Sunday night’s greatest victory and the linchpin for greater progress), it doesn’t hold insurance companies accountable for escalating prices. There hasn’t been a National Insurance Rate Authority established (although Sen. Feinstein attempted to sneak one in), but there has been traction in getting the antitrust exemption removed. Still, the failure to establish an authority is especially problematic, considering that a health insurance company’s business model involves collecting from the healthy to pay for the unhealthy. And what is to stop an insurance company from jacking up premiums across the board (as Anthem notably did back in February)? What is to halt CEOs from collecting compensation? Will we see a legion of Nick Riverias offering cheap and possibly ineffectual insurance to help people purchase the mandated care? Time will tell. But many of these possibilities could have been avoided with a public option.

The Democrats were forced to make some serious concessions on these points. And their long-term strategy may involve a clever alliance. Since the responsibility for paying for healthcare now falls upon a large cluster of businesses, perhaps these businesses may align themselves with government against any premium spikes from the insurance industry. On the other hand, any potential alliance will inherently favor the corporation or the business with more than 50 employees.

Let’s say that you’re someone looking for a new job in 2014. You don’t have any savings. And you need to get a job. Because you don’t have any healthcare. And if you don’t get the healthcare, essential and vital as it may be, you’re going to be hit with hard financial penalties. Corporation A offers you a job for $40,000, which includes healthcare benefits. Meanwhile, Small Business B has made you a counteroffer of $42,000. But because Small Business B employs only ten workers, under these arrangements, you’d be forced to pay your own healthcare costs if you decided to take this job. So in order for you work for Small Business B, you’d need B to pay you about $5,000 more, so that you can purchase the federally required healthcare. But Small Business B can’t afford this. For Corporation A, which must pay for healthcare, and Small Business B, which doesn’t have to, there’s certainly a financial advantage to the small business. But the worker is going to opt for Corporation A. Because the employee is going to get less income after healthcare costs working with Small Business B than with Corporation A. Therefore, potential innovation that might emerge with the small business job is lost to the corporation. And I haven’t even begun to examine the impact on the self-employed — MJ Rose tweeted back to me last night her nightmarish escalation of costs — along with the abortion restrictions (followed by cries of “baby killer”).

A public option and a central insurance rate authority (along with a 21st century recognition of gender realities) would help to create affordable healthcare rates, work to rectify these imbalances, and begin the journey to a greater goal: universal health care that regular people can afford and, if they can’t, care that they can receive for free, without an IRS or an HMO invoice attached, and without the spoils going to private industry. That is the mark of a civilized nation. That is the true mark of progress. But maybe, just maybe, we’re on our way.

Obama, the Medicare “Doughnut Hole,” and the Working Poor

Last night, on Twitter, I got into a lively exchange relating to last night’s Obama infomercial. I had initially watched ten minutes of this broadcast, and I grew increasingly upset by the manner in which basic realities about health care and the working poor have been severely overlooked in this presidential race. Upon being pressed, I watched the whole thing from the beginning. “Those weren’t the working poor in that video? The 72 year old guy working at WalMart not poor enough?” argued Seth Harwood. While retired railroad man Larry Stewart putting on his Wal-Mart badge and taking out a loan on his house to help his ailing wife is indeed a crushing story (beginning at 7:30 in the Obama video), at least the Stuarts have a house to take a loan on. What of the doughnut hole created by a Republican-led Congress through the Medicare Modernization Act of 2003? What of those trapped in Medicare with chronic conditions who skip out on vital medications because they don’t have the money? The situation is this: Under the Medicare Part D prescription drug program, if a senior has more than $2,250, but less than $5,100 in annual drug costs, the senior is required to pay these costs out of pocket.

Now consider the case of 65-year-old Frances Acanfora. Thanks to the MMA, this retired school lunchroom aide saw her drug costs jump up from $58 to $1,294 courtesy of the doughnut hole. She even had to temporarily stop taking her drugs after talking with her doctor. Did Acanfora have a partner or a home to fall back on? We know that she had a credit card. But is she still alive? One wishes that the Washington Post would conduct a followup story. Meanwhile, other seniors have stopped taking their drugs altogether. They couldn’t afford it.

While it is true that Obama advocates the federal government negotiating with the drug companies to reduce prices under the Medicare Part D drug program (similar to what the Department of Veteran Affairs now gets), permitting citizens to purchase prescription drugs from outside of the United States, and closing the doughnut hole, let’s consider why this policy was effected in the first place. The MMA came into being because of rising costs in prescription drugs and the inability of the federal government to allocate enough funds to pay for it. What we have here is a scenario in which the pharmaceutical companies hold all the cards. The companies set the prices. The generic drugs that were supposed to save people money have proven to be more costly thanks to the MMA. The companies claim that the drug prices are high because the companies need to spend this money on R&D. And, of course, the drug companies have lobbyists.

And if the drug companies hold such power, how can there possibly be negotiation? I can see the conversation going something like this:

Government: We need you to lower the costs of drugs. Now we’ll be happy to take them all off your hands, guaranteeing X number of drugs over the next five years, if you’ll lower the prices.

Drug Companies: You’re already going to be getting X number of drugs over the next five years from us. With all due respect, what’s changing here? We’re your supplier. And wait a minute. I thought we agreed back in 2003 that we wouldn’t be negotiating.

Or as Robert Laszewski put it, “If you go to a car dealer and tell him you’re going to buy his car no matter what, and then try to negotiate, you’re not going to get a very good deal.”

Which puts the government in the awkward position of going overseas to import its drugs for Medicare. But if Medicare’s chief drug source comes from another country, how then can the FDA provide the essential oversight for the drugs? This leaves the government coming back to the pharmaceutical companies with its tail between its legs. I’ve looked around numerous places, but Obama has not specified how he can “negotiate” with these draconian realities in place. But to his credit, he did issue a press release last year condemning the Senate’s failure to consider legislation permitting Medicare negotiation.

Let’s return to the issue of Larry Stewart and Frances Acanfora. The rhetoric in this presidential race has involved speaking to Main Street and the middle-class, who we are told increasingly are having to “tighten their belts” to make ends meet. But what is not really being talked about by either camp are the 29.4 million Americans — up 4.7 million from 2002 to 2006 — living below the national poverty line. Tayari helpfully directed me to this Democracy Now! segment from a few days ago, which goes into this issue at some length. And indeed why should either candidate talk about low-wage workers when Obama leads 2 to 1 over McCain? (Incidentally, a majority of low-wage workers polled in this article indicated that their personal finances were unlikely to change — even with an Obama presidency.)

When you consider Medicare’s reliance upon pharmaceutical companies and this regrettable framing emphasis away from the working poor, what Obama essentially presented to us last night was comfort food for the middle-class. (So flexible is the term “middle-class” that one can make a six figure salary and still remain lodged within an income bracket that likewise includes someone making $20,000 a year.) But none of this takes away from the fact that nearly 30 million Americans are impoverished, and that 47 million Americans are without health care. What this nation needs more than “hope” is a concrete and realistic plan. We need something more than promises to “negotiate” in nonnegotiable situations. Something that returns us to the dialogue kickstarted by John Edwards last year. Something that ensures that the dread P word spelling out our poverty will return to our national dialogue with neither shame nor flash, but with the maturity and grace that Obama has built his campaign image upon.

American Health Care: Grin and Bear It

Freelancers do indeed need health care. Shame on the spineless Democratic presidential candidates for failing to bring this up or call for universal health care, proper. I admit that I say this out of self-interest. Because I am now a freelancer. And I do not have health care. And I play Russian roulette every day hoping that I will not get sick or viciously maimed or otherwise be the target of expensive hospital bills.

“Well, you chose this life,” you might say. “You knew you had it coming.”

Maybe so. And I’m pretty damn committed to it too. That’s what passion will do for you. Because I am, in part, a crazy bastard. But does this mean that I, and other freelancers who are in the same boat, should be denied free or low-cost health care? Is it selfish for freelancers to expect health care as a basic right? Or do we just grin and bear it?

Shortly after moving to Brooklyn, I contracted one of the worst bouts of pneumonia and bronchitis that I have ever experienced in my life. There was no money to see a doctor and, being on deadline all the time and not having nearly the kind of high octane energy that I usually have when I am the pinnacle of health, I foolishly didn’t go to a free clinic. Because I didn’t have the time. I ended up losing my voice for almost a month — and yet I still continued to conduct interviews.

I coughed so hard that I actually threw out my back, and spent two days in more pain than I cared to divulge to my girlfriend, who was absolutely kind to me throughout — just one of the many reasons why I’m exceedingly lucky. But there came a time when I woke up at 3 AM in which the pain was so severe that I hollered at the top of my lungs and tears streamed down my face. If I moved an inch, my entire back would feel as if it had been stabbed repeatedly. I pretended that all was well, and I learned to live with the pain until it went away. And it was all because I was terrified of paying hundreds of dollars just to get some goddam antibiotics that would fix the problem. The pain was an assault to my very being, yet I was determined to carry on, as vigorously as possible, not being a corporate whore.

But I was a whore of an altogether different sort. A whore to patriotism and a severely flawed health care system in which the sick, the ill, and the wounded are expected to carry on with their business as if all is well. Because this is America, an ostensible nation of progress and democracy. And we really should shut up and tough it out. This is the American way.

If I was sick, then I damn well better get well. I damn well better have the constitution to pretend that all is fine when it isn’t. That this bronchitis or pneumonia was just a protracted cold. And how different is that really from the cavalier manner in which we look the other way and accept other problems that we believe will get resolved of their own accord?

My intention in 2008 was to vote for a Democrat. But if the Democrat that becomes a presidential candidate cannot get behind universal health care, s/he won’t have my vote. I’m voting for a candidate who has the conviction to guarantee health care for everyone. It may very well be a wasted vote (or maybe not in this blue state), but if I have to grin and bear it when I get sick, I sure as hell have no intention of grinning and bearing it when it comes to this much larger question. In a just universe, this would be one of the major issues of the 2008 election. But this is a nation that would rather pretend things aren’t as bad as they are.

I could vote for Hillary Clinton, who gives you the illusion of choice, or Barack Obama, who promises that no American will be turned away. (Well, you may not be turned away. But you’ll still foot the bill.) Clinton and Obama are big on “lowering costs,” but they haven’t bothered to toss out any concrete figures. (The only thing we get from Obama is that “the typical consumer would save $2,500 a year.” But that’s more like promising voters that they will continue to carry on the long American tradition of collecting coupons from the Sunday newspaper. Big whoop. I’ll pay $5,000 for open heart surgery instead of $7,500. Thank you for shopping at Target Greatland. (The Edwards plan is more interesting, in that it boldly pits a public health care industry against a private one. But it is likewise reticent about costs.)

But here’s what I want to know. What’s the bottom line? How much will each of these health plans cost me if I want to sign up? And can these plans seriously curtail the crazy costs that come from even an ambulance ride? These are the questions that every uninsured American is asking. These are the questions that keeps someone uninsured. The three major Democratic candidates simply will not, or maybe just cannot, recognize the worries and concerns of working-class America.

So, in the meantime, grin and bear it, America. You may not have health care anytime soon, but this is the greatest country on earth.