Oct 252013
 
Hospital in Richmond, Virginia

Hospital in Richmond, Virginia

In the fall of 1948, my mother was a senior in high school.  She competed in Original Oratory on the school’s National Forensics team. Her topic was Why We Need National Healthcare. Mom was seventeen.

She died in a nursing home in 2012. Fortunately for her, she and my father lived in an independent apartment with a skilled facility attached. After he could no longer care for her, she moved to the nursing facility where she died three weeks later. The nursing home days were not covered by any insurance; my family paid out of pocket.  Had she lived one more day, a large portion of her care would have been covered by private nursing home insurance which she purchased in her sixties.

My family is very fortunate that these options were available.

Don’t we all deserve care?

Our present health insurance system started after World War II as employers wanted to attract returning  GIs. Jobs were plentiful, and every added benefit helped. While most western countries do it differently, our employer-based system grew. With full employment, it was successful.

As early as 1945, President Harry Truman proposed an optional national health care system.  Then freshman Congressman John Dingle was one of three sponsors of the legislation, which was defeated after the American Medical Association soundly attacked it.

In the 1960s,  President Lyndon Johnson worked with Congress to implement the then-unpopular Medicare program. Like other large scale health care programs (both public and private), Medicare has its problems primarily on the provider side, as reimbursement for services shrinks.

But ask the patients… For the older patient, it is often literally a life-saver.

The AMA’s battle over Medicare began as soon as the early 1960s.  They  hired a B-actor named Ronald Reagan who had been working as a public speaker for General Electric.  He recorded an album about Medicare which contains a famous quote, used by politicians in almost every context about everything BUT Medicare for two generations.

“We do not want socialized medicine … behind it will come other government programs that will invade every area of freedom as we have known it in this country until one day as Norman Thomas said we will wake to find that we have socialism … We are going to spend our sunset years telling our children and our children’s children, what it once was like in America when men were free.”

The genesis of the famous “there you go again” quote came from a debate with Jimmy Carter in the 1980 presidential election.  Reagan backed off his famous stance:

“There you go again. When I opposed Medicare, there was another piece of legislation meeting the same problem before the Congress. I happened to favor the other piece of legislation and thought that it would be better for the senior citizens and provide better care than the one that was finally passed. I was not opposing the principle of providing care for them. I was opposing one piece of legislation versus another.”

Starting in the late ‘70s cracks showed in the veneer of the employer-based system.

Recession and high unemployment led to something called cost-shifting in healthcare.

Since hospitals had more charity care due to increasing numbers of uninsured, the haves paid the price for the have-nots.

  • Prospective payment started yanking the chains of providers.  Diagnostic related groups, DRGs, groups of payments bundled back to a hospital for a specific treatment, became the norm in 1982.
  • I started my first hospital job just a few months before at the fourth largest hospital in Florida, where physicians routinely placed Grandma in the hospital for weeks at a time if she had no caregiver.  The hospital where I worked had 980 beds, and an electronic sign in the lobby proclaiming “Today’s Census.”  Routinely, the daily census was over 800 in those heady fee-for-service days.

DRGs changed all that.  

Hospitals were paid for so many days of care, and then Grandma got bumped to the nursing home.  Medicare paid for so many skilled days, and after that Grandma had to spend down her life savings to qualify for Medicaid and stay in the nursing home, or go home with care she found herself.

Ironically, it was Reagan who presided over the largest expansion of Medicare since its implementation.  In 1988, he signed a major expansion that provides some prescription drug benefits, home health care, and insurance for lingering illnesses. The 1988 legislation caused a $4 per month increase for Medicare enrollees, and the deductible was estimated at $564 for 1989.

  • Another societal change was improved technology. More Level III intensive care nurseries saved more premature babies.
  • Huge cost increases came  at the end of life. Medications that were improbable  for unimaginable diseases suddenly were advertised on TV. Imagine how many lives have been saved by statins?  And then there are the plethora of meds for things we never heard of, like low testosterone “low t”.
  • Watch a national news program and you’ll get the full gamut of branded drug commercials for products that may not have existed a generation ago. It’s fairly easy to understand the demographic of the Nightly News. If you don’t get this, you aren’t there yet.
  • More people wanted and needed services, and more and more services became available. The switch to outpatient services was unbelievable.  Hospitals added marble lobbies, while making the traditional crowded double rooms into single suites.  Doc-in-a-boxes appeared in every strip mall and soon in national pharmacies.
  • Costs continued to escalate until 2009 when the rate of spending slowed.  That’s still under study, but the Henry J. Kaiser Family Foundation reports it has slowed to 2.9 per cent per year since.  It was not unusual in the years prior to find the percentage rate over eight percent and often over ten percent.
  • The third party between the provider and the client, the insurer, wasn’t left out in the cold during price increases. I’m not accusing anyone here, but what I’m saying it that there are always plenty of hands in the healthcare pie.

In the midst of this came a great unfunded mandate — Medicare Part D— in the middle of two wars.

My mother, father, and mother-in-law benefited greatly, even though my father grumbled about the then-doughnut hole period.We’ve all heard about the old cliché of the $12 aspirin.

Still there was noise in the marketplace about improving our health care system.

In 2006, then Massachusetts governor Mitt Romney (and future presidential candidate) signed legislative for “Romneycare”, giving access to thousands of Bay State citizens. A 2012 Forbes article reviewed the program,

On April 12, 2006, Massachusetts governor and now presidential candidate Mitt Romney happily signed the landmark Massachusetts Healthcare Reform Act into law at historic Faneuil Hall.  As a result the Bay State known for world class medical center, has most of state residents covered.

Many do not know that the genesis of this legislation came from neo-con researchers at the ultra-conservative Heritage Foundation.  Far from being a single-payor or socialized system, this concept does not address cost in the macro sense.  What it does is provide access to free-market insurance to all participants.  The federal coverage (or in the Massachusetts system, the state government, is merely the conduit through which the enrollees go.)

Care is provided the private practitioners and paid for through private insurance companies.

Another interesting sideline is that claims for work-related disability rose greatly in the last decade.

No one is much paying attention that the Disability Trust Fund is also running out of money, and is expected to be in trouble by 2016.

When Barack Obama put his hand on the Lincoln Bible on that cold January day in 2009, he pledged to gain access for uninsured individuals, millions of Americans who could not pay for basic health services.

Signed into legislation  in 2010, the Affordable Care Act  was immediately controversial and rankled the Tea Party wing of the Republican party.

SCOTUS upheld the law in July 2012 with a 5-4 majority.  The highest court in the land rejected the argument that its individual mandate was justified by Congress’s power to regulate interstate commerce. The vote was again 5 to 4, but in this instance Chief Justice Roberts and the court’s four more conservative members were in agreement.

Still the House kept at it with its 42nd vote to defund the ACA in September.

Hang on, look’s like its going to be a bumpy ride.

We went through a three-week government shutdown and on the eve of default the Senate hastily passed a bill  the House also passed.  The President signed the bill just after midnight on the day our government supposedly would have gone into default on its debts.

If you do a Jay Leno man-on-the-street survey, and ask people if they like Obamacare, most will say no.  Rephrase the question and ask them if they like the ACA, and most will say yes.

What we have here is a failure to communicate.

So that’s where we landed at launch time, a cobbled-together program of insurance companies to provide care with ten essential benefits, no pre-existing conditions.  This is not national health insurance; it is an amalgam of the free-market based program that the Heritage Foundation initially proposed and Mitt Romney started in Massachusetts.

It is certainly not what the Lion of the Senate, the late Ted Kennedy, proposed.  It is not single payor like Canada,  it is not socialized like the National Health Service of the United Kingdom.

Because of SCOTUS’ ruling, many states, including my own, chose not to accept the Medicaid expansion dollars so the feds ended up running 36 state exchanges as well.  This explains why one mile from my home across the Ohio River, the Kentucky exchange is running very well and signing up thousands of people.

Just for fun I went to the Kaiser calculator to see what my family’s cost would be if we didn’t have my husband’s insurance.  Indiana is five thousand dollars more a year for us than Kentucky, can’t explain that, but I can’t explain much of anything about this.

More than anything, I want this or some semblance of it to work. I want everyone in America to have access to a basic level of health care.

The ill-advised launch is a huge disappointment, considering that the computerized ground game of this president was unprecedented and high tech in the last two elections.   This is highly unfortunate, but it is no different than the slow launch of Part D in the previous administration or the current screw-up with the implementation of the Common Core application across colleges and universities this fall.

I personally believe that the individual mandate should be delayed until the computer glitches are worked out.  I did not believe that using the federal government shutdown and impending raising of the debt limit as blackmail was the time nor the place to fix it.  Now, let’s get it fixed and move on.

There is still much more work to do; while the program addresses access, there is still much inequity in our health care system. We need more young people going into medical school so that we can have fine doctors providing this care.

“A nation’s greatness is measured by how it treats its weakest members.” ~ Mahatma Ghandi

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