wonkinprogress

Freedom and health care

In their defense of AHCA Paul Ryan and his cohort of free market fans keep touting freedom. “FREEEEE-dom!”, a la Mel Gibson in Braveheart. We talk a lot about our freedom in America, but for all our loving of freedom, we seem to be not so much fans of rights. Freedom to choose a health plan (or not) whether it’s affordable (or not). But mention the idea that we each have a right to health? Whoa, whoa, whoa. The GOP doesn’t want us to get carried away and think we have a *right* to health or health care or health insurance.

Elsewhere, the idea that health is a right: health care is a human right is not controversial. To be fair, neither is climate change. It’s only America still “debating” climate change and evolution and the fossil record and whether or not people with the least should get to live lives in safety and health.

We as America don’t even believe you have a right to not get shot. Right? Public and court opinion are that police can shoot people. Unarmed suspect? Doesn’t matter. Running away? Doesn’t matter.

How do we reconcile this literal bowing to the police state with FREEEEE-dom?

WHO and our OECD peer nations all declare health care is a human right. It’s not up for debate. It is the premise on which their health systems are based. America? Nope, we’ve got freedom. Individual choice. (Except if you’re a woman who needs an abortion.) Paul Ryan and his teammates keep saying “freedom to choose the health insurance you want.” Which will be unaffordable, unless you really believe a person can spend 50% of their income on health insurance premiums, and also pay rent, buy food, oh and handle the out of pocket expenses if they actually *use* their health insurance. Where does that money come from?

So who exactly in this America gets freedom? And rights?

Repeat after me: Health insurance is not health care

I keep forgetting that health insurance is not health care. It’s easy to mistake insurance for health care. We call our insurance a health plan, after all. If we think that insurance is health care, then we start to think that insurance companies must want us to use health care when we need it so that we can stay healthy, or cure what ails us and return to good health.

It turns out insurance companies and other Payers want us to use as little health care as possible. Or more accurately, they want to pay for as little health care as possible. And that makes sense, I suppose. Does your employer want to pay more for employee health insurance? Do your coworkers want to pay higher premiums because someone among you required expensive cancer treatment? Why does it work this way? Well, because we’ve monetized health care in the U.S., and have been using this employer-sponsored health insurance system since about World War II, and changing it is going to take time.

There’s a lot of talk about Health Savings Accounts. They’re growing in popularity with Employer Sponsored Health Insurance (ESI) and they are mentioned frequently by politicians. Health Savings Accounts (HSAs) are individually-owned, pre-tax funded bank accounts that are used in combination with High Deductible Health Plans (HDHPs). You get to keep the HSA forever, even if you change jobs. You have to have an HDHP in order to spend the money in the account. The money you put in the HSA is pre-tax, so it lowers your taxable income. Sounds good so far. The HDHP has a lower premium, so you and your employer are paying less to own a health insurance policy. And you have a minimum deductible of $1300 for an individual (employee only) plan or $2600 for a family plan. Those criteria are determined by the IRS. Wait, what? What does the IRS have to do with health care?

The IRS deals with all the tax related parts of health care spending. Health insurance is a tax-free benefit bestowed upon employees in the U.S. We get health insurance instead of higher wages, or employer sponsored health insurance is considered part of compensation. When job seeking or trying to decide on a job, you consider the benefits including health insurance, right? And the money spent on health insurance (which doesn’t feel like income because it’s paid directly to the health insurance company) is really part of your compensation but is not taxed by the IRS, so works to reduce your taxable income. And the IRS is responsible for the advanced premium tax credits (APTC) for consumers who buy their insurance on the Marketplace (Obamacare)! (Every day I learn that health care and health insurance are really complicated.) I could keep going, but tax talk is making me dizzy…

ah yes, so Payers (health insurers and employers) want us to use as little health care as necessary, in order to keep spending down. Enter HDHPs. By requiring a higher deductible, that shifts health care costs to you, the employee/worker/consumer! You pay a lower premium, which sounds good. But then you’re on the hook for the first $1300 of health care, which you pay with your HSA. Where does the money in your HSA come from? From you! You divert pre-tax wages to your HSA. Your employer might contribute as well, kind of like the employer match for your 401K. The idea behind HDHPs and HSAs is that consumers will use less health care, because when you have to pay for it, people are less likely to. Hopefully that means consumers/employees/workers/people seek out unnecessary care less often, which I suppose would be waiting out a common cold with rest and fluids and chicken soup instead of running to their physician to request unnecessary antibiotics. But what if it means avoiding needed care because of the cost?

Work harder or work smarter?

I’ve been trying to understand the rejection of health insurance reform by people who seem to be average middle-class Americans. I’ve spoken with some hard-working friends and family members with varying degrees of college education, who in at least one case abandoned the field of their dreams in order to provide for a growing family. I proposed an alternative scenario to them, which is the reality in countries with universal healthcare: What if your dream job had paid a living wage and your family had health care? In other words, the job you really wanted provided a modest but sustainable living: enough to pay the rent and keep food on the table, and health care was either free or close to it. The response: but then we would never want to do better/be more/improve.

If you’re working at least 40 hours a week at a job you love in the field you spent 4 years (and a few thousand dollars) studying in college, why is it not enough? Is the need to do better/be more/improve based solely on compensation? Do we diminish some fields strictly because they don’t pay? If we don’t value work in the arts or natural resources, we risk losing key elements of our civilization. What is life without art or music? How can we sustain human life on the planet without managing our natural resources? Why not expect a system that values the work people do and compensates them adequately?

More than once I’ve heard someone express the idea that “I couldn’t afford health care (or housing) and didn’t qualify for assistance; so why should anyone else get assistance?” Perhaps the problem isn’t the people who do qualify for or receive assistance, but with the programs we have in place. We can change housing and health care programs to make services available to more people. Maybe expanding availability of health care would be more palatable to the tax-paying Middle Class if they were receiving the benefits their taxes fund.

Do we want our children to have to weigh the same choices: pursue their dreams or choose job security in a field for which they have no passion or interest? The ultimate sellout: trade dream to  cling with gratitude for a less than satisfying job which provides health insurance (which they still have to pay for and may not cover all necessary healthcare). We’re all paying for something.

Status: Government Beneficiary

I recently learned that states confer citizenship. Either I really wasn’t paying attention during that Senior-year government class in 1992 (could be), or I was never taught this in school! It is a surprise to me! And reinforces the slowly-dawning realization that my fandom of the Federal Government might be influenced by the fact I’ve spent most of my life as a government beneficiary. I have been saying it more often: I am a beneficiary of the Federal Government. Born at a U.S. Navy hospital. The bill for my birth: a couple of bucks for my Mom’s meals during our hospital stay.

I wasn’t even born here. The only government entity that has certified my birth is the State Department. That’s the U.S. State Department. I am a Citizen of the United States. All of them, I always figured. I’ve lived in a few states… California, Virginia (shudder), Massachusetts, Vermont, Montana, Hawaii, Washington, Oregon, Texas, South Carolina, Maryland, and then an August in Georgia (thanks, Army!). Those are the states I’ve lived or worked in; adding in the ones I’ve spent time in or driven through, brings us up to about 45 of the lower 48 (I don’t count airport layovers). This isn’t a brag, I just always focused on the “united” in the name of our country: I drift from state to state as though they’re all part of one place. Because I don’t have a home state, they’re all mine. Ours.

Turns out that isn’t everyone’s perspective. I learned more about State’s Rights last semester than I ever thought I could. And though I understand how it works, and the historical context and all that jazz, I don’t *get* it. States really want to be in charge of everything, including health, with little or no interference from the Federal Government. A frequent response to proposed public health or other social policy from the Fed is something like “States know what’s best for their people.” They don’t need or want Big Government telling them what citizens of (state) need or how to go about providing it. I would buy that response, if there weren’t 22 18 states refusing to expand Medicaid right now. They are choosing to leave the people of their state (or Commonwealth, Virginia) uninsured and with no access to affordable health insurance or healthcare. How is that best?

It’s not just Medicaid expansion; it’s mental health, food assistance, housing, welfare, education, and infrastructure. States are responsible for these social services, but have cut funding or insist on adding hurdles between people without, and the food, housing, and healthcare they need. In the case of rejecting Medicaid expansion, that means refusing funds from the FedGov, as in “no thank you, Federal Government, we don’t want that Billion dollars.” And because each state decides what is best, there’s a difference between being poor in D.C.* and being poor in Virginia or Alabama or Michigan. I wandered across this handy chart from Kaiser Family Foundation that breaks down state spending by category. You can see which state spends more on corrections than on education, and which states spend more on corrections than on public assistance.

This post will be the first in a series exploring each area of need and how benefits vary from state-to-state, and how the states and FedGov share those responsibilities.

*okay, you got me: D.C. isn’t a state. (Yet.) But the District works hard to provide more for its residents than its neighbor Virginia does.

On universal healthcare and portability

“Coverage must not rely upon employment or other mutable qualities in a woman’s life. Reform must include a portability option so that women with ovarian cancer can move, change jobs, and live their lives as fully as possible.” (from OCNA Principles of Healthcare Reform)

We Americans put our individual freedom at the top of the values we hold dear. But if our ability to receive medical care is in the hands of our employers, how free are we? We have to include access to affordable health care when considering taking or keeping a job. What happens if we separate health insurance from our jobs?

In the U.S., health insurance has been tied to compensation since about World War II. In an effort to attract and retain workers, and restricted by law from offering higher wages, employers added benefits like paid health insurance and pension plans. How many employers still fully fund pension plans?

System failure

One of the problems with healthcare in the U.S. is that we have a series of fragmented facilities, practitioners, and payers instead of a system*. Each medical practice or clinic or hospital exists on its own and is responsible for billing and for keeping medical records. This is part of what drives up medical spending: it costs a lot to decipher and bill different health insurance plans; purchase or create or maintain electronic medical records; retrieve and compile clinic and lab and prescription data. We have a system that requires redundancy.

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ACA Q&A

I fielded questions about Obamacare in an impromptu Q&A! Not yet ready to hold a press conference, but it felt great to be able to answer my (non-MPH) classmates’ questions about the ACA. Always happy to do a little myth-busting and righting of wrong information.

Yoga matters

The stereotype is that yoga is for skinny bendy white women. I’m not particularly bendy. Usually when I mention yoga to a new acquaintance, whoever I’m talking to tells me they’re not flexible. Neither am I! That’s why I need yoga. Yoga keeps my body working at its biomechanical best, and leaves me feeling serene and emotionally connected. I’ve started calling myself a yoga-vangelist because I often tell family and friends (and strangers in line at Starbucks) that yoga will fix whatever ache or pain they’re complaining about. No, I don’t think yoga will cure (or treat) cancer. I do believe that it can improve the emotional wellbeing of someone undergoing cancer treatment, and get the muscles and heart working in a low-impact way which may ease some of the side effects of chemotherapy. (A little cat-cow does wonders for chemo-induced constipation.) For me the subtle muscle movements that are required for alignment-based yoga achieve the same results as physical therapy.

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Gutting Obamacare

In Halbig v Burwell, the D.C. Circuit Court of Appeals ruled that subsidies for health insurance premiums can only be provided to individuals buying insurance through their state-run health insurance exchange. Only 16 states and the District of Columbia set up their own health insurance exchanges.

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