The Mandate

Continued from Anna’s Story.

Fortunately, Anna didn’t need a payment plan.  Her sinus infection responded to the antibiotics and she recovered.  Eventually she found a job with more money and health insurance, and was able to move into a house with heat and hot water.  Anna’s story is no fairy tale, but if it were, it would end “and they lived happily ever after.”

Before you read further, here’s a heads-up.  It’s been a while since I wrote anything about access to healthcare.  I promised to post an ostrich alert any time I do, so that those who don’t want to read about the politics of universal coverage would have fair warning.

The American College of Physicians website includes a blog by Dr. Bob Doherty, and a recent post there, Confusion rules the day, discusses the possible unintended consequences of the recent ruling in Florida about the constitutionality of the Patient Protection and Affordable Care Act (PPACA).  Dr. Doherty closes his post with a question for those who oppose the individual mandate, and asks, without a mandate, how society can get insurance for all.  I responded in the comments section, but another person’s response reminded me of Anna’s story.

The individual mandate would not have helped Anna.  One must have money in order to spend it – a simple economic fact that politicians don’t seem to grasp.  Mandate or no, Anna could not have purchased insurance. 

A mandate is/was unnecessary because Anna did not need insurance.  She needed a doctor.  Think about it; when we send aid to third-world countries, we don’t send boatloads of insurance policies.  We send medicine.  We sponsor doctors and nurses to go work in their professional capacity.  How futile it would be to ship insurance plans to sick people!

Instead of a mandate, our nation needs medical care to be available and affordable.  The mandate does not make medical care available to people.  The mandate does not make medical care affordable.  It just adds expensive layers of bureaucracy to something that doesn’t need to be that complicated.

Insurance does not equal access to medical care.  Every January, my family physician’s office (and likely many more throughout the country) has a sign near the reception desk saying, “We no longer have a contract with xxx insurance company.”  If an insurer won’t pay a reasonable fee, doctors won’t accept that insurance, hence the policy is worthless.  Consider difficulty that seniors have in finding a doctor willing to accept Medicare.  Insurance as we know it now is not the solution.

I’m puzzled as to why the focus is how do we give everyone health insurance?  A more appropriate starting point would be how do we make it possible for patients to see a doctor and get treatment when they need it?  We need to give people better access to medical care without the burden of insurance that costs more than a house payment.

Anna’s Story

Freshly out of college, Anna faced a tough job market.  Her education wasn’t opening any doors for her desired career. She searched and searched, but finally quit being picky about the type of work she’d do and accepted a job with no benefits, paying slightly over minimum wage.

Although she’d been sharing an apartment to keep costs down, when her roommate got married, they young lady needed new living quarters. Fortunately, an apartment was available in an inexpensive part of town – about what it had cost when sharing rent with someone else. Anna had $200 left after paying her monthly rent.   Utilities, food, and transportation quickly devoured every cent.

Bus fare was $1.50 each way, so she had to reserve $3 per day for transportation to get to and from work. Not much, but it added up to $60 a month, and if she didn’t set it aside, it might not be there when needed.  Another $25 for the electric bill meant she had lights in her apartment and a refrigerator that worked.

The first gas bill arrived, and Anna’s jaw dropped at the $187 total. She contacted others in the complex and discovered that everyone else paid $15-$20 per month for their heat and hot water. Armed with this news, a call to the gas company got someone to test the line for leaks, but they found none. Anna matter-of-factly stated that there was obviously a mistake somewhere, but she wasn’t going to argue with them. She didn’t have that kind of money, so they’d better cut off the gas.

Without gas, the kitchen range was useless. Anna found an electric skillet at a thrift store and ate only foods that could be cooked in it. Clean-up meant heating water in that same skillet so she could wash the dishes.

Showers were out of the question; the small bathroom only had a tub. Cold baths in a poorly insulated apartment were fine – even welcome – when it was 90 degrees outside. When winter came, that didn’t work. Sponge-baths using water heated in the electric skillet didn’t suffice. Anna learned that a YWCA membership was $30 a month; it seemed like the best solution to her shower situation.

If you’re keeping track, there was now only $85 left to pay for telephone service, quarters for the laundromat, and a month’s worth of food.  Skipping the phone was tempting, but Anna decided that (given the neighborhood), a telephone might be a good security investment.  Also, she’d never be able to find a better job if potential employers couldn’t call her.  Laundry expenses could be cut if she washed clothes by hand, but the clothes wouldn’t freeze-dry on a line strung across the bathtub.  It took $8 to wash and dry her clothes every week.  There just wasn’t enough money for food.

Searching for solutions, Anna discovered a pizza parlor two blocks from her apartment. When she asked the busy manager if he was hiring, his response was, “When can you start?”

Far from the dreams of a young professional life she’d trained for, Anna left her apartment at 5:30 every morning and rode the bus to the YWCA.  After a nice workout in the pool and some time in the weight room, she enjoyed her hot shower before heading to her 8-5 job.  At 5:00 she was out the door and quickly hopped on a bus. Unable the be two places at once, starting her second job at 5 (as scheduled) was impossible, but the manager understood and let her arrive as soon as she could. After answering phones and making pizzas until midnight, Anna walked home in the dark and stumbled into bed for a few hours of sleep.

Anna was as grateful for the free dinner every night as she was for the extra money.  Minimum wage wasn’t much in those days, but after taxes, the extra job resulted in an extra $70 a week.  It allowed her money for food, and even a bit for new stockings occasionally.  As long as no emergencies came up, she was scraping by.


Eventually, Anna got sick.  Staying home would have meant no paycheck, no food, and ultimately nowhere to live.  She dragged herself to work until the day her boss insisted that she needed a doctor and sent her home.  Anna used the yellow pages to find a doctor’s office near her apartment and explained to the receptionist that she’d been sick for a month and was pretty sure she had a sinus infection.  It was a long shot, but was there any chance of getting an amoxicillin prescription without seeing the doctor?  The receptionist asked why she didn’t just make an appointment, and Anna, near tears, replied that if she did that, she wouldn’t have money to buy medicine.  Silence.

She was put on hold, then the doctor picked up the line and asked questions – history over the phone.  Finally he asked how, out of all the doctors in the city, Anna had chosen him.  “Your office is close enough that I can walk there to pick up a prescription.”

More silence.  “It sounds like you probably do have a sinus infection.  I can’t be positive without examining you, but I’ll prescribe some amoxicillin and we can phone it to the pharmacy.  You don’t need to come here.  If the amoxicillin doesn’t work, though, you need to make an appointment.  We’ll work out a payment plan for you.”

To be continued

What I Wanted vs. What We’re Getting

Ostrich alert:  The following post deals with healthcare reform.  Skip it if you don’t want my opinion on this depressing topic.

Back in July, a bunch of medbloggers went to Washington DC for a Health Care Reform:  Putting Patients First panel.  When (prior to the trip), people pointed out the irony of politicians and physicians claiming to put patients first without asking patients what they want, Dr. Rob openly invited input.  Here’s my wish list, which I originally posted as a comment on Dr. Rob’s Speak To Me post:

Retain Insurance
I want to be able to keep my insurance at a reasonable price. I don’t want to be forced onto a different plan (or dropped) when the insurance company stops making money off of me.

Real Coverage
For the most part, my insurance is good. However, some things are covered only in theory, not in reality. Example: according to my plan booklet, speech therapy is covered. Since many speech issues are developmental, therapists often recommend waiting until children reach age seven or eight to see if they outgrow the problem. I waited. And waited. Finally, our doctor wrote a referral. And I learned that there’s more to it than the plan book we received, and that the fine print (in a file in some obscure closet) says “only until age six.” This means that speech therapy for children is not really covered. At all. Insurers can write whatever they want in a policy, but they shouldn’t be able to claim they’re offering coverage for something when they really aren’t.

Malpractice Reform
I want my doctor to be free to do what is best without having the threat of a frivolous malpractice suit hanging over his head. If premiums for malpractice insurance weren’t so high, doctors would have more take-home pay without having to generate more income. When there is a physician shortage, obstacles such as this need to be addressed.

Fair Pay
I like my doctor, and I don’t want him to retire early or take a different job because he can’t make ends meet. I’d like my doctor to be fairly compensated for his services so that he stays in practice as long as possible.

Most service providers (the electrician, the plumber, the housekeeper, the babysitter, the tutor) are paid an hourly rate for their labor. It is in their best interests to take the time to do my job right. Whether the job takes thirty minutes or two hours, they take as much time as is needed to get the job done, and bill accordingly. Another example is the legal profession. Attorneys bill by the hour – not just time spent with a client, but also for time spent working on behalf of a client.

Medical services are the exception, and medical services suffer as a result. Doctors do not get paid for their time, but for the number of people they can see. Sometimes a simple medical issue could be thoroughly addressed in twenty minutes instead of fifteen, but doctors only get paid for it if they bring patients back for a second appointment rather than take the extra time to take care of the problem in a single office visit. By paying doctors for their time, they would be freed from the tyranny of running patients through exam rooms as if they were working on an assembly line. Patients would benefit by getting the time they really need, without the inconvenience of a second appointment.

Fair pay would include compensating doctors for time spent on behalf of a patient, for things such as writing referrals, determining a treatment plan for complicated conditions, phone calls/emails, or jumping through insurance hoops for preapproval. If insurance companies knew they’d be billed for the amount of time it took the doctor to deal with them, would they respond differently?

I realize that this topic typically comes from doctors, but it comes from patients, too. “You get what you pay for.” I am accustomed to paying for high quality work, firing people who provide poor service, and giving a bonus for a job well done. Yet when I read the EOB’s from my insurance company, I wonder how doctors can afford to run a practice on the reimbursement they receive.

I want what transpires between me and my doctor to be confidential. It is not. The solution is not additional regulation, nor is it threat of punishment/fines for violations. The solution is to permit doctors to maintain confidentiality. Doctors are required to provide information to insurers, and insurers have demonstrated an appalling propensity for releasing medical information to employers. The system needs to be fixed so that doctors can be paid without releasing a diagnosis code (or any other information).

A Level Playing Field
I have no confidence that the politicians will do what is best for anyone, unless they have some skin in the game. “Separate but equal” doesn’t exist in civil rights, and it won’t exist in the healthcare world. Our senators, representatives, and president need to have the same plan that the rest of the country gets.

Respect Good Doctors
Give my doctor the freedom to do his job. I want my doctor to use his expertise to diagnose and treat me. My doctor should be able to order tests based on his medical judgment of what is needed, not based on the pre-approval of an outside source. I want a treatment plan based on what is most appropriate for my specific situation, not based on some cookie-cutter recommendations developed for the “average” patient.

Responsible Use of My Tax Dollar
Healthcare reform should include having a team of ER doctors rewrite the emergency access law. Why do I include this in what patients want? Because when my two-year-old falls on a big piece of metal and cuts a three-inch gash across his forehead, I don’t want to wait while the emergency doctor writes a non-emergency prescription for a Medicaid mom to get her kid some children’s Tylenol. The people who are most affected by the problems of the current law would have good ideas on how to fix it.

I am willing to contribute taxes toward the healthcare of people who fall sick due to misfortune. I don’t want tax dollars to pay for treating people if they willfully make lifestyle choices that cause their own poor health. Someone who can find money for cigarettes can find money for their own lung cancer treatments. People who have been able to purchase enough food to weigh 400 pounds (not caused by a medical condition) can come up with their own money for insulin, heart medication, knee replacements, etc. I know doctors aren’t supposed to judge patients, but other patients do it all the time. Tell the politicians that making people live with the consequences of their actions will help keep costs down.

Affordable Meds
I want medication to be affordable. Actually, what I really want is a cure. Until a cure is discovered, I’ll make do with meds. My concern is that healthcare reform, done wrong, can result in companies being unwilling to develop new treatments. Pharmaceutical companies (like all businesses) need to earn a profit. Look at biologic response modifiers. Biosimilars (generic biologics) sound like a great idea to the person paying for these expensive drugs, but if the pharmaceutical companies decide there isn’t enough profit in these, we all lose. Reform needs to encourage research and the development of new treatments. 

So how’d Congress do last night?

  1. Effective 2014, insurers won’t be able to deny coverage based on pre-existing conditions.  Rates charged are a whole ‘nother thing.
  2. No.
  3. Nope.
  4. Didn’t happen.
  5. This didn’t change either.
  6. You’ve got to be kidding!
  7. Don’t see this addressed.
  8. Not even considered.
  9. Sigh

I predict that we’ll see more emergency rooms close, more doctors drop medicare/tricare, and people have a harder time finding a doctor.  But at least everyone will be able to say that they have insurance.