My argument for & research on healthcare reform

This is a paper I wrote on healthcare reform and what I think needs to be done.

Healthcare Reform in America and Why We Need It

We have all heard the rhetoric on the evening news about healthcare reform and we have all seen the commercials promoting different viewpoints on the issue. What exactly are they trying to change though and how do the people (i.e. the patients and healthcare providers) feel about what needs to be done?

Healthcare is one of our biggest national expenses yet millions of Americans are without easy access (or in some cases any access) to quality healthcare. Health insurance companies make billions of dollars in profit each year according to the stories we see on TV or in the newspaper while denying coverage to millions, like me, because they either have a pre-existing condition or are seen as "high risk" due to things such as age, family background, past illness, or family history of particular illnesses. In essence saying "you can't have health insurance because you might actually need to use it". There is no perfect solution to our healthcare crisis but something must be done to allow more Americans access to quality medical care- both treatment for illnesses and preventive care to minimize the risk that a person will suffer from a catastrophic illness.

The website www.barrackobama.com includes a page outlining President Obama's goals on this matter. It lists quite a few but chief among them are:

• Ending discrimination by insurance companies against people because of age, gender, or preexisting conditions.
  
• Capping out of pocket expenses so people don't go broke because they get sick
  
• Provide tax credits to help people buy insurance
  
• Immediately offer new, low cost coverage through a national "high risk" pool to protect people with preexisting conditions from financial ruin
  
• Require large corporations to cover their employees as well as requiring people who can afford to do so to buy insurance so that everyone shares in the responsibility of reform
  
• Order immediate malpractice reform projects that could help doctors focus on putting their patients first, not on practicing defensive medicine.
  

The first health insurance plans resulted in a downturn in the U.S. economy in the 1920s leading up to the Great Depression. During the 1920s and the decade prior medical knowledge and technology had increased rapidly and for the first time the requirements for being a physician had become stricter requiring more formal education and training. These were, of course, important developments in human welfare but also added to the expense of treating illness and by the '20s, for the first time, a week's hospital stay became more expensive than the average American family's monthly income. People couldn't afford to get sick. Economist Lou Reed said at the time, "Very few of these families are indigent in the accepted meaning of that word. They have a home, they buy their own food and clothing and pay their doctor's bills in ordinary illness but when serious illness occurs, these families are unable to pay their way." (Cohn. 2008. p.6.) A blue ribbon commission, after spending five years conducting the first national census on healthcare, recommended that Americans share collective responsibility for medical costs. "In other words, it recommended the creation of insurance for medical care". (Cohn. 2008. p.6)

Industrial countries, other than the U.S., were beginning to guarantee the availability of medical care to their citizens either through government sponsored organizations or directly through the government itself. They were making healthcare a right rather than a luxury. In the United States this was strictly opposed by physicians worried about outside interference in how medicine was practiced and also by large corporations which feared government managed medical care would lead to interference elsewhere in the private sector. (Cohn 2008)

Patients weren't the only ones suffering though. Hospitals were also having financial trouble. Baylor Hospital in Dallas, Texas was one such hospital and had a mounting debt. They also had a new and quite innovative administrator, Justin Kimball. Kimball had come to the hospital from the Dallas public school system and decided to approach his former co-workers with an offer. He proposed that any teacher who agreed to a donation of fifty cents per month would be guaranteed coverage for a hospital stay of up to 20 days so long as a minimum of three quarters of the teachers agreed to join. Kimball had no problem recruiting teachers to join in his plan and the first health insurance plan was born. (Cohn. 2008)

The original intent of health insurance plans was simple, to help people be able to seek medical treatment without going broke and assist the hospitals being viable and able to stay open and available to care for people when they got sick. Everyone involved benefited it seems. What happened to change insurance from a mutually beneficial arrangement then, and why did it happen?

By the early 1980s most American families were covered by employer sponsored health insurance plans and the benefits had become more comprehensive in the extended years of prosperity following the end of World War 2. As the benefits expanded they grew to include wellness and preventative screenings and the premiums had grown to reflect the expanded role insurance was playing in healthcare. (Cohn. 2008) Given the sustained prosperity over the past several decades why would either the employers or beneficiaries mind an increase in cost given that there was also a continued growth in income? During the '80s though the U.S. economy stalled and manufacturing jobs began to disappear. Businesses began to look for ways to cut costs- one of those costs being how much they spent on healthcare coverage. (BNet. 2009.)

By the 1990s the majority of companies seeing economic success were companies like Wal-Mart which had reduced their employee benefits to the bare bones and enacted policies that limited access to what benefits they did offer. Sometimes these limits were so severe as to require an employee be a full time employee of a company for a period of up to two years before qualifying for medical coverage! (BNET. 2009) Despite having a job my entire adult life I never had insurance coverage from 1991-2000 so can remember these policies all too well.

Companies, such as General Motors, which were bound by agreements with their employees' union to provide health insurance for their workers paid a very high price which was usually passed on to their customers. For example in 1993 GM said, "health insurance for its' employees alone added more than seven hundred dollars to the price of every car and truck". By 2004 that number had grown to $1400.00 per vehicle. (Cohn. 2008) While these costs were being absorbed by businesses and consumers however health insurance was growing to a multibillion dollar industry with steep profits and a reputation for denying benefits to the people it was purporting to protect.

Insurance had changed. It had begun as just what its' name implies- insurance that people could get sick without going broke and insurance that hospitals could afford to operate and care for those same people. It had grown it would seem, to be in the business of insuring its own financial health rather than insuring people's physical health.

Today the increased cost of medical coverage has left millions of Americans without coverage and at risk. The risks for people, like myself, without coverage are many but topping the list would have to be increased risk of complications from illness coupled with financial ruin. The premiums for individual health coverage are high and unaffordable for many people- if they can find coverage at all. As we see on the evening news, millions are simply denied coverage due to having a preexisting illness or being seen as being at risk for developing a serious illness in the future.

As a lupus patient, I am one of the millions of Americans who are seen as "uninsurable" but at least in my case they can give me a reason. It doesn't make the lack of coverage any easier, nor do I think it's fair that I am denied coverage over a condition I had no control over developing. At least I know why they won't sell me a policy though. Millions are turned down simply because insurers think they could become sick later thus actually using the policy they are paying for. Among the reasons I have heard people being considered as "high risk" are age, income level, and family background along with their personal medical history.

Having an insurance policy doesn't guarantee anything though. Insurance companies routinely deny payment for medications and treatments. I spoke with a fellow patient in my rheumatologist's waiting room who was waiting to pick up paper work she needed to submit to her insurance company. We'll call her Mandy. Mandy has lupus with severe organ involvement and the Dr had recommended Cytoxan to try and slow the damage to her lungs and kidneys. Cytoxan is primarily a cancer drug though and its use in lupus patients is considered "off label". (Off label is a term used when a medicine is being used to treat a different condition than what it was developed and approved by the Federal drug Administration.) Most drugs currently used to treat lupus are "off label" (primarily chemotherapy drugs or anti-rejection medications) but are used because they have proven beneficial in lupus for many of the same reasons they are beneficial in treating a disease such as cancer or helping to prevent organ rejection, they suppress the immune system and in lupus (and all autoimmune diseases) by suppressing the immune system they slow the progression of and damage from the disease. Well, Mandy's insurance company had denied coverage for the Cytoxan because they said it was experimental despite having been used successfully in thousands of patients to treat lupus. She and the doctor had been fighting with the insurance company to approve the treatment for six months and had yet to succeed. (personal communication. October 2009) Cytoxan is an expensive course of treatment to be sure, but surely less costly than what further damage to a person's kidneys or lungs would seem.

In addition to speaking with Mandy informally while we were waiting at the doctor's office I also conducted two more formal surveys over the past few weeks, one of patients in my online lupus support group and in an online support group for fibromyalgia and the second of healthcare providers including two doctors here in Louisville, a nurse practitioner, and a pharmacist in Lexington, KY. I asked both groups what they see as the biggest obstacle in the U.S. healthcare system. Everyone agreed that it was the insurance companies. Patients said they have had to appeal decisions to deny payment for hospital stays and tests ordered by their doctors as well as the myriad of paperwork required to get approval for scheduled procedures recommended by their doctor or nurse practitioner (ARNP). Providers said they spend countless hours that should be spent caring for their patients dealing with an archaic amount of paperwork required to both receive payment for their work as well as to convince an insurance company of what treatment is best for their patient. One doctor said " the red tape involved and stonewalling by the insurance companies in receiving approval for newer, more effective treatments to help my patients often causes more stress for my patients and a higher long term cost because delay in treatment often leads to a longer and more complicated recovery". Again, it seems to me as if it would be more cost effective to approve more effective treatments and do so faster rather than prolonging the illness and thus requiring a longer (and often costlier) course of treatment. (personal communication. October 22, 2009)

Patients other major concerns with our healthcare system were fear of losing access to treatment and fear of not being able to afford getting sick. The group included patients with private or employer sponsored insurance, patients with government sponsored care (Medicare/Medicaid), and patients with no coverage. The patients without coverage admitted to going longer than recommended between visits to the doctor, putting off lab tests, and either not following their treatment plan or requesting a less expensive treatment even though it could be less effective (I have done this myself as well). The patients with insurance were a bit better about following their doctor's orders but feared what would happen if they lost coverage and both sets of patients were afraid of what would happen if they were to have a serious injury or complication as most insurance plans have high deductibles, maximum allowed benefits, or both. (personal communication. October 22, 2009) In addition to being sick they feared they'd also be bankrupt, the very thing that was behind the beginning of modern health insurance.

I asked providers what they would recommend if they were asked by Congress or President Obama to consult on healthcare reform. There were two answers that really stood out to me. The first was the subject of tort reform and malpractice laws. All agreed that there need to be protections and limits passed on malpractice lawsuits. They said that fraudulent malpractice suits cost both them and their patients more because of the rising malpractice insurance rates and all agreed that even were it not required by law they would still maintain malpractice insurance to protect themselves and their families. (personal communication. October 22, 2009)

I interviewed Dr Tad Seifert, a neurologist here in Louisville who pointed out that the tort reform laws in Texas has greatly reduced the number of frivolous lawsuits while still allowing the legitimate cases to be heard and in doing so has brought down the cost of malpractice insurance and increased the number of healthcare providers per capita in the state. The other thing I heard from them was a recommendation to expanding the qualifications for Medicaid. Specifically one doctor said he supported in raising the allowable income for families and individuals to allow more people to qualify for Medicaid. According to the information he provided currently a family of four is only eligible if they have less than $21,000.00 per year in income. Dr Seifert recommended raising that to $35,000 as well as saying he would support expanding the Medicaid system to allow uninsured Americans with chronic illnesses to be included even if they aren't disabled and even if they are single with no children. (personal communication. October 22, 2009). I agree with this as it would expand coverage and the current limits on both income and disability status seem to encourage people not to work. For example, because I am single and want to do basic things like go to school and have a job for as long as I am physically able I don't qualify for any type of medical assistance but under his idea I would be able to qualify for Medicaid without also having to be on disability (everyone who is on state or federal disability is automatically covered by Medicaid or Medicare). I would no longer be punished for wanting to be as responsible and productive a citizen of my community as I am capable of being.

The U.S. is the only large, industrialized nation in the world that does not guarantee all citizens access to medical care. Canada has found a way to do so, as have Britain and France. Even Cuba has found a way to do it. Why then can't (or won't) the U.S. do the same? Do we value corporate profits above the health of our citizens?

Bibliography
BNET. (2009) The Rising Cost of Healthcare: Strategic and Societal Consideration For Employers. Retrieved from http://findarticles.com/p/articles/mi_m3495/is_9_49/ai_n6206615/

Cohn, J. (2007) Sick. (2^nd ed). New York. Harper Collins

Organizing For America. (2009) The Obama Plan. Retrieved from http://www.barackobama.com/issues/healthcare/