Friday Editorial: Chronic problems
The older you get, the more likely you are to develop a chronic illness such as heart disease, high blood pressure or cancer. The more chronic illnesses you have, the more health care you need.
The inevitability of illness is why we buy health insurance in the first place; that way, when we get sick, we can afford medical care. At least that’s why we bought insurance back in those good old days when insurance covered almost all of the cost of treatment. For many of us, however, that’s no longer true.
About two of every five Americans — more than 100 million people — have at least one chronic illness, including heart disease, high blood pressure, stroke, cancer or lung problems such as asthma or emphysema. Most of those afflicted are working adults who are too young to qualify for Medicare.
A study published in July in the journal Health Affairs finds that working people with chronic illness are having a more difficult time getting medical care than they were a decade earlier. The study was conducted by researchers from the nonpartisan Kaiser Family Foundation, building on the results of a similar survey conducted in 1997. As you would expect, the problem is most acute among the growing numbers of people who have no health insurance.
National health spending soared by 87 percent between 1997 and 2006, to $2.1 trillion. Those cost increases have caused many doctors to cut back on the amount of free care they provide.
At the same time, many companies have stopped providing health insurance to their workers. That spells disaster for those with chronic illnesses. Because they’re sick, insurance companies don’t want them. As a result, many of them can’t find insurance coverage on their own at any price. Some insurers even can cancel policies retroactively when doctors diagnose a chronic disease or one that’s expensive to treat.
In the Kaiser study, about 34 percent of uninsured adults with chronic illness reported that they had no regular source of medical care. That’s up from 31 percent a decade earlier.
A little more than 35 percent said they had avoided seeing a doctor or seeking some other form of medical care during the previous year because they couldn’t afford it; that’s up from 32 percent in 1997.
People who had private insurance coverage were more likely to have a regular source of care in 2007 than they were in 1997. But in 2007, they were more likely to skip care recommended by their doctor. For example, the percentage of people who reported not filling prescriptions because of cost was nearly twice as high in 2007 as it was in 1997, which was before many insurance plans began imposing what are called “tiered” co-payments for drugs.
Under tiered plans, co-payments for drugs and even medical treatment are separated into categories according to cost. Patients who pay $20 to visit their regular doctor are charged, say, $40 to see a specialist. Co-payments for brand-name drugs are substantially higher than co-payments for less expensive generic drugs.
These kinds of plans have become widespread in recent years. They’re designed to encourage people to stay well and prevent what researchers call “inappropriate use.” An example of that is getting a hangnail trimmed in the emergency room instead of a doctors’ office.
But as the Health Affairs study shows, tiered co-pays and higher deductibles are as blunt instruments that also can discourage “appropriate” use. Yes, someone with a chronic illness may be more expensive to care for than someone without one. But in the long run, most experts agree that not treating the illness leads to higher expenses and worse outcomes.
Many, if not most, Americans will develop chronic illnesses. Without major reforms to the system that provides and pays for health care, they’ll face an increasingly uphill fight to get the care they need.
Post-Dispatch photo of nutrition class for diabetes patients by Sarah Conrad
I’m a Vietnam vet, 61 years old. I have high blood pressure, asthma, tinnitus and back problems. My wife and I have always been grateful for the lives we have had and the blessings we have received. Forty years ago, I was heavily exposed to Agent Orange. I expect that when I die, that will have something to do with my passing.
When that time comes, I will not look back on what might have been, or how the government of the United States should taken care of me better. If anything, I may wish that I had taken better care of myself, watched my diet and exercised more. When that time comes, it will not be because I was foresaken by an uncaring central government. It will be because it was my time.
I have loved my family, loved my life and loved the fact that I was born in such a wonderful country. I’ve never been a victim. Never short changed. I’ve had every chance. I may have done things wrong in my life, but sometimes that’s just the way it is. When I die, I hope to God that nobody says; “If only the government would spent more.”
Thank you, Star20, for sharing your perspective. It’s something we need to see more of nowadays.
http://www.grafshepherd.com
The question here, Star20, is not whether the government should spend more. It’s how the health care system can do a more efficient job of delivering care we already pay for and provide.
To use one simple example, it’s very expensive to provide treatment for someone who had a stroke because of unchecked high blood pressure. It’s much less expensive to spend smaller amounts over time to provide that person with access to medicine and regular doctor visits. So how do we make sure that patient gets medicine and regular doctor visits?
The answer surely isn’t to impose tiered co-payments and high deductibles to make routine care and medication more unaffordable. After all, nobody likes taking blood pressure drugs — they can have some unpleasant side-effects — so this isn’t a case of someone seeking scarce resources for a nonexistent problem. But that’s just how many insurance comapnies, which are concerned about meeting Wall Street’s short term earnings expectations, treat it.
And why not? They don’t know if they’ll still be covering the patient when he has a stroke. Maybe he’ll be covered by a competitor. Maybe he’ll be on Medicare, with taxpayers picking up the bill.
If insurance companies had to cover people for life, or if their earnings were risk-adjusted so they couldn’t profit by covering only healthy people and dumping those who develop chronic illness, these problems would be addressed. There may be other ways to do it, also. But the problem is very real, and we’re all paying more for health care because it’s not being addressed.
“If insurance companies had to cover people for life, or if their earnings were risk-adjusted so they couldn’t profit by covering only healthy people and dumping those who develop chronic illness, these problems would be addressed.”
Really? How?
Switzerland requires every citizen to buy their own health insurance. Swiss insurance companies have to report demographic information about the people they cover. It’s fed into a system that “risk adjusts” their customers (in the same way that hospitals and insurance companies risk adjust their outcome measures). Insurance companies with a greater than average share of high risk patients are subsidized with money raised by a tax on those with a lower than average share of high risk patients. That gives the companies an incentive to patient patient care, rather than managing risk by “cherry-picking” only the healthiest individuals. I think the Netherlands has something similar, though I couldn’t quote the details without looking it up.
In France and Germany, insurance is purchased by large worker or business groups on behalf of all their members. They’re covered for life through those plans, although contracts are let for shorter periods of time. That does essentially the same thing, taking away the incentive to cover only the healthy and dump the really sick onto the government-funded health plan.
The larger point is that insurance companies will play by whatever rules govern them. The system we have in place now allows them to gain financial advantages by cherry-picking and risk shifting. If we don’t want — or can’t afford — those inefficiencies, we should change the rules and incentives. They will respond accordingly.
“Insurance companies with a greater than average share of high risk patients are subsidized with money raised by a tax on those with a lower than average share of high risk patients.”
“From each according to his ability. To each according to his need”
Karl Marx
Two things to consider, Star20:
Switzerland is the only other developed country besides the U.S. to rely so extensively on private insurance companies to finance health care. Like us, it spends considerably more than the average of other developed nations. We spend twice as much (to achieve what are, by any objective measure, worse outcomes), it spends one-and-a-half times as much.
The Swiss model is the one most touted by free market economists like Regina Herzlinger of the Harvard School of Business. She’s been called a lot of things, including “the godmother of consumer-directed health care.” I’ve never heard her called a socialist or communist, at least not by anyone who is familiar with her work.
In fact, she’s among the most influential health care economists on the right. I interviewed her when she came to town a few years ago to keynote a health industry event. We talked for quite a while. We ended by agreeing that we had both enjoyed the conversation, but respectfully agreeing to disagree.
I appreciate your ability to quote Karl Marx. But I’m not sure how that’s relevant here.
John,
There are either those who can’t see the relevance of Karl Marx in this election, or those who try to deny it and just say; “Move along. Nothing to see here.”