Health Care
During the late 1990’s and the early part of this decade, my parents were finally beaten down by long-term chronic conditions. They died. I was their intermediary with the health-care system. They had Medicare, a paid Medicare supplement they could barely afford, and at the end, Medicaid. It wasn’t enough, and their care was compromised as a result.
In 2006, my wife was diagnosed with a potentially life-threatening condition. She’s all better now, but the experience was instructive and expensive. And we were well-insured, or so we thought. It was the quest for more-better health insurance that drove me back to work after the bracing autonomy of retirement.
I’m now a pubic employee, a member of that great big union the conservatives love to hate, and because of the collective bargaining agreement negotiated by this union, I have premium health insurance, a guaranteed payout pension, and a measure of job security virtually unheard outside of the C-officer suites and boardrooms of today’s corporations. Yet even though my coworkers enjoy all of these same benefits, including the premium health insurance, many if not most of them are in alarmingly poor health.
Citizens of the United States aren’t at the top of the list of the world’s healthiest people anymore, and an inadequate and over-priced health care system is part of that problem, but not all of it.
If you find yourself without health insurance, do whatever you need to do to get some. Sell the pickup, tap the 401-k, get a second mortgage and a third job, whatever. Providing of course, that a policy is available for you at *any* price. Not having insurance can be fatal. Being poor can kill you.
When I was growing up, like most working-class families, we went to the doctor when we were sick. We went to the dentist when we had a toothache. If we couldn’t see the blackboard at school, we got glasses. My parents, in order to make these visits possible for my brother and me, did without themselves.
I was seriously ill a couple of times as a child, and I remember that the entire process was stage-managed by a general practitioner, who coordinated and explained everything.
When my parents started to get seriously sick, I had to run interference for them with the health care and social services bureaucracies, and the first thing I learned is that nobody coordinates anything. You are totally on your own. And if you’re not proactive, or God forbid, if you’re an elderly person without an advocate, your care is going to suffer and ultimately, so will you.
At the Medicare end of the spectrum, a lot of sick people are competing for relatively scarce healthcare resources. Not all doctors see Medicare or Medicaid patients, and the ones who do usually aren’t the best resources available.
My parents relied on the health care infrastructure of the decaying mill-town ten miles down the road. The mills closed up and moved out in the 1970’s, leaving their aging former employees with a legacy of chronic health problems. My parents didn’t work in these mills, but my paternal grandfather and many of my aunts and uncles did. And almost all of them died from the kinds of chronic lung conditions endemic to the textile industry.
The children of these mill workers, or the luckier ones not imprisoned in the service and retail ghettos, now work primarily in health care, the only growth industry that pays, left in the wake of industrial decay and abandonment. Except none of them are doctors. They fill the more menial roles, while the doctors are largely graduates of medical schools in Mexico, Central America, India, and The Philippines. Are these doctors competent? Who knows. They are the only game in town.
I remember taking my mother to one of these Medicare Mills for the first time, and walking into a dirty, crowded waiting room full of people with chronic respiratory problems. A security guard in a blue blazer and name tag stood in the hall. After 40 minutes, we saw the doctor, a south-asian, and the exam was cursory, at best. The whole office appeared harried and over-worked.
And this office was the rule, rather than the exception. The process of dealing with the various providers was fraught with error and miscommunication. Follow-up was necessary for each and every item. Conflicting appointments and appointments at impossible hours, missed tests, misplaced test results, a reluctance to do hospital admittance and attempts to discharge from hospital sick, elderly people too weak to care for themselves were common.
Threats and even yelling were sometimes necessary to eke out a bit more care, or a higher quality care for my parents. But the sad thing is I know that every advantage I was able to secure for my parents probably came at the expense of other poor elderly without advocates.
If I could have pulled my parents up out of that mess and possibly prolonged their lives, I would have. But by the time I became involved in their care, it was already too late. They’d been misdiagnosed, over-medicated and under-treated for too long. And there *was* nothing else. It was Medicare Mills filled with indifferent and marginally competent foreign-trained doctors. Or nothing.
My Father died from complications related to lung cancer in a Medicaid nursing home bed November 8, 2001. Patients with his diagnosis and better care often live five to ten years. He lived three. My Mother died from complications related to COPD and emergency room error March 25, 2002.
My wife is also a public employee, and at the time of her diagnosis, she was carrying the health insurance for the entire family, a policy that is generally perceived as one of the best you can get. As we started making the rounds of the doctors, it was immediately clear that we were at a different tier of the health care system than the one my parents were forced to occupy. The doctors were graduates of US medical schools. The waiting rooms were both less crowded and cleaner. And the doctors were more available to talk at length about prognosis and treatment.
Yet the whole process was still largely self-service. We gleaned the majority of our information about my wife’s condition and treatment options from the Internet, and leveraged this information with the health care providers we were using to improve care quality and options. And we still had to coordinate tests, follow up for results, and double-check for errors and omissions. Once again, if you just passively take the default in all the interactions without questioning and following up, your care will suffer.
And from the very beginning, there were ominous financial rumblings. It was made crystal clear immediately that any amounts not paid by insurance were due and payable immediately, up-front and prior to treatment. At this point, we found out that the first $5000 would be out-of-pocket. Luckily, we had a flexible spending account, and were able to distribute this out-of-pocket expense over an entire year, and pay it with tax-free dollars. And ultimately, it cost a lot more than $5000 to satisfy that requirement, as many of the things we had to pay for out-of-pocket didn’t count toward satisfying this out-of-pocket minimum.
But the major shock came when we realized that there was a chance my wife could be disabled by her condition, and unable to continue working. In which case, she’d have no health insurance, and she’d either have to continue her coverage via COBRA, which is extremely expensive and is only temporary, with an 18 month cap, or we’d have to buy private coverage, which was unlikely to be available at any price, given that my wife would have been disabled. A disability retirement with pension and Social Security Disability with Medicare would be an option in this situation, but this takes years to apply for and get. And of course, the rest of the family would still be without coverage.
Luckily, the doomsday scenario didn’t happen. My wife continued working, with health insurance, through her treatment. But it was a major wake-up call.
If only one member of your family is carrying insurance for all of you, what happens if this person gets sick? What happens if they are disabled? That’s the question that sent me back to work. Now my wife and I both carry full coverage on each other, so in the event one of us becomes too sick to work, or loses a job, there will still be uninterrupted coverage. And health insurances can be set up as primary and secondary, with charges not being paid by the primary policy falling through to the secondary coverage for payment.
Short-term disability coverage, which was a part of my compensation package with a private-sector employer (albeit a very good one)
twenty years ago is no longer available, even in a public-sector unionized environment. If you get seriously ill and need to be off work for three to six months, and you don’t have the sick-time saved up, you’re just shit-out-of-luck. So now I also carry a private short-term disability policy that will pay me 75% of my salary if I’m disabled for 30 days up to two years.
Granted, it’s expensive and redundant; a belt-and-suspenders approach. But the consequences of *not* having medical coverage and income when you need it, unlikely as this may be, are too dire to contemplate.
So, what’s the solution? Two words. Single Payer. Nationalized health insurance for everyone, with an enhanced social safety net to cover short and long-term disability, as well as long-term and systemic unemployment and underemployment. Universal health insurance will benefit the poor and working poor, obviously. But it would also act as an engine fueling innovation, as a major operating expense for small and medium-sized companies would be eliminated.
But great universal health insurance, disability, and catastrophic employment-change insurance is only part of what’s necessary to bring the United States back up to world-leadership in citizen health and well-being.
Let’s go back to my new coworkers in the public sector for a minute. These are folks that already have much of what I think all of us deserve. They have good job security, great health benefits, and a pension to buttress Social Security in their old age. Yet many of them are in startlingly poor health. Most are significantly overweight. Many still smoke in middle age, and eat an extremely poor diet.
The diet, the smoking, the overweight are in large part due to ignorance as a result of inertia and social and media conditioning. Fast food tastes good, and is advertised ad-infinitum. Cigarette advertising is now illegal, but 007 smokes. I also suspect busier schedules, an inability or unwillingness to cook, combined with an over-reliance on pre-packaged food. Trans-fats and high-fructose corn syrup are culprits too, I think. And there is a justified mistrust of the medical profession — if you’re unsophisticated enough to take things at face-value, and you’re too timid to bark back, anything can happen. Diagnostic screenings and early detection efforts often seem arcane, painful, and unnecessary, especially if you’re feeling OK.
But yet, it’s the diagnostic/preventative stuff that keeps you well and really pays off in terms of extended years of quality life. I had a colonoscopy myself last year. On an unpleasantness scale of 1-10, prepping for the colonoscopy is a 10. Yet the procedure is invaluable in heading off colon cancer. In my case, I had a benign polyp in my ascending colon. Maybe nothing would have come of it if it hadn’t been removed. On the other hand, if it had turned malignant, by the time I had sensed any symptoms or discomfort, it would have been way too late.
It takes education and awareness to convince people that the most productive visits to the doctor are the ones you make when you’re *not* sick. Many of my coworkers aren’t getting routine physicals. They’re doing what we did in my working-class childhood. They’re not going to the doctors unless/unitil they’re sick. And by then, it’s usually too late. A chronic condition has already taken hold and is irreversible.
Education about the importance of diet and exercise in long-term health needs to be stressed, and coupled with a new regulatory structure with teeth. Poisonous foods, sham diets, snake-oil health claims, and sales of products that damage people or make them sick need to be stopped.
The social interface to the current health care system sucks, sucks, sucks. Three people I work with are diabetic. Our medical coverage *pays* 100% for diabetic testing devices and consumables, yet all three until recently were either paying $200 out-of-pocket a month for these supplies, or doing without them, simply because no one was able to tell them that the Durable Medical Equipment benefit, which is administered separately from the health coverage proper paid for the meters and the test strips. What they needed was a meta-interface that straddled all the care available and could direct them quickly to the appropriate resource for their needs. I suspect in my organization, health issues go under-treated, and insurance resources go under-utilized simply because people don’t know *how* to intelligently apply the resources they have.
I get really pissed every time I see a billboard, advertisement, or slick PR magazine handout from a health care institution. I say *fire* the marketing vice presidents, drain the ad budget, and spend that money on making sick people well. Spend that money on project managers/caseworkers/coordinators for people who don’t have the resources to do this for themselves, because God only knows, you need it if you’re going to get decent care.
After nearly fifteen years of dealing with the health care and social service bureaucracies, I can say with 100% assurance that the system is definitely, irreparably broken beyond fixing. Greedy insurance companies and for-profit healthcare have got to go if the United States is to regain world leadership in terms of citizen health and well-being.
Where will the money come from? We’re already spending more per person than most of the world. We simply need to redirect more of the money to care that matters. Fire the CEO’s and marketing vice presidents. Let the Doctors run the show. And then there are taxes. I suggest we start with private equity firms, hedge funds, and their traders/managers. These people by and large profit from a zero-sum speculative game that drains public companies and pension funds of resources while creating absolutely nothing of productive value. If these ill-gotten gains can be confiscated, and better yet, if the whole thieving business category can be taxed into oblivion, so much the better.
