#and getting myself financially independent as efficiently as i could afterwards

[chthonic-cassandra]

I have all these moments of being wistful about leaving academia, dance, theater, but I always come back feeling such clarity about having made the right decision for myself. Not only because I love the work that I do, because I believe in it, but also because for me it was the right decision to choose a career that could give me the possibility of a long-term, more stable future; it's a lot more possible to heal this way, in this context. I couldn't have counted on what I have now, working among people who care deeply about me, and respect me, accept my idiosyncrasies. But I am very grateful to have it.

[eichy815]

Health Care Reform That Actually Makes Sense

“These proposals are like solving the homeless problem by requiring the homeless to purchase a house.”

– Paul Craig Roberts

********************************************************************************************

There’s no doubt that the implementation and existence of the Affordable Care Act (ACA) – alternately known as “Obamacare” – has been a fiercely contentious topic for the past eight years.

With a Trump-led GOP Congress poised to eliminate it – and then replace it with Who-Knows-What? – it’s worth examining how we got to this point...and where we should collectively go, from here.  Democrats hoping to win back seats in 2018 and 2020 would be wise to consider floating several of these proposals if they truly want to get back into power.

As I wrote about in my February 2015 op-ed entitled “How ObamaCare Became ObamaSCARE,” the Democrats squandered a valuable opportunity back when they controlled both chambers of Congress and the White House in 2009 and 2010.  President Obama and his party made the mistake of pushing a signature bill that was massive in size, while trying to get at least some Republicans on-board so their legislation could be considered “bipartisan.”

What ended up happening was that Democrats saddled themselves down with what ended up morphing into a convoluted bill (the ironically-named Affordable Care Act) that combined the worst of both worlds:  it mandated that Americans be required to buy health insurance, but it offered no public option to compete with the private health insurance market.  In essence, the bill criminalized being uninsured (via a financial penalty), but did nothing substantial to actually bring down costs

Conservatives and libertarians – who want the federal government to take a mostly “hands-off” approach in terms of health care regulation – viewed the ACA as going too far.  Liberals and progressives – who wanted a single-payer system, similar to those found in Europe or Canada – viewed the ACA as not going far enough.   And everyone else (centrists, moderates, and the politically-uninformed) failed to see any benefit to society as a whole from the version of the ACA that passed.

This put Obama in a Lose/Lose situation where he could either sign what had become a heavily-flawed bill in the hopes of avoiding being viewed as ineffectual...or decline to sign the ACA as it was written, and be demonized by the media and the GOP as having wasted a whole lot of legislative time and capital.

Obama chose the former option – and his party suffered the electoral consequences in 2010, 2014, and, to a somewhat lesser extent, 2016.

Had the Senate Democrats not permitted Finance Committee Chair Max Baucus to hijack the process by writing a bill that was heavily favorable to subsidizing private insurance companies – they could have passed a much better bill that most likely would have been far more popular with the American people.

Bar none, the most controversial aspect of the ACA has been the individual mandate.  However, economists and health policy experts point out that the individual mandate was necessary in order to achieve long-term solvency through “risk-pooling” and universal elimination of preexisting conditions.  

But the reason *WHY* the individual mandate was so unpopular was due to the astronomical costs of health care to consumers in the first place.  The ACA failed to put any meaningful cost-controls into effect; the federal subsidies did nothing that would have motivated private companies to cap the prices of premiums, deductibles, copays, or prescription drugs.

Thus, the ACA essentially ended up mandating that Americans continue to fund an out-of-control system that showed no signs of “reining itself in.”

What many supporters of the ACA fail to grasp – even to this day! – is that the individual mandate simply doesn’t work without some form of a “public option.”  Otherwise, there’s no incentive for private health insurers to proactively lower their costs or make their delivery more efficient.  With no regulatory authority tempering their ability to hike up costs, there’s nothing stopping them from bloating premiums while shrinking the health plans’ benefits.

Back in 2009, when debate over the details of the ACA were still in flux, a dear friend of mine opined – in a Facebook post of hers – how she’d rather see “a compromise” reached, in terms of health care, as opposed to lawmakers doing nothing at all.  Her sentiment, she clarified, was fueled by how painful it felt for her to watch her friends and loved ones have their lives ruined by our broken health care system.

I piped up and raised the point that a health care system with an individual mandate but no accompanying public options would be detrimental.  And I was right.  That’s precisely what the ACA ultimately ended up resembling.

But, at the time, my warnings fell upon deaf ears (at least, in that little corner of cyberspace).

Another friend of hers complained about how inefficient the U.S. government is when it comes to managing entities such as Medicare and the U.S. Postal Service.  Yet, he hypocritically defended the concept of “pooled risk” through an individual mandate from the federal government – claiming that there should be enough not-for-profit insurers, mutual insurance companies, and federal subsidies available out there to cover those who can’t afford their own private insurance.

He then proceeded to write off people who might fall through the cracks under Obamacare as basically being the same types of people who’d gotten themselves into home ownership when it was financially-irresponsible for them to do so (i.e. subprime lending and high-risk borrowing for mortgages).  He endorsed the idea of K-12 and post-secondary curriculums integrating financial management courses, so that younger Americans aren’t so easily preyed upon by predatory companies (and I actually agreed with him on the latter point).

But he told me that it was my own fault for putting myself into debt by taking out student loans...and he passive-aggressively declared that he wasn’t going to continue our conversation because, apparently, I was an “angry” person who wasn’t looking at all of my options.  He lectured me about how I’d made an impractical degree choice in college (he, for the record, had majored in Mathematics, and ended up working for a medical informatics company coordinating installs for billing software).

His unsympathetic, neoliberal, Suze Orman-esque approach and philosophy is exactly what’s emblematic of the tone-deaf attitudes that most certainly run rampant in Washington D.C.  It’s a Darwinian, reductionist worldview that many Republicans swallow like multivitamins...and which Democrats took for granted when agreeing to the so-called ACA “compromise” in 2010.

I still maintain that there were several smaller-scale reforms that the Obama Administration could have passed via a Democratic-controlled Congress throughout 2009 and 2010, in piecemeal fashion.  If there truly weren’t enough votes in the 111th Congress to pass any “public option” – let alone single-payer – then pushing through a less-ambitious slate of bills would have been the smartest course of action for Obama and the Democrats to take.

Obama could have gotten together with then-House Speaker Nancy Pelosi and then-Senate Majority Leader Harry Reid to twist arms and pass a bill facilitating the importation of cheaper prescription drugs from Canada and other developed nations.  Of course, this would have required certain Democrats to divest themselves of their corporate loyalties to the health insurance companies and pharmaceutical companies who’d been generous contributors to their own reelection campaigns.  But the Obama Administration only would have needed a simple majority of 51 Democratic senators (out of the 58 Democrats and two Independents) to go along with it.

And, most of those Democrats probably would have been rewarded with the ultimate prize of reelection in 2010, 2012, and 2014.

Another legislative solution could have been to reduce the costs of medical imaging in patient care.  Often times, patients end up paying through the nose because duplicate diagnostic imaging procedures are ordered...or even diagnostics that are completely unnecessary!  This epidemic of unnecessary testing, inaccurate readings, and extraneous follow-ups could be alleviated through three basic remedies:  1.)  stricter accreditation standards for advanced imaging; 2.) publication of imaging costs to empower patients with transparency before they agree to have tests done; and 3.) improved Radiology Benefit Management (RBM) protocols.  Nothing was stopping the Democrats of the 111th Congress from packaging a concise, stand-alone bill to address these problems.

A third congressional proposal could have been to establish federally-protected Health Savings Accounts (HSAs) for citizens to electively set up.  Granted, the drawback with HSAs is that one must generate their own capital to place into them.  Some options to facilitate this could include allowing Americans to automatically divert a portion of their federal/state tax refunds into HSAs, making them tax-deductible for subsequent fiscal years, or integrating a lower-deductible HDHP plan based on income.   Perhaps this concept could have been combined with tax incentives for employers who interweave FSAs (Flexible Spending Accounts) into their employees’ individual/family coverage.

In terms of HMO and PPO reform, the government should have considered providing incentives for health insurers who charge an upfront premium or a “flat flee” for members’ network participation, rather than charging patients per individual service rendered afterward.  It would, in effect, encourage investment in “integrated care” models for healthy and “underage” (i.e. younger than 65) people.  This would give doctors an incentive to diagnose and treat medical problems efficiently in lieu of ordering unnecessary tests or procedures (aka “defensive medicine”).  In a nutshell, this would be a conservative alternative to a complete transition to a pure fee-for-results model.

Even within the heavily-flawed version of the ACA that ultimately came up for a vote:  Democrats could have chosen to insert a “trigger” that would have nullified the individual mandate in cases where there weren’t any not-for-profit insurance options or premium caps (based on one’s income level) available to individual citizens.  This was similar to a concept briefly floated by moderate Republican U.S. Senator Olympia Snowe – before she ultimately decided to vote against the ACA.

Legislatively, the Democrats should have introduced a separate bill to address the nursing shortage by making it easier for qualified/accredited nurses to provide some primary care services under circumstances where they’re certified to do so.  This could have been financially supported by grants and public/private partnerships – including efforts to make nursing school and medical school more affordable for those who want to train to work in primary care.

They could have structured legislation that was narrowly focused on expanding preventive care (including prenatal services) to low-income people and the middle class.  This wouldn’t have solved the overall affordability problem when it came to consumer purchasing of health insurance plans – but it would have empowered the uninsured and underinsured to utilize more resources to prevent themselves from becoming seriously ill.

Some critics would present me with the whiny rebuttal of “That’s not the way Congress does things.  It’s just not the way Congress works.”

To that, I say:  BULLSHIT!  Obama, Reid, and Pelosi were in total control of the Executive and Legislative Branches, at that juncture in time.  They could have done whatever they wanted.  What stopped Reid from eliminating the filibuster, four years later, to get around the Republican minority blocking Obama’s federal court judicial appointments?  And what’s stopping current Senate Majority Leader Mitch McConnell from eliminating the filibuster for everything else – including U.S. Supreme Court nominations – when the current Democratic minority conceivably tries to block Trump’s SCOTUS selections?

You can argue that “Hindsight is 20/20” all you want.  But with President Trump and the current Republican-controlled House and Senate determined to “repeal and replace” Obamacare, the focus should be on what the future of American health care is going to be for the upcoming decades.

Proponents of single-payer health care often point to the “superior” (from their perspectives) health care systems of other countries.  I’ve lost track of the number of times I’ve heard leftists broadly squawk, “Oh, we should do what Europe does!”

As though Europe is one monolithic nation...rather than a diverse collection of nations, each with their own unique health care system.

So let’s look at several of the world’s most revered health care systems, and assess how exactly they deliver that coverage.

Switzerland is the European country with the system that perhaps most closely resembles “Obamacare.”  The Swiss model has no free public health services (or publicly-funded option), but purchasing private insurance is still mandatory for all citizens.  An exemption to the mandate is granted for governmental dignitaries.  Swiss consumers must meet their annual deductible, which results in high-quality care that is also very expensive.

The Netherlands, likewise, has a health care plan that’s similar to the ACA.  However, the Dutch model makes great use of home doctors for referrals.  Along with exorbitant costs, health care patients in the Netherlands also endure fairly long wait times for their medical services.

Over in Italy, family physicians are funded through a centralized national health service (the Italian version of a “public option”).  Prescription drugs are heavily subsidized by the Italian government.  There are low patient copays for diagnostics or specialist visits when prescribed by a primary care doctor; on the downside, wait times also tend to be quite long for those who don’t have a private sector plan.

Germany uses a universal multi-payer system divided into three coverage categories:  general maintenance, accident, and long-term care.  Also, its private sector provides ambulatory care while a strong system of nonprofit independent hospitals render impatient care.  Wealthier German workers must pay a special tax if they wish to opt out of enrollment into the public insurance option.  This standard, publicly-available insurance (a “sickness fund” into which one is automatically enrolled after falling below a certain income level) is paid for by the government using contributions from both employees and employers as well as income-based subsidies.  While the German system experiences shorter wait periods for its patients, the negative trade-off has been high expenditures, high prescription drug costs, and long periods of hospital stays.

The much-lauded health care model used by France employs doctors who are mostly in private practice, although those physicians are still paid through public funds.  It differs from the German model in that French doctors are not allowed to manage themselves; instead, the government links premium amounts to a patient’s income level.  Generally, between 70%-100% of out-of-pocket costs are refunded to patients by the government depending on the service.  In addition, most of the private insurance companies that offer supplemental plans are nonprofit entities; however, there’s still a ton of hospital bureaucracy.  Only 20% of French hospitals are for-profit, which makes it easier to allow portability between privately- and publicly-owned hospitals.  The public health care component is largely financed from tax revenue rather than risk pools.  The French government imposes fixed rates for specific medical services; it regulates prices so that premiums and copays are based primarily on a consumer’s income, and those premiums are derived from workers’ salaries.

Sweden has a decentralized health care system that’s split along local/regional/national lines.  Individual city councils run the hospitals, collect taxes for health-related revenue, and regulate prices along with the quality of service.  Elder care and disability services are overseen by local municipalities.  There is an annual deductible that a Swedish citizen must meet before her or his prescription drugs are covered.

Finland has a system buoyed by excellent preventive care; this is delivered predominantly by nurses who work out of health care centers, similar to the U.S.-based Community Health Centers (CHCs).  There are also excellent screening and vaccination programs within the Finnish model, which have led to one of the highest life expectancy rates worldwide.  The public health care of Finland – funded by tax collection and user fees – will potentially be threatened in future generations by a declining population and low fertility rates.

In Norway, there’s a universal annual deductible for basic care.  An additional deductible exists for specialized medicine.  The Norwegians must import their pharmaceuticals at full price from other countries, making their system one of the less comprehensive health care models on the continent.

The United Kingdom tasks Clinical Commissioning Groups (CCGs) to oversee hospital and outpatient services in local communities.  England, Scotland, Wales, and Northern Ireland each has its own CCG – resulting in provincial differences when it comes to pricing and access.  As with most European nations, the U.K. has a chunk of private sector options that deliver additional medical services not readily offered by the publicly-funded health care entities.  Community-based pharmacies are privately-owned.

Belgium has a publicly-funded health program functioning as a “mutuality” that reimburses patients for consultation fees and prescription drug costs.  Belgian consumers pay a capped fee for hospital stays approximately one week in advance; private sector options are also available.  

Ireland has set up a “Health Service Executive” – a governing body of public health care funded by general tax dollars.  This entity oversees the hospitals, where the user pays a subsidized fee.  The Irish model charges flat fees for hospital stays...although there are notoriously long wait times at its hospitals or for the inpatient stays at other medical facilities.  Ireland also has a National Treatment Purchase Fund (NTPF) for those who don’t wish to wait any longer than three months for a critical operation or procedure.

Portugal, in my opinion, appears to have one of the best health care models amongst international examples.  It utilizes three categories of patient care, working cooperatively but independently:  1.) a publicly-funded National Health Service – again, similar to a “public option” in nature; 2.) health delivery “subsystems” for workers in specific occupations; and 3.) private sector plans for those who can afford to purchase them, when they don’t want to be tied down to a government-run delivery system.

Also, similar to the American-based CHCs, Portugal has made locally-based ACES available for preventive treatment and urgent care.  In both the NHS and ACES facilities, Portuguese medical patients are sometimes charged user fees at the end of specific treatments.  For more serious ailments, the country has ��hospital centers” (or Centro de Saúde) – which can be either general medicine or specialty-based – grouped together by region.  Out-of-pocket costs for more minor tests and procedures are relatively low.  Prescription drug costs, nationwide, are very low.

The “subsystems,” based strictly on one’s employment, are mandatory for workers in specific occupational fields.  They function sort of like union membership, and can be present in the public and private sectors alike.

Portugal’s system isn’t without its flaws.  There’s a General Physician shortage.  Emergency Room services have long wait times and must use triage to admit patients.  State approval of pharmaceuticals should become more streamlined, and hospitals could be given more local autonomy over their management practices.  But, overall, the Portuguese people benefit from a pretty efficient health care system when compared with the rest of Europe.

Even on the other end of the globe, there have been some well-received health care models.

For example, Singapore diverts a portion of a worker’s payroll deductions into a Medisave account; funds from each citizen’s account can be pooled across members of one’s extended family.  There’s also a larger Medifund (or Central Provident Fund) that contains the two “sub-programs” of Medishield (for low-income people) and Eldershield (for the elderly).  Means-testing is conducted to determine subsidy amounts.  Singapore’s private sector offers plans for those who can afford higher payments.

We must keep in mind that Singapore boasts less than 2% the size of America’s citizenship...and its population is extremely condensed within 278 square miles.  Still, the U.S. could conceivably scale up its own model based on some of the Singaporean concepts that work. 

In Japan, along with the public health care option, Japanese law mandates that all hospitals be nonprofit and managed by physicians.  Monthly thresholds are designated for households’ premiums based on a combination of income level and age.

When looking at these international examples, what is one of the most common variables?  Again – COST-CONTROLS!

We can’t (and shouldn’t) assume that EVERYTHING that works in other countries will necessarily work within the parameters of America’s broken health care system.  But, when broadly examining the health care throughout Europe, Asia, and Canada...the one overlying trend that has brought these systems varying levels of success has been their governments’ willingness to have a publicly-funded source of health care directly competing with privately-run plans.

Conservatives tend to drone on about how government favoritism of certain health care plans would be us choosing “winners and losers.”  But what they fail to grasp is that, if exorbitant health care costs eventually cause our economy to collapse...then we will all be “losers” with absolutely no “winners.”

If I was constructing a new national health care system for the United States, I’d loosely develop sort of a hybrid cross between the models used in Portugal and Singapore.  If we’re going to make serious efforts to increase competition for consumer benefit, we must keep in mind that competition only works if there’s a mechanism to keep across-the-board costs relatively stable.  That’s why a “public option” was such a critical component to what so many people desired as part of a “universal health care” package.

Why can’t the U.S. government offer an optional publicly-funded health care plan – or, at the very least, give robust financial incentives to not-for-profit insurance companies – to compete alongside of the private insurance market?  Under this principle, there would actually be a control factor or a benchmark by which private insurers would be motivated to offer competitive prices (rather than jacking up premiums and deductibles, ad infinitum).

This could loosely resemble Portugal’s National Health Service while allowing the private market to remain mostly unregulated.  The occupation-based “subsystems” found in Portugal could be excluded from an Americanized version, in favor of maintaining the status quo of a free market for employers to provide employee coverage. 

Singapore’s Medisave program would also be a smart type of concept for the U.S. to adapt in the name of generating revenue and savings; the Medifund and Medishield programs found in Singapore wouldn’t necessarily need respective American counterparts, since the U.S. already has Medicare and Medicaid.  

In addition, America could borrow other components found internationally – such as the nonprofit hospitals found in Germany and Japan, the nursing incentives enjoyed by Finland’s medical sector, or income-based safety nets utilized by the Germans, the French, and the Japanese alike.

Bottom-line:  the free market won’t experience the best circumstances for competition unless you have either government-imposed cost-controls or government-mandated standards.  Preferably both.

You can employ the rhetoric of calling it “Socialized Medicine” all you want...but the alternative would be “Darwinian Medicine.”  And that just isn’t cutting it.

I’d also like to leave you with a quotation from Whoopi Goldberg, who, as moderator of The View’s daily talk show panel, has expressed the outrage felt by ordinary citizens when it comes to the ridiculously spiraling-out-of-control costs of health care in America.

During a panel discussion on health care reform during the October 28, 2016 episode, Goldberg said, in a passionate mini-rant:

I pay a lot of money for my insurance, and less and less and less is covered, and it’s really pissing me off, and so, with the stuff we had [past benefits], why are you fucking taking stuff [those benefits] away when we’re paying [higher premiums] every month?...My costs, when I don’t get sick for ten years, I still got to pay.  They don’t send me any money back saying, ‘Hey, Whoop, you’ve been well for all this time.  Here [is your rebate], babe!’...I get that they need to make money, but you know what? – we’re all in this together.  They have to help – I’m sorry!  They have to help because I’m tired of having to be the person who’s watching other people’s kids die because they don’t have insurance or they don’t have enough money to make a decision to either feed the family or buy frickin’ insurance.  And I’m tired of it.

Libertarian-minded cohost Jedediah Bila pointed out that the best way to get costs down is through competition, and that’s been lacking throughout all of these years.  Goldberg verbally tussled with Bila, shining a skeptical light on this popular “competition”-argument by saying:

They’ve had competition for millions [of years]...they do!  Blue Cross, Red Cross, LMNOP...there’s all these ‘crosses,’ all these insurances, and this-insurance and that-insurance, and this one won’t take that...it’s all BS and they need to get themselves together, it’s BS!  That’s my opinion!

The European countries with health care that’s most similar to Obamacare – France, Switzerland, the Netherlands, and Italy – have anywhere from one-fifth to one-fortieth the population of the United States.  Furthermore, their economic (revenue-collection) systems and overall cultures are much different than America’s.

To you leftists who would accuse me of overvaluing “American exceptionalism” – it isn’t “exceptional”-anything.  It’s just a reality.

If the U.S. is going to have a functional health care system, we need to take the best elements from other countries (i.e. Portugal, Singapore, Finland, Germany, and Japan) who pointedly model their systems closer to what our needs are...and then we have to figure out a viable way to transfer and apply them to a specific model that works for us.  

By combining the very best selective variables of other nations’ health care delivery models into a reworked system that’s still uniquely American – and equipped to deal with 320 million citizens – we can get American health care costs under control while cultivating a healthier overall population.