No Such Thing as Health Insurance

Politics, theology and economics agree.

There is no such thing as health insurance.

There is care. There is non-care.

But insurance is a bet against odds. You bet with the car insurance company you’ll get into an accident. You bet with the life insurance company you’ll die.

This is not true with “health insurance.” The need for care is a certainty. The need varies by age, by circumstance, and by chance. But everyone needs regular, preventive medical care. Nearly everyone needs some type of medication to deal with mild symptoms like headache and stomach upset. Nearly every woman of child-bearing years needs birth control. Nearly every kid falls or gets sick more than once a year.

An ounce of prevention is worth a pound of cure. This is 100% true when it comes to health care. It’s why everyone needs preventive care. You need to be warned, regularly, loudly, that bad habits such as smoking, drinking, and lack of exercise will lead to disease, and you need to be given alternatives to these things. You need to be carefully taught. If you are, your chances of getting sick are greatly reduced.

The biggest part of our national health care budget comes in dealing with these chronic conditions preventive care is meant to forestall. Diabetes is a chronic condition. Heart disease is a chronic condition. If you monitor chronic conditions carefully, if you fight them actively, you keep people out of the hospital, people of any age.

When people think of “health insurance” as something optional, they’re thinking of the odds they will need acute care, or emergency care. They’re willing to bet they won’t get cancer tomorrow, that they won’t get into a traffic accident, that they won’t fall and be unable to get up. This is a bad and stupid bet. Everyone gets sick, everyone falls, and once you do you will demand care – whether you have “insurance” or not. Emergency care is guaranteed under law. Ronald Reagan signed it. If you go to the emergency room because you lack “insurance,” the people who have insurance pay for your care, and those costs are extremely high because emergency rooms are built to deal with emergencies.

The great failure of liberal politicians over the last 25 years has been to frame this as a “health insurance” debate when it has always been about care. Even the market agrees. The “Obamacare policies” that won in the exchanges have been managed care plans. Managed care companies like Centene or Kaiser get a set amount of money per-patient, and if they keep their patients around under this budget they profit. This is how Medicare and Medicaid work. Medicaid and Medicare operate at a much lower per-patient cost than ordinary insurance, even though they are dealing with greater risks, with old people and poor people who are more likely to have accidents or contract expensive diseases.

This is not even news in the so-called “private insurance” market. For years, big employers have been engaged in a form of self-insurance. They contract with a “health insurance” company to manage these costs. The insurer acts as a gatekeeper to the system, negotiating bills down in ways ordinary people and employers can’t. For this service, they get an up-sell fee. It’s something like building an addition to the house. Sometimes (and this is true) a company will not charge employees for health insurance for a pay period or two, because their experience of the previous year showed they were overpaying. The employees’ part of the bill goes back to the employees, and the employers pocket their portion. This gives them an incentive, not to refuse care, but to make sure there is preventive care, and good chronic care, and to support things like healthy meals in the cafeteria and exercise rooms.

There is a simple way to save hundreds of billions of dollars, maybe trillions of dollars, without changing our current system. Simply let Medicare, and private insurers, bargain on drug costs, drug formularies, and medical devices. Stop allowing ads aimed at patients who don’t know Otezla from Humira. The reason there were “Obamacare horror stories” this decade was because drug companies bought up generic production, raised prices to the skies, and pocketed the profits – sometimes in other countries. Your EpiPen didn’t become prohibitively expensive because the cost of making ephedrine rose. It became expensive because Mylan raised the price. They could get away with it because no one could bargain against them on that price. End monopolies, eliminate advertising, allow bargaining, and costs plummet.

I have been following the nation’s health care debate for over a decade now, and it is infuriating. No one involved in the policy even mentions the key drivers of health care costs – drugs – or the key drivers of mistakes – doctors’ refusing to use checklists and the ignoring of standard procedures for sterility in hospitals. Put nurses in charge of medicine and you’ll save money.

There’s another thing that can cut costs dramatically. Health IT. Despite $19.2 billion in “sweet, sweet stimulus cash” as I called it, doctors and hospitals still don’t use technology effectively. Every doctor’s office still has a little bureaucracy in front of it, clerks who are involved in appointments, or billing functions that every other industry automated long ago. We tried the carrot. Time to get out the stick. If you’re not automating, you’re not getting paid.

The costs of care, in other words, can be cut dramatically. But we need to stop talking about “insurance,” simply because a huge industry developed, starting during World War II, to cover health as an employee benefit. This system became unaffordable a generation ago, yet still it continues, because policymakers still talk about “health insurance.”

By talking about health as something you can write a policy on, we have the present nonsense debate. For the last decade Republicans have been arguing that costs can be dramatically reduced if insurers can simply write policies that don’t cover people, for one reason or another. Maybe because the person was sick before. Maybe because the company doesn’t want to cover this or that, and one state or another allows it. This doesn’t mean people aren’t going to need that care. It simply shifts all the burden to the patient. Patients go bankrupt, but more important they die for lack of care. You want a nation divided between young, poor, sick people and rich, old heathy ones? Only if your name is Louis XIV. In a country spending 17% of its GDP on health care, this is ridiculous. Especially when other countries cover everyone, and don’t have these problems, while spending as little as one-half that – making them more competitive, and allowing people there to take home more of what they earn.

This complexity of contract languages can hit anyone, even someone with the “good insurance,” which we have. My wife is constantly getting bills from hospitals or clinics that didn’t go through her insurer before sending the bill, or that are billing for care they were already paid for. Thank got she is detail-oriented and a little OCD. ADD people like me are driven crazy by this crap.

The largest customer for health care in the world is the United States government. The cheapest care, on a per-patient basis, is provided by the Veterans Administration, which is a classic “single payer” plan akin to England’s National Health Service. They deal with our highest-risk patients, people who have gone through wars. The next cheapest form of care is Medicare and Medicaid, managed-care programs serving the poor and the aged. The most expensive form of health care in our system is private health insurance, which covers the least-risky portion of our population, working people aged 22-65 and their kids.

It’s insane. And it’s time we talked honestly about it, because people are going bankrupt, even in Trumpistan. People are dying in droves in Trumpistan, and it’s going to get worse. People are dying everywhere, but Trumpistanis are more likely than people in TechLand to suffer chronic conditions or to have problems with addiction.

You want to blame Democrats when grandma gets kicked out of the nursing home next year? Good luck, but she’s still going to be sitting in front of your TV watching her “stories” instead of letting you see the sports.