Good ideas are plentiful, but no one seems to know how to put them into motion. Seriously now, how are we going to get health care? The answer may not lie in making little steps in the right direction. It may take something totally unexpected and radical to upset the status quo.
The direct approach hasn't worked in Congress, and I see no prospect of it working in my lifetime. I was a little boy the first time I heard that you could get taken care of for free by the British National Health, which was established in the year of my birth. Over the years, stories pop up every so often about people who go there to get treated. Now, I'm retired and need some medical attention, but my government isn't doing any more for me in that respect than it was in 1948. What's it going to take? If we can't get our socialized medicine the way the British did, then we have to figure out something else. I've watched those around me get sick and die sooner for lack of medical care, and now I'm not feeling that great. I'm getting desperate.
The tiny number of people who voted in the poll and made comments to Monday's diary entry may reflect poorly on my mass appeal, but I am heartened that the those who did comment showed some serious thinking. Good on you. As if I had not already bored my minuscule readership already, I'm going to muse on the results of the poll and speculate some more.
The way I have always wanted to do in the health insurance companies, but did not present as one of the poll options is to pass legislation and set up a national health service as they did in Great Britain in 1948. This is socialized medicine, pure and simple. It seems that most Americans still can't bring themselves to directly embrace the concept of no-fee medical care as a public utility, so we have to cloak it in the euphemism of "single payer" to prevent geezers still hidebound by McCarthy-era paranoia from going into apoplexy. I'm resigned to playing the game of not dressing up like Che Guevara or sporting my blue Mao cap and exhorting the downtrodden masses to storm the barricades. No, not any more. My undergraduate years at UC Berkeley in the late 1960's are long past.
The strategy I'm groping for is to get the job done in a way that an overwhelming majority of people will go for. This means that it has to be something subtle, that kills off the insurance companies as a side effect. I didn't put the national health plan in as a choice in the poll because, even though it's the "right" answer, it's still not a viable option. We've been pleading for it since 1948, but the grip of the socially regressive corporatist hegemony is so strong here that even those who support it think of socialized medicine, the norm in the developed world, as weird, futuristic fiction. You can't fight a propaganda machine that can sell a free clinic as a Faustian nightmare, and make that idea stick with a sizable segment of the population.
Given that sobering reality, it occurred to me that a full frontal assault on the insurance system might be more fruitful than the oblique attacks we've staged for the last sixty years or so. The choices I had in my poll were some of the ways I had rolled around in my head over the years. I didn't put all of them in because a lot of them were violent, mainly involving firing squads and confiscation of assets. I included an "other" choice, but those who voted for that and explained in a comment mainly wanted single payer, as do I, so I didn't get any really new ideas from that. I was intrigued by the surprising support for some of the more innovative, and better, ideas that I've had. I'm focusing on these three because they are the most realistic, and the readers picked up on that. These could all work in certain circumstances.
- 15%: The people boycott health insurance, negotiating fee for service with providers and enrolling in medical clinic subscription schemes administered directly by health care providers.
- 21%: The government opens the doors of all U.S. Public Health Service facilities as free clinics, expanding the program as Congressional appropriations permit. (It's the Microsoft model for Internet Explorer that killed Netscape Navigator: Why pay for what you can get for free?)
- 31%: Compete with private insurance using a public option that does not exclude pre-existing conditions, does not limit or rescind and guarantees never to cancel. All checkups and preventive procedures have no copayment.
I'm only going to cover one of these today. I'll cover the other two in subsequent diary posts. I tried doing all three at once, but it got too long.
The boycott idea seems to be something that hasn't gotten much press, but I'm sure that everyone who is frustrated with American medicine has considered it. My guilty secret is that I've already taken this step on an individual basis. I've dropped out of the health insurance treadmill. When my last temp job ended in April, 2008, I declined COBRA because I vowed that United Health Care wouldn't continue to extort from me. That $1.78 billion to their CEO a few years ago was the last straw. I just gave up on trying to be insured.
I went to a doctor and found out that I had a few things wrong with me and began treatment. The MD was aghast that I had no insurance, so he figured out a treatment plan and medications that were cheap. We communicate by e-mail so I don't have to pay for very many office visits. Since then, I've heard about local medical practices that don't take insurance, just cash. I may switch to one of these. There are doctors who take subscriptions, that is, have you put them on retainer, and they promise to treat you to the extent you need, but I haven't looked into this yet. I get the feeling that this is a growing trend because there are just too many people, like me, who are being shut out of affordable health insurance that actually pays out any benefits. We are the people with pre-existing conditions who are shocked to find what individual health insurance policies cost. We are dismayed to find that the thing we worry about is excluded from the benefits of the policy, so what's the point of having it? By denying my premium dollars to the insurance company, I'm directly attacking their revenue base. If they can't collect from me the can't make money.
If everyone did as I did -- the insurance companies call it "going naked" -- it would shut them down overnight. The government would step in and set up an agency to handle the situation. This would be the result of pressure from medical care providers. As much as they hate paper work, they hate being bill collectors even more. If no one had insurance, many people would choose not to pay. Denial of service would become rampant and angry mobs of desperate poor people who couldn't pay would flood medical facilities demanding treatment. They would overwhelm the facilities. Oh, wait. That's pretty much what's going on now.
Denial of service and insistent patients are not triggering structural changes in the health care system at the moment because it's still a manageable minority. You can still get people to kick in for that kid who needs a transplant and Marlo Thomas pulls on your heart strings with her pitch for St. Jude's. Never mind that thousands of diabetics and hypertensives are untreated and die more quickly. The illusion that only a few people "fall through the cracks", fostered by high-profile public relations for charity hospitals, allows us to ignore the fact that we have about 45,000 premature deaths per year because these people were denied routine medical care.
If enough people boycotted insurance companies, eventually a tipping point would be reached and no one would buy it because they would see people without it doing at least as well by paying out of pocket. They would feel like chumps, which is exactly what they are now, but don't realize it. The group-think mentality puts more stock in polls than logic. (Notice how the President's approval rating gets more discussion than the merits of his policies.) With no health insurance companies, health care providers would figure out how to get people in to fill their facilities and still get paid. The government would get into the act as a follower, not a leader, and agree to public funding of medical care to get in on the revenue stream.
The critical flaw in the boycott scheme is that people are frightened and cling to the false notion that insurance will pay off for them. They rarely act rationally with respect to probability. If they buy lottery tickets for $1 with an expected return of 50 cents or less, then they also see nothing imprudent about only being able to expect about a 70 cent return on their health insurance premium dollar (the medical loss ratio). Both are terrible sucker bets, but the health insurance gamble is worse. With the lottery, you're just out $1 most of the time, but with the insurance lottery, you still lose when you "win" and stay healthy. If you have the same level of health whether or not you pay the premium (i.e., make the bet), it yields no return from your investment. But, if you "win" the health insurance lottery, and come down with a horribly expensive medical condition whose cost far exceeds the amount of your premium/bet, you still are likely to lose. If the insurer doesn't pay for it all, tries to avoid paying by legalistic fraud or rescinds the policy to avoid paying altogether, you're worse off, and thus have lost the bet. At best, you will have to pay 20% or so, which might still impoverish and bankrupt you. The only benefit you got from your premium bet was to reduce, but not eliminate, the extent of damage from a catastrophic loss.
Health insurance that does not pay off in full is a sucker bet because it denies the basic principal of insurance, pooling the risk. If you have to pay huge premiums, but can still be ruined by an unlikely but all too frequent catastrophe, then you're not really insured at all. You might as well do what I do, bet on yourself and pay up if you're unlucky. This may seem logical and rational to me, but convincing enough people to take this risk is unlikely.
A boycott would fail for lack of popular support. You can't get healthy people to expose themselves to even the slightest risk. They feel they are getting off cheaply by paying their modest premiums for peace of mind. They may be smug and satisfied that they will never be ruined by medical costs, but they are also so afraid of catastrophic illness that they will pay for the illusion of being "covered" even though they hear horror stories every day about sick people being cheated out of their benefits by greedy insurers. Again, people don't believe in probability and statistics.
By the same token, you can't get sick people to boycott insurance companies because they are on the short end of the deal already. They cling to any shred of hope that their loyal support of the insurance pool lottery in the past will qualify them to receive more in benefits than they have paid in premiums. They are absolutely right and morally justified, but insurance companies are not bound by law to do this, so they do not. They cut people off and let them die to the extent that they are able. That's just the way it is, and there is no arguing with desperation. People who need insurance benefits paid out are its stanchest supporters. They are the people least likely to boycott it.
That leaves two groups who boycott insurance, the poor and cheapskate statisticians. People who have to choose between the necessities of life and insurance always let the policy lapse. Who can blame them? While the poor are a growing segment of the population, there are not enough of them for the insurance companies to care. That leaves cranks who have enough money to buy insurance, but choose not to. How many do you know? I'm the only one over fifty I know.
Tomorrow, we'll get into the USPHS scheme.