The Fierce Urgency of Now Starts…NOW

by Karoli on January 4, 2009 · 8 comments

in Patients,Payers,Providers

Just over a year ago, US Senator Barack Obama spoke these words:

One year from now, we can stop campaigning on the outrage of 47 million uninsured Americans and finally start doing something about it.

That time is NOW. Yes, the economy is in the tank, Israel is bombing Gaza, we have troops in Iraq and Afghanistan is looking gloomier by the day. Still, the true foundation of the ‘fierce urgency of now’ is reforming our health care system and opening access to all citizens of this country without regard to employment or pre-existing conditions.

As employees are laid off and jobs outsourced to foreign countries, more and more people are faced with this choice: Go bankrupt paying for health insurance or go bankrupt paying for health care. I know this from personal experience. I am a self-employed person who was also a full-time employee with health insurance benefits until December 31st, when I also made the layoff list.

The fierce urgency of now means that I must maintain my health insurance for me and the family no matter what the cost, because of pre-existing conditions which require that I have continuous coverage in order for them to be covered in the future. Did you follow that? It’s an important distinction for many, many Americans facing layoffs and looking for new jobs.

The cost for me to continue this insurance is exhorbitant. It costs twice what I can get as an individual, except that if you are an individual and you have COBRA continuation available, you must exhaust the COBRA coverage first. That means that I will pay $1,300 per month instead of $650 per month for similar coverage as an individual.

Or, I can go without coverage and take the risk that no catastrophe strikes our family before I find another job with insurance. That would also mean we would be forced to wait six months before getting any coverage for pre-existing conditions, which could be a catastrophe in itself.

I’m one of the lucky ones. Other families have no means with which to pay for health coverage and have to rely upon good luck and Medicaid, which means they are less likely to focus on wellness, much more likely to wait until a condition becomes an emergency, and ultimately become the responsibility of the government.

On the business side of things, profit margins drop with every new enrollment period. Employers shave away benefits without dropping them completely in order to stay afloat.

Health care is not optional. When George Will rather sneeringly suggests that the issues surrounding Medicare are a function of overutilization, price-fixing, and — gasp! — recipient ignorance about the cost of goods and services being furnished to them while ignoring the fact that the patient is a captive audience, he misses the larger and far more urgent picture: People die without health care. If they can’t pay for it, the government picks up the tab. This is because health care is as urgent a need as shelter, food, and warmth, and it is slipping from our grasp in real time.

I have paid (or my parents, their employer and my employers have paid) for health insurance since the day I was born. After 50 years, I do not wish to be told that I am responsible for a drain on the national budget or a spike in the national debt. Amortize what has been paid by me and on my behalf for 50 years and it will surely exceed the average lifetime cost of health care that has been provided to me, even with the birth of three children on that tab.

This is it: the future of our country in real time. ‘Bankrupt or bare’ are not viable options. Health care reform has to be on the agenda at the very first Cabinet meeting on January 21st. President-elect Obama has asked for our stories, suggestions, and solutions to the problem. Let’s be ready to serve them up on the first day of his Presidency.

Here are my suggestions for the first steps to take:

  • Establish baseline federal standards for health care that override the widely varying current state-to-state standards.
  • Begin an immediate public audit of the payor/payee system, beginning with insurers and related entities. There should be full transparency as to actuarial assumptions used to calculate premiums, criteria for claims processing, administrative fees and costs, as well as any profit-taking from related companies. In particular, examine the relationships between Pharmacy Benefit Managers and Insurers, which appear to me to be rather incestuous in some cases. This audit must be undertaken in public, in real time, either via streaming video, webcam, or on CSpan so that the public will have the opportunity to follow and participate.
  • Give immediate education financing incentives to qualified pre-med and medical students to enter the field of general medicine rather than specializing.
  • Streamline and consolidate medical records. Electronically, of course.
  • As a stopgap measure, open enrollment in the Federal government plans to private citizens at the same rates (as candidate Obama promised) so that laid off, unemployed and self-employed individuals have the opportunity to buy health insurance at a cost that won’t bankrupt them and get coverage that will be meaningful when needed.

These are my first-blush ideas. We have 2 weeks until Barack Obama’s inauguration. I hope you’ll add your ideas, thoughts, suggestions and stories in the comments. As more voices rise, so will the best ideas rise, answering the urgency, the absolute need of NOW.

  • kflanagan

    “Now is the time, this is _our_ moment, we are the people we have been waiting for”

    Great minds must truly think alike ;') http://tinyurl.com/a78fmz

    I believe that we should all do as much as we can to prod, push, nudge, shove, cajole, berate, anything we can to get the incoming administration to pull no punches, do what the Clinton administration couldn't do. I believe that there is a window that is slightly more open that it has ever been.

  • http://www.drumsnwhistles.com/ Karoli

    Great minds *do* think alike. Loved your post, and agree completely. Despite everything companies have on their economic plates, finding a way to contain health care costs and shift employees' focus to wellness measures is the one that gets the most traction toward economic stimulus, in my opinion.

    Obama has been swept in with a Congressional majority. Now he needs to use it wisely and quickly.

  • http://www.preferredhospitals.com Gregg Masters

    Karoli….. completely agree with your simple yet on point audit/plan. My story is your story though seasoned somewhat from a different time-line. So been there done that…..What I find interesting is the elements that give rise to you/our strain remain the same but the stakes have risen considerably.

    What an opportunity we have! The time is now to actually address this tsunami of folk who currently or will shortly face similar options. As noted elsewhere, we have a primary care crisis in this country…..the needed assets are finding ways to exit the system that so many of us can not afford or may otherwise no longer access.

    On the cost efficiency side, let's take a close look at this entity we call “a hospital” and why it's so inherently not viable…..

    So lets face it….. the organized chaos known as a hospital, consists of an arms length relationships with a club of independent contractors aka “the medical staff”, opposed or supported, as the case may be, by a para-military organization aka “the nursing staff”; who in turn are occasionally supported or opposed by a union card/credentials aspiring army of allied or ancillary health care professionals from technologists to technicians ALL THEORETICALLY orchestrated in a patient care mission by an often “lay” general management structure that can't keep the lawns green, let alone assure value in the health care exchange relationship.

    A bit over-reaching? Perhaps, but lets look under the hood (as you suggest) both from a macro and micro perspective. Thanks for the thread!

  • http://www.preferredhospitals.com Gregg Masters

    Part deux…. of simple solutions for the Obama administration to consider, absent comprehensive, systemic reform (which one should not hold one's breath for):

    kinda simple, but here it goes……

    1. allow uninsured to join clubs (e.g., discount medical plans, not insured vehicles per se) to leverage the power of group purchasing into hospital and physician pricing concessions/methodologies, for this under-served and under-represented constituency, including the growing ranks of the under-insured or HDHP crowd.

    2. hospitals, physicians and other institutional and professional health care practitioners extend “most favored nations” terms to all club members, for material discounts proactively and contractually honored at the point of service.

    NOTE: There is no material relationship between a provider's cost basis and what's actually charged in health care, other than accounting journal entries. Why reference a charge basis for anything? Real provider compensation is based on fractional cents on the dollar. Why stick the anyone with the acute pain of retail medicine?

    3. participating “providers” as above, also agree to “member friendly terms”, meaning: (a) waiver of all upfront fees, deductibles, coinsurance, etc., with the (b) creation of member friendly and budget realistic automated time payment plans that are fully integrated with electronic funds transfer or auto-debit from member accounts.

    4. tie/credit contractual discounts to “community benefit” for tax exempt organizations. This will materially contribute to the legitimacy of their deductions.

    5. all others get to feel better knowing they are doing the right thing.

    There is more particularly with limited benefit, or so called wrap around plans that can create additional levels of coverage and/or reinsurance for catastrophic or out of area service needs.

  • WebPixie

    The Federal Employees Health Care Benefits plans have no exclusions or waiting periods for pre-existing conditions. The TOTAL cost for a family of any size is $1027.95/month, of which the employee pays $356.59. The family deductible is $250/year. Co-pays are $20/visit, and not counted toward the deductible. The deductible only applies to ER visits, experimental treatments, etc. Acupuncture is covered at 60% if done with an out-of-network provider or 80% if your acupuncturist doesn't mind filling out the government paperwork.

    That's one of the more expensive plans.

    Sounds a little better than $1300/month, maybe. I heard Obama propose it last year. I heard a Republican Senator from my state propose it maybe 10 years ago. Karoli, I believe you have more experience than most when it comes to understanding how insurance works. Maybe you can shed some light on why this type of insurance isn't available to the rest of us?

  • http://www.preferredhospitals.com Gregg Masters

    Karoli….. completely agree with your simple yet on point audit/plan. My story is your story though seasoned somewhat from a different time-line. So been there done that…..What I find interesting is the elements that give rise to you/our strain remain the same but the stakes have risen considerably.

    What an opportunity we have! The time is now to actually address this tsunami of folk who currently or will shortly face similar options. As noted elsewhere, we have a primary care crisis in this country…..the needed assets are finding ways to exit the system that so many of us can not afford or may otherwise no longer access.

    On the cost efficiency side, let's take a close look at this entity we call “a hospital” and why it's so inherently not viable…..

    So lets face it….. the organized chaos known as a hospital, consists of an arms length relationships with a club of independent contractors aka “the medical staff”, opposed or supported, as the case may be, by a para-military organization aka “the nursing staff”; who in turn are occasionally supported or opposed by a union card/credentials aspiring army of allied or ancillary health care professionals from technologists to technicians ALL THEORETICALLY orchestrated in a patient care mission by an often “lay” general management structure that can't keep the lawns green, let alone assure value in the health care exchange relationship.

    A bit over-reaching? Perhaps, but lets look under the hood (as you suggest) both from a macro and micro perspective. Thanks for the thread!

  • http://www.preferredhospitals.com Gregg Masters

    Part deux…. of simple solutions for the Obama administration to consider, absent comprehensive, systemic reform (which one should not hold one's breath for):

    kinda simple, but here it goes……

    1. allow uninsured to join clubs (e.g., discount medical plans, not insured vehicles per se) to leverage the power of group purchasing into hospital and physician pricing concessions/methodologies, for this under-served and under-represented constituency, including the growing ranks of the under-insured or HDHP crowd.

    2. hospitals, physicians and other institutional and professional health care practitioners extend “most favored nations” terms to all club members, for material discounts proactively and contractually honored at the point of service.

    NOTE: There is no material relationship between a provider's cost basis and what's actually charged in health care, other than accounting journal entries. Why reference a charge basis for anything? Real provider compensation is based on fractional cents on the dollar. Why stick the anyone with the acute pain of retail medicine?

    3. participating “providers” as above, also agree to “member friendly terms”, meaning: (a) waiver of all upfront fees, deductibles, coinsurance, etc., with the (b) creation of member friendly and budget realistic automated time payment plans that are fully integrated with electronic funds transfer or auto-debit from member accounts.

    4. tie/credit contractual discounts to “community benefit” for tax exempt organizations. This will materially contribute to the legitimacy of their deductions.

    5. all others get to feel better knowing they are doing the right thing.

    There is more particularly with limited benefit, or so called wrap around plans that can create additional levels of coverage and/or reinsurance for catastrophic or out of area service needs.

  • WebPixie

    The Federal Employees Health Care Benefits plans have no exclusions or waiting periods for pre-existing conditions. The TOTAL cost for a family of any size is $1027.95/month, of which the employee pays $356.59. The family deductible is $250/year. Co-pays are $20/visit, and not counted toward the deductible. The deductible only applies to ER visits, experimental treatments, etc. Acupuncture is covered at 60% if done with an out-of-network provider or 80% if your acupuncturist doesn't mind filling out the government paperwork.

    That's one of the more expensive plans.

    Sounds a little better than $1300/month, maybe. I heard Obama propose it last year. I heard a Republican Senator from my state propose it maybe 10 years ago. Karoli, I believe you have more experience than most when it comes to understanding how insurance works. Maybe you can shed some light on why this type of insurance isn't available to the rest of us?

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