It’s fascinating to me – in a totally unpleasant way – to watch what has become of our health care debate. The process began with the inclusion of all elements of the health care system working to fashion a solution to what everyone considered a broken system. Many of us may have forgotten all of the debates during that time, when single payer option folks were concerned that insurance companies were getting to much input and specialists were getting more support in solutions than the general practitioner/family practice doctor who provides that initial diagnostic visit that often determines our health care outcomes. Our debates were at least about analysis of the present system and which aspects of the system to address with health care reform.

The ACA emerged from what we have learned in class is a very non-linear and messy process. This article by John Cannan in the Law Library Journal is very telling. Here is a quote from the beginning of his article:

And just so you know, you can read the entire article here. It is very detailed and dense (I didn’t make it all the way through), but I think it is indicative of our health care debate reality. The introduction of the ACA and it’s legislative process were indicative of the process of implementation.

Cannan calls this an “Ad Hoc” legislative process, Stone would say it is the result of legislation by the polis and Kingdon would probably tell us that all the streams are working overtime in this one. I think we have forgotten what drove us to this process in the first place.

Health Care in America

Hopefully you have a better understanding of these issues now that you have watched “Sick around America” and “Sick around the world.” But with all of the debates we are having about the ACA, we seem to have totally forgotten the problem that was health care in this country.

Health Care Problems is a website where problems withthe health care system are logged by anyone participating in it. But they also compiled a very interesting set of health care statistics from a variety of sources. Here is just a sampling:

• In 2012, nearly half (46%) of adults ages 19 to 64, or an estimated 85 million people, did not have health insurance for the full year (30%, or 55 million) or were underinsured and unprotected from high out-of-pocket costs (16%, or 30 million). (Source: Commonwealth Fund Biennial Health Insurance Survey 2012)
• The amount people pay for health insurance increased 30 percent from 2001 to 2005, while income for the same period of time only increased 3 percent. (Source: Robert Wood Johnson Foundation)
• The average annual premiums for single and family health insurance under employer-sponsored coverage was $5,615 and $15,745, respectively, in 2012. (Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2012)
• Healthcare expenditures in the United States exceed $2 trillion a year. (SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group;) In comparison, the federal budget is $3 trillion a year.

The underinsured are those who have health insurance but still struggle to pay their healthcare bills. Many of them are faced with rising health care premiums, deductibles, and copayments, as well as limits on coverage for various services or other limits and excluded services that can increase out-of-pocket expenses.

The following statistics are from the Commonwealth Fund Biennial Health Insurance Survey of 2012:

• The number of adults who were underinsured (if insured all year) climbed steadily over the past decade, rising from 16 million (9%) in 2003 to 30 million (16%) in 2012.
• People in the lowest income levels are affected the most, as 75% of working-age adults with incomes under 133 percent of the poverty level ($14,856 for an individual or $30,657 for a family of four) were underinsured or experienced a time without insurance.
• 72% of the total number of Americans who were uninsured or poorly insured in 2012 were people with incomes under 250 percent of poverty ($92,200).

Yes, we are in a real mess and we have been for awhile. To suggest that there were alternatives to the ACA is to be functioning in an alternative universe. And the political elements of our process that want to throw it out don’t present realistic or reasonable alternatives. That is not a matter of opinion, folks, that is reality. Here are some of our favorite fantasies about the ACA.

It’s socialized medicine like those other bad countries

The Commonwealth Fund does ongoing research regarding health care in our country and others. They just released their International Survey. You might want to take a look at it. After watching your two videos you should be somewhat familiar with it’s findings. One NY Times reporter calls it The Shame of American Health Care. It turns out we score worse in virtually all measures of health care studied, we fare worse in the United States than any of the other countries. Hum….. you haven’t been hearing much of that in the debate about the ACA?

And in the most recent hearing, this professional from Canada took one of the Senators to task for his grossly generalized and inaccurate statements about health care in Canada. Jonathon Kay discusses the complexity of the system. You can see the video of their conversation here. It’s worth watching.

But if you read Jonathon Kay’s article more closely you will realize that the issues are so much broader than our simplistic beliefs about health care around the world.

Metaphors and Synecdoches and Political Numbers are the real problem

Kay takes us down an important path in his brief article. We have reduced the complexity of health care reform to slogans and sound bites and synecdoches that make for good politicking, but not so good social policy. Please spend time on the Commonwealth Fund’s section of their website on health care reform. It will give you a history of the REAL debates about the REAL issues and the REAL implementation.

“IF you like your plan you can keep it” has become a synecdoche for virtually everything and anything that opponents think is wrong with the ACA. But it also has become an excuse to call our President a liar. That relates to my last point about this vitriol. And here is an interesting article about the FACTS regarding that extension on policies you like so well. Perhaps not the big deal it was presented to be?

People as Examples of the Good, Bad and Ugly

Both sides have used the “people” as a metaphor approach in the health care reform debate. Each side has placed individuals in the public eye as examples of the successful elements of the ACA or the disastrous elements of the ACA. This article by Jonathan Weisman talks about some of the disastrous effects of using individuals to represent something as complex as health care reform. The individual who hated it now finds themselves insured with better and more cost effective coverage, the individual who was thrilled now finds that the coverage for employees has skyrocketed. Which is right? If you track out these stories after the fact, you tend to learn that everyone comes out reasonably well in the end – it just takes a while to find your way through a complex and controversial system.

Just so you know – I have a negative person story I could tell you about the ACA. When I was self-employed in DC I purchased insurance for myself and at 50% for my single employee. When we moved to Atlanta, I was uncovered for 8 months until we were able to get me on my partner’s plan at her organization (which took time and a policy change). I was relieved to have coverage.

After the introduction of the ACA, insurance companies are looking for ways to cover what they are anticipating will be the cost of universal coverage (you can’t dump somebody or refuse them for whatever you want). In this case, the insurance company decided the existing plan was no longer available (they weren’t offering that plan any more). Changes like these by insurance companies for employer based plans has been happening regularly, with some significant changes in structure. (you might want to take a look at this article).

Now the plan we are on has been changed. The new plans available from this company are based the age of the employees. The older you are, the more expensive your insurance. That meant departments with older and more experienced staff had greater insurance costs than folks with young and new staff. For me – we pay for my coverage, by the way – my premium tripled.

Now, I could go on a nut and say that the ACA has cost me money. But that would really be a misstatement, wouldn’t it? Change in a complex system caused one element of that system to react to try and protect themselves. I could get off the policy and go to the exchange, but let’s not forget, the exchange is filled with insurance company policies. We didn’t elect the public option. Remember that discussion? So because I am over 60 (yes, I am really over 60), I cannot get affordable health care without risking a huge deductible.

So are my problems the result of the ACA or the messy, disruptive, difficult, complicated process of change in a system that doesn’t change easily? I believe the latter – and give it a couple of years to settle out and we will see where we are.

The ACA and Poverty

I am lucky because I can financially weather the disruption in our health care system caused by the way we are implementing the ACA. But this infographic describes an even more stark problem.

We have not been able to tackle the issue of unemployment as completely as we intended. But, as I said in class, unemployment and health care and poverty are totally and completely entwined. Another Commonwealth Fund Study talks about the relationship between poverty and health care and it should be damning. We are truly debating the wrong things.

I recommend you study the interactive video they provide for their state comparison report. I truly wish we could debate these issues and not just use metaphors that don’t represent any of the important issues to stop debate.

Here is their infographic. It will be one of our topics of debate when we return from spring break.

What is all this vitriol really about?

The ACA was vetted extensively in a long and arduous process. It was approved by the US Supreme Court (yes, that is the highest court in our country’s process of appeal). It has made a difference for hundreds of thousands of people who needed help NOW. One of the staff in an agency where I consult was overjoyed. She is a student and doing an internship. She has never before had health insurance. She got insurance through healthcare.gov and is now finally making her way to doctors to assure adequate health care.

Perhaps we need to look closer at what this vitriol really represents? What is the metaphor for all this? It’s an important and interesting question and could be applied to any of the debates we are now having on virtually every single social policy being explored in our country today.