Monday, August 26, 2013

The Ridiculousness and Real Cost of Heath Care in America

After some 30+ years of living in this country (the US being "this country" and Denmark being "where I came from") I have come to the conclusion that one of the things that annoy me the most about living here is insurance.

Or rather... the cost of insurance-- and especially the cost of health insurance.

People talk a lot about the "standard of living" in the US, but how do you really measure the standard of "living?" Sure if you look at the median income, it's a pretty nice number, compared to a lot of places in the world. You can also look things like Gross National Product per capita, and things still look pretty nice. The problem with those metrics is that they are "just numbers" but don't really look at "where" people truly are.

Here's the thing... when you look at "what can you actually DO with your life once you've paid for the basic expenses of living" things kinda suck. And that's the fundamental truth of living in 21st century America-- we may look like we have a lot of money... but we also have to pay a monumental pile of expenses... and when you consider the equation from the angle of "how many units of basic lifestyle can I buy with an hour of averagely compensated work" things are not so good.

And then... things are complicated further by the fact that we have utterly unrealistic expectations about what we "should be able to get" with the money we do have... there's this odd sense of "entitlement" that we "should" be able to buy boats, McMansions, trips to Europe, $300 sneakers, flat screen TVs and redecorate our house every three years with the relatively tiny pile of actual disposable income we have left over, at the end of the day, after basic expenses. And that really doesn't work, in a functional sense... the only thing it "works" towards is creating a bunch of underlying anger and frustration about how we "never have enough."

But I am digressing.


It's "a job" around here to pay the bills... And I keep looking at just how many of these bills are about insurance. Health insurance, auto insurance, homeowners insurance, title insurance, life insurance... insurance, insurance, insurance.... we're up to our eyebrows in insurance because we all seem to be hanging by such a fragile string that unless we're "insuring" ourselves to the hilt, everything we have and believe in could all "go away" if the slightest mishap comes our way.

Top of my "annoyance" list is health insurance. Now, granted, I grew up in a part of the world that has socialized medicine... so perhaps my perspective is skewed. In this household, we have been paying $611.00 per month in health insurance premiums... all for the privilege of being "insured" but still having a... get ready for it... $6,000.00 deductible.

"On paper," what that adds up to is that no matter what, our "healthcare" costs us over $7,300.00 per year (the premiums)... before we even grab the first Kleenex to blow our noses. Now if we do need the services of a doctor or "something medical" (as most of us do, as we move into our 40's, 50's and beyond) we're still out-of-pocket for the next $6,000... meaning that our health, allowing for occasional mishaps and visits to the doctor + medications means we've spent $13,300 per year before we've derived any damn "benefit" from "being insured."

Of course, just because we "hit that mark" doesn't suddenly mean that "it's paid for." Now we get into all the technicalities of "co-payments" and "disallowed" items and so forth.

Now, a $6,000.00 deductible may sound like a HUGE amount... but it's really less than you think. Why? Because we live in this society where it's (a) assumed that "it'll be covered by insurance" and (b) everyone is incredibly litigious, which drives up the cost of malpractice insurance, which drives up medical costs... you can use that up that deductible in a hurry. For example, Sarah went to the doctor this spring ($180.00) which required some bloodwork and labs costing $1,270.00, of which the insurance company covered no more than an "administrative adjustment" of $127.00. That's pretty normal, in the real world.

But getting back to that out-of-pocket annual amount of $13,300.00 for our health... that amounts to $1,108.00 a month just for "breathing air" without being seriously sick. That's more than most people's rent. Or mortgage payment. Or all utilities and food, combined. And we haven't even covered the "other" kinds of insurance we're having to pay for... auto, home, life, etc.

Now, you might think we have a really crappy insurance plan... but based on a lot of research, along with the insistence from other people (medical and private) that "it's actually a really good plan," this seems to be pretty much "what to expect" in 21st century America... unless you're working for some large employer of the government and get medical as part of the package.

OK, so let me back up. I said "America." I don't mean "America." The United States. Our neighbors to the north in Canada don't really have these kinds of issues (at least not to such an extent) because they have a form of national health care. Although healthcare in Mexico is not fully nationalized, it is effectively of a quality and cost low enough that many US based health insurance providers actually require their customers living within reasonable distance of the Mexican border to go to Mexican hospitals for many procedures.

In the US, we're very proud of our national self-reliance... but that may also be our Achilles heel when it comes to public health. The entire nation was founded on a mistrust of government, so it is not surprising that the idea of socialized medicine is a "hot potato" in the US. And I harbor no delusions that this attitude will ever substantially change. And then there's the age-old argument "yeah, but you would have to pay it in taxes, anyway!"

We'll get back to that one...

For me, such a central part of where the healthcare debate in the US completely misses the mark is in the way the vast majority of dialogue is centered on the practical aspects of public health. From where I am sitting, the vast part of it actually looks more like a social and societal issue that gets swept under the rug most of the time.

In the US, we're very attached to the whole "equal rights" thing, and how everyone should have "equal access" and all that good stuff, and yet... when you have a "for profit" type of healthcare system (or, for that matter, any type of for profit system) you automatically create a sort of "meritocracy" in which service is more readily available to those of means and is dished out according to financial ability, rather than actual need. Bottom line-- which we really don't like to look at, as a free enterprise culture-- in a for-profit system there is really no (or little) money to be made from peddling services to poor people.

The other-- and subtler, but potentially more pervasive-- issue involves the subtext and implications that go with living in a culture that has no "safety net."

We may not think of this on a conscious level, but for many people in the US, "getting seriously ill" basically means "losing everything you have" or going into bankruptcy... same end effect, either way. That knowledge "lives" as a constant undercurrent in our society. Probably two-thirds of the population-- if faced with some kind of major medical event-- would find themselves "on the rocks."

"True," you might say, "but so what?"

Well, if your life is subtly but constantly influenced by an underlying fear that you're "not going to have enough" it is also going to fuel a constant drive to try to get "more" to compensate for this fear. That's simply human nature-- psychology 101. Of course, fear of "lack" drives the quest for "more," and the quest for "more" ultimately drives "greed" (subtle, or not so subtle)... and the failure to get "more" leads to an undercurrent of frustration and anger. And where does living in a perpetual state of subtle anger and frustration lead? On the "soft" end, to ulcers and anxiety (requiring healthcare!) and on the "hard" end to marginally abusive and violent tendencies.

No, I'm not talking about actual physical violence, I'm talking about about the violence and abuses inherent in extremely competitive workplaces where the actual "contest" for "more" and "overcoming our fears of not having enough" play out.

Now, let's get back to those taxes... and how "we'd have to pay for it, anyway." To some degree, true. Of course there would be taxes. But it would be less than we pay out of pocket, right now... because the cost of the "profit motive" would go away. Healthcare would be a "basic service" like police and fire.

Funny, how that works. We're "OK" with having firefighters be a "public service," but not our health.

Ever considered a conversation that goes "Well, Martha, the house is on fire but we couldn't afford the fire service insurance this month, so it'll have to burn down because we can't afford to pay the fire fighters to come out." Probably not. Yet... that's what we do with our health.

"Yeah, but the really GOOD people would no longer become doctors in a non-profit system... "

Mmm... really? I have some major philosophical issues with that line of thinking.

Maybe I'm being overly naive or idealistic here, but the fundamental fallacy behind that argument is that it assumes "doctors are only in it for the money." This assumes that people go to medical school not because they are actually interested in medicine and healing people... but only because they can "make $400,000 a year."

Two (major) things to consider:

One, if "the lure of big bucks" was actually a bit less, wouldn't we actually end up with more doctors who were genuinely interesting in healing people, rather than those mostly looking for wealth? In a sense, wouldn't the system be self-adjusting towards creating a pool of doctors who care more, rather than care less?

Two, if you were a physician who was part of a structured not-for-profit system... where-- for example--your malpractice insurance premiums would all but vanish, and the need to constantly market yourself and "run a business" largely dropped away... wouldn't you not only be able to focus more on "practicing medicine" and still actually be "relatively" well off since your drop in gross income is partially offset by a drop in operating expenses?

Meanwhile... on a more personal level... if I there was some kind of safety net between me and the potential for destitution, I wouldn't have this eternal knot of worry in my stomach. And if I wasn't out this monthly $1,108.00 I might not feel quite so much like no matter what we do, it never seems to be "enough."

What do YOU think? I know it's a complex debate-- but everyone seems to have an opinion. And if you live outside the USA... what's your take on "healthcare in America?"

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