June 26, 2007
A Letter to Blue Cross
This is a real letter written by a reader to Blue Cross of California, after they rejected his application for insurance. Because -- I shit you not -- of heartburn. Read the whole thing. It's far more powerful, and illuminating, than anything I write. And if any of you have similar stories, e-mail me.
To Whom It May Concern:
I'm not sure if this letter is going to be read, or even cared about in the
least, but as a taxpaying American I would hope that a responsible
corporation would acknowledge opinions or complaints originating from the
public they aim to serve. Let your corporate conscience be your guide as I
will let my faith in the overall good of people serve me as a motivator to
continue with my opinion.
That being said, I have a serious problem in regards to your eligibility
requirements for individual health care plans. A bit about myself: I am a
very active 28 year old male, who exercises regularly (4-6 days a week),
does not use any tobacco products, eats organic foods whenever possible,
takes vitamins, gets enough sleep, rarely even catches a cold and has
absolutely no history of disease. I recently applied for one of your
"Tonik" health plans because it was finally affordable to me. I have been
without health care for over 5 years and felt that the time had come for me
to make a financial commitment to my health. However, as a young, perfectly
healthy average male, I am appalled that you would deny my claim for health
insurance. After speaking with a representative over the phone, I was told
in a very polite tone and with no hint of sarcasm that I was ineligible due
to the fact that I had had Heartburn in the last 6 months; and furthermore
that I could reapply in 6 months (again with no hint of sarcasm or
acknowledgment of the fact that I clearly wouldn't state I'd ever had
Heartburn if it meant no health care).
Needless to say, I find it insulting and ludicrous that such a benign
symptom as Heartburn can deem me uninsurable by even just one of your plans
Not to mention that I received an email stating that I should apply to the
California Major Risk Program. Major risk of what I ask you? (rhetorically)
Not only are you compelling applicants to lie about seemingly innocuous
symptoms that nearly everyone experiences from time to time (I challenge you
to find any member of society who doesn't experience Heartburn occasionally
from spicy foods or even minor food allergies), but you are standing
hypocritically against the very reason that we are forced have health
insurance in this country. If I can't get health care without insurance
(alas I am not a millionaire), and I can't get insurance to obtain health
care if I need it, then to whom and for what does said insurance serve it's
Despite the fact that I am sure this letter is falling on deaf ears, I urge
you to rethink your ethical stance of denying health insurance applicants
the very care that they may need but are financial inept at attaining.
Is your company not in existence for the very nature of helping people
obtain medical care for an affordable cost? If you deny people with a
possible condition the right to affordable health care are you not going
against the mission of your company in the first place? Or is profit all
you care about? And please don't mistake me from the above questions, I
hardly consider Heartburn a costly or even dangerous "condition" in an
average 28 year old male and I'm sure you'd be hard pressed to find a health
care professional who would disagree with me. That aside, had I even a
slightly more serious symptom that would point towards a great need of
health care, than I am certain my claim would have been denied even
faster...if it were humanly possible. Sure, for the right price, any sort
of insurance is possible, but why not try to actually serve the real public?
People who can't afford health care and therefore turn to you as their only
You have a great responsibility bestowed upon you by our present health care
system. You have the opportunity to bring health to many underprivileged
people (and do not mistake my use of the word 'underprivileged' to adhere to
solely those who are not as fortunate to utilize the market forces for their
personal financial gain…I am only referring to the underprivileged slice of
the societal pie that is without health care regardless of class and such).
And thus, I too am given the golden key of choice. By this you can be sure
I will not be choosing your company's services, and though I am not thrilled
with my other choices, I will seek out a company with a seemingly better
understanding of the massive responsibilities entrusted to it by our
country's present health care system...if it even exists.
Let me close in saying that I don't expect to receive any sort of response
from your corporation. If by some stroke of conscience you are compelled to
respond to my letter, than please refrain from sending me some lawyer jargon
about how you are always right, that it was in the fine print, and that
Heartburn may in fact be a sign of a serious problem. Furthermore do not
respond with statistics or righteous finger pointing, or worse: trying to
sell me a more expensive plan. If you are not writing a heartfelt, sincere
response, then don't bother.
April 26, 2007
Your World in Charts: Uninsured Edition
As of late, we've had some commenters hanging around demanding we redefine the word "uninsured," attempting to downplay the problem of lack of coverage, denying all widely accepted measures of the uninsured, and, when that fails, writing the uninsured off as statistical artifacts of momentary lapses in coverage. Soon enough, they suggest, insurance is procured; no harm, no foul. So this struck me as relevant:
When it comes to insurance, the stability of coverage matters. Indeed, what we tend to see is that the effects of having uncertain coverage -- or insufficient coverage -- are very much like the effects of being totally uninsured. The intermittently insured ignore prescriptions, forego specialists, skip treatment, and deny themselves doctor's visits at nearly the rate of the uninsured.
Meanwhile, so far as the total number -- 45.3 million Americans uninsured -- goes, I was struck to see that even the insurance industry uses it. Hell, they even think (or at least say) that "Politicians need to prioritize this issue. Our community has put forth a workable approach to meet the needs of the uninsured - a diverse population that needs targeted solutions which can be implemented in the short term."
The insurance industry isn't prone to overhyping the millions of Americans without insurance, and if they thought themselves capable of calling it 15 million rather than 45 million, they would. They don't. And so, if you're a denier, ask yourself: Are you really comfortable with a world in which the insurance industry is more intellectually honest than you are?
February 28, 2007
You Don't Know The Shape I'm In
I'm unconvinced by the mortality data in here, at least as it relates to the present day, but there's no doubt that a primary role of programs like Medicare is to simply insulate individuals from financial ruin. Indeed, I've never thought the health benefits are the most important reason to extend coverage to the uninsured -- though there will be health benefits, and they are important. In any large population, particularly one that trends young, as the uninsured do, only a small number in any given year will see real health improvement from easier access to care. But the economic security and freedom offered by medical coverage will aid every member of the community, freeing them to search for better jobs and see doctors without anxiety and treat nagging-but-not-mortal conditions that harmed their quality of life.
That said, for the small number who do need the care and currently forego it, insurance is crucial, and its absence is catastrophic. Indeed, I don't even know what to say about this...
January 25, 2007
Gotta Give Them Credit
It certainly is a new day in Washington when the wonderful Elizabeth Warren is being called to testify before the Senate Banking Committee. On that note, I've been remiss in not linking to this startling study (pdf) by Demos connecting credit debt to medical care. According to their findings, about 30% of middle- and low-income households with debt say medical costs have been a contributor. Of that group, 40 percent had more than $10,000 in debt, and those without health insurance carried a crushing $14,512 load. Indeed, the households with medically-related debt had more debt than those in hock for other expenses -- $11,623 to $7,964.
Nowadays, hospitals and health care providers often accept credit cards, which means the uninsured and underinsured are not only paying worse absolute prices (good insurance bargains down the total prices of each unit of care), they're also paying interest on those bad deals. Just another way in which it's really quite expensive to be poor. What I'm really excited for, though, is when HSAs and their mega-deductibles enter wide use and individuals who haven't socked away sufficient money begin putting their care on the plastic. Even now, about half of all HSA users haven't put a penny into their accounts. So the next step isn't only to transfer more risk onto these individuals, it's to help plunge them deep into debt.
January 12, 2007
The Hacker Plan
I'm getting near-overwhelmed with the array of new health care plans, but I'd be remiss not to mention Jacob Hacker's new plan through EPI. And I am never remiss. Hacker's plan isn't Medicare-for-All, at least not quite. As he puts it, it's really Medicare-for-Many. The government will create a new, Medicare-style health plan that's open for enrollment to any and all individuals interested in jumping in, covers mental health and maternal care, and has strict limits on out-of-pocket spending. Simultaneously, all employers will be required to offer insurance as good or better than the new government plan. If they don't want to contract out with the private sector, they'll pay 6% of payroll to enter their workers into the government plan. The unemployed and self-employed will have to buy coverage, and there'll be heavy subsidies tied to income. Done.
You'll notice that, unlike the other plans, Hacker's took four sentences to explain. It's a simple, elegant mechanism for coverage, requiring none of the complex market restructuring and odd coverage schemes of the plans that seek to preserve the private insurance market as a protected whole. Its secondary virtue is that it offers an easy, potential path to effective single-payer, allowing the government insurer to compete with private insurers, and possibly outcompete them as well. And by using the example of Medicare, Hacker promises familiarity with what's being offered -- a crucial advantage given the dangers complexity pose in the public arena. It's worth noting that the plan also has another name: HR 5886, introduced by Pete Stark during the last Congress. The differences between the two are minimal, and Hacker boasts involvement in both.
Also at Tapped
January 09, 2007
Individual Mandates and Universal Health Insurance
I want to spend some more time digging into Schwarzenegger's health care plan before analyzing it in full, but a quick point on the early reactions: I'm hearing a lot of hating on the individual mandate* -- and I don't get it. Some are complaining that the mandate "criminalizes the uninsured," others are saying ""The uninsured shouldn’t have a financial penalty onto top of the health and financial consequences of being uninsured." So let me try and say this clearly: Single-payer health care is an individual mandate. The enforcement mechanism, in that case, is taxation. If you don't pay your taxes, you're breaking the law. If you decide to withhold the portion of your taxes that go towards health care, you're a criminal. In fact, there is absolutely no universal health care system that wouldn't include a mandate of some kind -- that's how you make it universal. Indeed, without a mandate, you can't have a decent health system: If the healthy can opt-out until they get sick, coverage will be unaffordable for everyone. For a risk pool to work, it needs members at low risk.
The question with an individual mandate is subsidization and affordability. If we pass a law levying an individual mandate and subsidizing premiums down to $50 a month, there'll be few complaints. A mandate with no subsidization, however, is an impossible burden on millions of families. When evaluating an individual mandate, that's where liberals need to focus: The generosity of the subsidies. The Wyden Plan, for instance, subsidizes up to 400 percent of the poverty line. The Massachusetts plan subsidizes up to 300 percent. The Schwarzenegger plan subsidizes up to 250 percent. That looks too low, and I'll talk more about it later today. But for now, folks need to keep in mind that you can't simultaneously demand universal health care and reject mandates. Universal health care is a coverage mandate -- whether the enforcement comes through tax receipts or proof of premium payment is not a relavent distinction. Either one can be an overwhelming burden on the poor or the foundation of a progressive, generous system. The focus, always, should be on telling the two apart.
*An individual mandate is a law forcing the purchase of some minimum level of health insurance.
--Also at Tapped
Why Individual Health Insurance is a Cruel Joke
As follow-up to some of my earlier posts, Graham compiles over 84 reasons insurers may drop you.
January 08, 2007
From Lisa Girion's story on insurance underwriting (which I say more about at Tapped), here's a list of jobs which will lead major insurers in California to simply refuse to offer you coverage -- at any price:
Air traffic control
Circus or carnival work
Concrete or asphalt work
Furniture and fixtures manufacturing
Lumber work, including wood chopping, timber cutting and working in a sawmill
Oil well or refinery work
Sports, semi-pro or professional
Stockyard work, with or without butchering
Stables, all employees
Transportation and aviation
Window work at heights exceeding three stories
One wonders if making a living doing telecom installation, or roofing, or window cleaning, or lumber work, or construction is really so sinful that we think it acceptable for our health system to deny such workers health coverage.
January 05, 2007
It's The Economics (As Always)
Garance asks me to comment on this fascinating New York Times article laying out the strong correlations between health and education. She wonders if our health care debate isn't "too focused on questions of coverage and disease treatment, rather than on actually improving the long-term health of the population through public health initiatives whose are results are not immediately apparent."
That's simultaneously true and untrue, but let's bracket it for the moment. The question of whether we could vastly improve health outcomes in this country by forcing everyone into college is an interesting one, but I'm skeptical. Given that no one thinks the dedicated study of Proust unlocks secret immortality enzymes, the question is what education is correlating with to create these outcomes. Most likely, it's a host of factors. On the individual level, less physically taxing jobs, more occupational control, more social capital, less economic stress, more personal power (feelings of control are heavily correlated with good health), etc.
More globally, higher levels of society-wide education will correlate with higher economic growth, a less menial economy, higher incomes, etc. And the article strongly implies that a primary effect of more education is that it makes people smart enough to not smoke, in which case we should pump research into smoking bans (thank you, DC!). And it should be noted that we could make everyone much healthier if we could make them Hispanic.
Those concerns aired, Garance is absolutely right: Our health care debate focuses too much on insurance. Most everyone in this country can access some sort of care, even if only at the point of crisis. That's not an optimal situation, but the available strides in outcomes are fairly limited. The way we pay for coverage simply isn't the primary determinant of health. That said, I wouldn't pull the throttle back on the reform fight by even an inch.
The health care question is more economic than medical -- indeed, it's likely the most important economic problem facing the country. Everyone gets care, but the ambulance ride or cancer diagnosis bankrupts no small number of Americans. That they also lack access to preventive medicine and early diagnostics is deeply troubling. Meanwhile, health care is going to chew up our national economy if we don't get medical inflation under control, and the vagaries of the employer-based health system substantially reduce the freedom of individuals to pursue their own dreams, business ideas, and general bliss while simultaneously bankrupting employers and incentivizing a race to the bottom in benefits.
Indeed, though there are better ways to improve health outcomes than reforming the way our system delivers coverage (like massively funding the NIH), there's nothing that would do more to ensure the economic security and personal freedom of average Americans, or the financial health of the country, than reforming the system. And in the end, it's not an either/or question. A better system would save money, freeing up funds for other public health and social policy priorities.
Also at Tapped
December 31, 2006
Ankush points me towards an article in the Business section of The New York Times arguing for single-payer health care. That's not exactly a common pairing, so seeing such an unexpected marriage of section and socialism does my heart good. The piece is a perfectly adequate recapitulation of the arguments you already know, though it calls a lot of systems "single-payer" when they aren't. But then, the importance of such an article isn't its innovativeness, but its audience. The data comparing our spending and outcomes to those of other developed nations is an irrefutable, irresistible, condemnation of our system. Indeed, this graphic alone is a more than suitable argument for reform:
The more who know the statistics, the easier the next fight will be. And so I'm glad to see them being explained to audiences generally insulated against such revelations. In the end, the case for moving towards public provision of health care is a simple one: It makes damn good business sense. As the above graph shows, you may pay more through the government, but you pay far less overall. And any businessman knows that that's the important metric.