Saturday, December 19, 2009

And the winners are...

As the Senate legislative process to pass a health bill lurches its way along like Godzilla out for a stroll, it becomes clear that the biggest, probably the only, beneficiaries will be the health insurance companies. No one actually knows everything in the entire bill--because, at 2000-plus pages, it's not been read in full by anyone. However, we all know by now that it includes a requirement for everyone to buy health insurance, and no place to buy it from other than the health insurance industry, whose conduct was what prompted the call for reform in the first place. The insurers have given way on a few points--such as insuring people with pre-existing conditions--though I wonder if there is any limit set on what such people can be charged for insurance--and some limitations on cancelling policies, in exchange for this bonanza.

We already have requirements to have other kinds of insurance. You want to drive, you have car insurance--liability for everyone, and to protect your own car if it is financed. You have a home loan, your lender requires you to have homeowner's insurance and title insurance (to protect the lender, not you). Leases often require tenants to have renter's insurance (to protect the landlord, not you). Many types of business or profession are required to have insurance. As a Realtor, I'm required to have Errors and Omissions Insurance. Note that all of these are required so as to protect someone else's interests, not yours. But the biggest difference between these and the new health insurance requirement is that all of them are based on a voluntary choice--to drive, to finance a home, to lease from that particular landlord, to engage in certain types of business. You could, theoretically, not have any of those. We have never before had a requirement to purchase insurance from private companies merely as a condition of being alive and citizens of our particular country.

Now, I have no problem with the notion of paying for my own insurance, either as a premium to a company or a tax. Employers paying for health insurance is a legacy of World War II, when wages were frozen and providing benefits was one of the few ways they could compete for workers when the job market went from surplus to shortage overnight (the night of December 7, 1941). I'm self-employed, so it would be my responsibility in any case. My concerns are that said health care/insurance be 1) affordable by me, and 2) usable without fear of the consequences of using it.

When I had my bicycling accident in June, I had no health insurance. I paid for all the care--about $5,000--out of my own pocket. Fortunately I was able to do that--I had some money available and I was still able to work, though my productivity was reduced. I also discovered a little secret. All the health care providers I used willingly cut their fees substantially, to about half their initial quotes. The place I got my MRI actually offered to do this the moment they knew I had no insurance--"we give 'self-pay' patients [code for 'uninsured'] a fifty-percent discount." The dirty little secret I discovered is this: health care providers will routinely give uninsured people a 50% discount because the health insurance companies only give them half of the money. 

Now you might ask how that works--given that the only money actually changing hands here are whatever you pay in premiums, co-pays and deductibles, and whatever the insurance company actually gives the provider. That's a very interesting question. Any other questions?

Language Shapes Thought

Consider that a choice of a word can shape the entire discussion. George Orwell wrote a lot about this, and not just in his best-known work 1984. 

Today I am thinking about the difference between "health insurance" and "health care."

Insurance is, by definition, intended to deal with something unforeseen, calamitous, that should not happen. Modern insurance began with insuring ships and their cargoes in the 18th century. Ships were supposed to complete their voyages successfully. Some did not. Insurance, to compensate ship owners, cargo owners and investors for losses, benefited trade and commerce. It protected against what "should not happen." You have car insurance and home insurance to protect you against what should not happen.

But it's clear that everyone needs health care at some time in their lives, and that the longer they live, the more they will need. Thus it's not something that "should not happen," it's something that predictably will happen. Granted, exactly what will happen might include some of those things that "should not happen"--severe illnesses that not everyone gets. But we'll all have some need for care.

Insurance is basically the biggest legal gambling business there is. The insurer takes your bet--your premium--and agrees to pay out under certain conditions. The insurer plans on taking in more than they have to pay out (and adding to their take by investing the money they take in) and by careful attention to the details--the legal language in policies, the statistical odds of the risks they are insuring, and how much they charge--keeping more money than they have to give back. Casinos and bookies work the same way. They don't even need to cheat--the odds favor the house.

But everyone will need health care. So the insurers, whose goal is to treat paying claims as something that shouldn't happen (covering events that shouldn't happen), are basically at odds with the insured, who will inevitably need treatment they can't pay for themselves.

And this is the basic, underlying misconception of the whole discussion of "health insurance reform."

The countries that have universal coverage--which is practically all of them except the USA--have health care, not just health insurance. That's a big difference. How many lives would be saved, lengthened, improved by having health care that works for everyone? Apparently we are not going to get the chance to find out.