Over the past few days, Dr. John and I have been having a fascinating discussion about this post from September 2008. It is one of the first pieces I wrote for Extreme Thinkover, before President Obama was elected, as well as at least a year before the serious work on what would become the Patient Protection and Affordable Care Act, known as “Obamacare” (but which I prefer to refer as “the ACA”) was being worked on. It was also before Dr. John and I met and got acquainted.
I deliberately haven’t edited the post below, so our comments will make sense in the context in which they were written will make sense. I think my readers will enjoy the back and forth between us, and I invite you to add your own comments, should you feel so inclined.
IMPORTANT: Read the comments starting from the bottom of the thread. It is where the discussion starts. And you may have to move up and down a few comments for our replies because of the way WordPress publishes them: by the time stamp of the comment/reply and not directly associated with a given submission. Sorry for the inconvenience.
Health Care for All Americans: Part 3
In Parts 1 and 2, I discussed first, the assumptions needed from a medical perspective, particularly with respect to the scope of treatment plans that would lead to optimizing the health of Americans, and second, how those assumptions would create a radical transformation in the health of Americans that would work its way through all aspects of daily life. In Part 3, I now want to describe the logic that shows how the country would benefit.
We’ll start using my first assumption: Preventable diseases are prevented.
We could use any number of examples, but the format of the blog does requires some brevity, rather than a detailed White Paper or journal article. I also acknowledge that the ideas I present here have all been suggested by others, but this is how I choose to organize them.
For purposes of our discussion let’s call our example citizen, Larry. Larry works full time for minimum wage, does not have health insurance, and cannot afford to buy private insurance. He also does not qualify for any government health care benefits. Larry’s wife also works for minimum wage, but only 24 hours per week.
As long as his health holds, Larry can work and he has no medical needs. He pays local, federal and state taxes and uses no special government services.
But let’s say that Larry gets pneumonia. It is a very common viral strain, and can be treated successfully with antibiotics, and could have been avoided entirely if Larry had had a pneumonia vaccination. Now he’s faced with a dilemma. At first he thinks he just has a chest cold and he can wait it out. Being a conscientious worker, he toughs it out and goes to work, but exposes his coworkers to the bug through his worsening cough.
By the weekend, Larry is really sick. Over the counter cough medicines provide almost no relief, and on top of that, his cough is becoming increasingly productive. He cannot sleep because of the cough and not being able to find a position in bed where he can breathe without effort and pain. Larry knows he needs to see a doctor, but having no insurance, he does not have a primary care physician, so he has no idea who to call. Finally his breathing becomes so difficult that his wife calls 911. Larry is taken to an emergency room by ambulance, but one on the far side of the city because the hospital closest does not like to take patients without insurance.
By the time Larry gets to an emergency room that will accept him as a patient he is nearly in respiratory arrest. The ER doctor quickly diagnoses the pneumonia, but that it is so advanced that Larry’s life is in danger. She intubates him immediately and transfers him to the hospital’s intensive care unit. It is four days before Larry’s condition has improved enough to send him to a “step-down” unit and two more days before he can be admitted to a medical unit room, and he is discharged two days after that.
Larry is fortunate that the hospital he is at has Certified RN and MSW Care Managers. They work with him and his wife throughout the hospitalization, develop a treatment plan and a discharge plan, set Larry up with a local medical clinic that treats patients without insurance, and provide his wife with food vouchers and bus tokens so she can make the long trip back and forth to the hospital.
Despite all this, when Larry is wheeled out to the taxi to take him home, he has a hospital bill that is $250,000. Since Larry and his wife together make too much money to qualify for Medicare, that bill rests squarely on their shoulders. He has no way to pay it back. He will not be strong enough to work for at least another three weeks. He will have not earned a dollar since he got sick, and won’t until he returns to work. His wife’s income is not sufficient to cover all their bills, and if they pay the rent, they will not have enough money to buy food. The hospital sent home a week’s supply of medications, but after that, he will have to pay for them himself, and due to the damage to his lungs, he will need regular medications for at least six months. Those prescriptions will cost over $800 per month. Through the free medical clinic he can apply for medication cost support , but that can take up to four weeks to be approved assuming he qualifies.
Now multiply this basic scenario by twenty or thirty million Larrys a year. Every year. That is health care in America.
Here’s what happens. The only good news is that Larry has survived a brush with death, ironically from a completely preventable disease.
Larry and his wife now owe the hospital $250,000. They have no assets. Even though they signed a promissory note with the hospital, no one is under the illusion that he will be able to pay back more than a few thousand dollars if he is a very conscientious person.
Larry and his wife owe the ambulance service perhaps $3,000. They cannot pay it, or they will have to try to pay it off in very small amounts per year at a probably high interest rate.
Larry will lose at least a month’s income, and perhaps more if his recovery is longer than expected. If he is very fortunate, his employer will hold his job until he can return. In the meantime, his wife’s income is not large enough to cover their essential bills, starting with rent and food. If Larry’s wife cannot get more hours from her current work, her only realistic option is to get another part time job, likely at minimum wage. Whether that will at least let them pay for their basics is not certain. It is also uncertain how flexible their landlord will be to let them catch up with their current rent.
It should be clear by now, that one simple, preventable illness has created a cascade of events that affects the economy, are extraordinarily expensive and completely unnecessary. Yet, this is the true consequence of the current American health care system.
The hospital will have to write off the $250,000. To compensate they will have to pass this loss, as well as hundreds of others per year, to their patients with insurance.
The ambulance company will have to spend a lot to try and recover their fee from Larry, and will pass those added expenses along to their other customers who can pay, either privately or with insurance. If Larry doesn’t keep up with the payments, they may turn him over to collection, which will damage his credit.
Larry’s employer loses productivity from a good worker. The company may have to hire temporary labor to fill Larry’s absence, which will be more expensive.
Larry and his wife lose essential income, which at minimum wage is marginal to begin with, and may jeopardize their ability to even house and feed themselves.
Every day that Larry does not work means that his wages do not generate taxes, local, county and federal, as well as FICA withholdings. Multiply that by twenty or thirty million Larrys year after year and the loss is well into billions. The impact of this loss of tax revenue and productivity is staggering on the national economy.
All this from a preventable disease that could have been stopped before it was started if Larry had had access to the most basic medical care. Everybody loses. The nation is weakened through attrition in ways no external threat could impose on us. This national “epidemic” is progressive, it is close to end-stage, and we could all too easily end up with a terminal prognosis. We may reach a point that we literally will be too unhealthy to survive as a nation.
We still have a choice. Until the epidemic takes that away.