Michael Battalio


Saturday, November 25, 2017

Thoughts on AHCA

Since I’m on a friend-losing tear lately, I’ll go one last time to try my best to logically convince people of my position on healthcare. Because health insurance/care matters to me more than funding for science (i.e., funding for myself), education, energy, climate change, income inequality, or money in politics, I am willing to take a strong public stand (and lose friendships) on this issue. At least read to the end, and if I haven’t convinced you here, I never will; then you can unfriend/unfollow me if you wish. This will be the last time I address healthcare until the Senate does something (so that may be a year from now [or never]). Please leave questions, it will help me refine my position and yours too, hopefully.
As long as lots of sick people around you are neither dying nor going bankrupt, healthy people are subsidizing their healthcare in some way. Capitalistic insurance companies would never willingly lose money insuring sick people. The way insurance companies make money insuring sick people is to make the healthy people pay, which is definitionally how all insurance works. You buy it just in case. (E.g., you buy homeowner’s insurance in case your house catches on fire. You probably won’t need it, but if you do, the people who could have risked not having it because their houses are fine are the ones providing the money to reimburse you. Health insurance works exactly the same; except, unlike car/house insurance, you know with certainty that you will need health insurance eventually.) Participating in this system is beneficial not only to the sick but the healthy too, because the healthy never know when they will become unhealthy.
Under the personal mandate via the ACA (Patient Protection and Affordable Care Act [Obamacare]), the health insurance that healthy people buy allows insurance companies to remain profitable even if they lose money on sick people. They have to insure the sick at the same rates as the healthy, so they adjust rates for everyone so they remain profitable. The reason the AHCA (American Health Care Act, which was approved by the House 217-213 last Thursday) is awful is because companies are no longer required to insure sick people (definition of sick people: one with any sort of pre-existing condition that could affect future health) at the healthy person rate. A lot of advocates of the AHCA will try to catch to catch you in a technicality here; don’t let them. They might say that as long as you don’t lapse in coverage, pre-existing conditions don’t matter. Here’s the catch though: in the AHCA, there are waivers for states to allow them to ignore this mandate and change what must be covered in all plans. House Republicans suggest that this will prevent pre-existing conditions from mattering, but they actually have no idea what states will do because they aren’t the governors running the states. They are trying to sell you their ignorance in place of their honesty. Additionally, what if you have insurance but find that you have some new condition and your current insurance is insufficient to cover it? Well, you would need new insurance, but you don’t get additional subsidies from the government to cover that increased coverage. The insidiousness of the AHCA compared to the ACA is that regardless of whether you are sick or healthy, you get a certain amount of subsidy for your insurance based on only age if you make less than $75,000. If you have a chronic, debilitating disease, you get as much to pay for insurance as a perfectly healthy person at your same age. There is no slow, controlled increase in cost as your coverage increases as in the ACA. Under the AHCA, you get a lump sum, no more no less. *So while you may have access to insurance, you may not have the ability to pay for it.*
If insurance companies don’t have to insure a money-losing patient on the open market, they won’t, because they have a fiduciary responsibility to their shareholders to make as much money as they can (yay, capitalism). Under the AHCA, the sickest are pooled together on a state-by-state basis, and the government–minimally–subsidizes their insurance. In these high-risk pools, the government has to provide enough money to convince insurers that providing coverage is worth it. (You may ask, that sounds a lot like the insurance payments that the president was holding hostage in the budget debate last week. What a coincidence. They are essentially the same. The only difference is Republicans are willing to put up a lot [a whole lot] less money.) In the AHCA, there is only a set amount of money available for this high-risk pool, so logically, only a set number can be provided coverage. The people who don’t get into the pool are out of luck because a company isn’t going to insure someone if they aren’t paid. They have to buy insurance on the paltry subsidy described above. Even if you do get in the pool, states will have the option of setting a cap that limits the costs the pool can pay out for one person. Example, the high-risk pool that was set up in Wisconsin before the ACA ended the practice had a lifetime payout cap of $2 million. That seems like a lot, but if you have a chronic illness, you can blow through that in a decade or less. If the government doesn’t provide enough money, the sick won’t get healthcare because, again, a company isn’t going to lose money when they don’t have to. Advocates of the AHCA maintain that access to coverage will not be threatened. This is not technically a lie but only because of word play. Note that advocates only say access will not be curtailed but never say anything of the ability of people to purchase that access. I have the access to buy a 40’ yacht whenever I want to, but I do not have the ability. Similarly, everyone may technically have access to health insurance, but if you are a chronically ill person, you may only have the ability to pay for healthcare under the AHCA if you are wealthy. This disgusting conflation of access and ability provides the AHCA a deceptive rhetorical cover and nothing else.
Now, this might cause some of you to think (if your heart is made of stone), well at least sick people won’t be sucking up my hard-earned tax payments to the government. Not so fast. The approximately $1 Trillion (yes, trillion) being taken away from healthcare isn’t going back to you, regular citizen. It is being given to the rich as an enormous tax cut. So, not only in this plan are you stoically taking away money from sick people, you aren’t even getting any of it. The rich are. Logically, there is no way any of you–my friends/followers–are going to significantly benefit from this bill because I don’t know anyone who is making a few million a year (Also, statistically, none of you are ever going to be rich enough at some future point to enjoy these lower taxes.). (Admittedly, if you are in the bottom quintile, you’ll be netting about $100/year, but the top 1% will be netting about $40,000/year. The top 0.1% get >$200,000/year.) Make no mistake; the AHCA is not a healthcare bill. It is a tax bill. This is why it can go through the Senate on reconciliation only. (Interestingly, the repeal of the House provision exempting lawmakers from the AHCA must pass via 60 votes because it is not budgetary – just feckless. So, the Democrats have to save the Republicans from their own political stupidity.) 
If you are healthy, you don’t have to purchase insurance under the new bill, so that could save you money. However, that would mean we, the insured, are paying for you. Let me explain. If you forgo personal insurance, you are betting that you won't have an accident or get sick. You do so because you know that hospitals can't deny you service without insurance, so you take the gamble. Here's the thing; if you do have an accident, the hospitals must treat you, so they charge the rest of us who can pay (i.e. the insured) more. Waiting until you get sick to get insurance is screwing over the rest of us. Now you may argue that if you’ve never been to receive care, you aren’t guilty of this. However, whether you have been to the hospital or gotten care is irrelevant for whether others have paid for your insurance. Others may not have paid for your healthcare, but technically, neither have you then. This is conflating health insurance with healthcare. (That's understandable since most of our bloviating politicians do as well.) You are forgoing a formal health insurance policy by betting that you won't need care, but if you do get sick, you will still get care. *This by any definition is insurance.* You are indemnified against injury by an outside party (the hospital in this hypothetical case). You are guaranteed to get care regardless of your ability to personally pay. The hospital may try to make you pay, but as a private citizen you may never be able to afford it, so you will either be delinquent or go bankrupt. Either way, the hospital is still going to get that money from somewhere. It comes from the bills of the insured. The fact that someone hasn’t used that safety net and may never use it doesn't matter because that safety net is always implicitly there. They are covered in case something terrible happens, even if they don't have a personal health insurance plan. Everyone else is paying for the uninsured’s health indemnity whether or not they go to the hospital to ever actually receive health/care/. If a healthy person who can afford it does not get insurance, they are a leech on society and no better than those who perpetrate welfare fraud. This dichotomy of Republicans hating welfare but being okay with people not getting health insurance is incomprehensible to me.
Finally, Obamacare is not perfect. Premiums have risen for some. The lie that anyone could keep their doctor is why so many people hated the ACA for so long (that and some people hated anything with Obama’s name in it) (It does now have a positive approval rating among the public.). However, the AHCA does not move healthcare forward, it takes us back before Obamacare was enacted. We should not be asking for that. Before the ACA, the number of personal bankruptcies due to medical costs per year was over 1.5 million. It’s half that now. The way to make this go away altogether is single-payer (Medicare for all) insurance. It will reduce expenses because it cuts out an expensive middleman (health insurers). This system works everywhere else in the developed world. The care of these systems is superior to that of ours, and it also costs less. It costing less is easy to look up (I invite you do to so; you’ll be shocked at how much cheaper it is.). Some will try to argue via misplaced patriotism that because we are America our healthcare must be better even if it does cost more. This is also false. America is lagging in life expectancy over the last couple decades. Some of this is cultural, but much of it is due to our complicated, expensive, bureaucratic health system that has prioritized treatment over prevention. Infant mortality and death in childbirth are also up compared to the rest of the developed world. And on and on. Obamacare isn’t even enough (though it was better than before), and the roll-back under the AHCA will make the health care situation worse. That’s why I vehemently oppose the AHCA and the efforts of Republicans to move us backward. I have written and called my representative repeatedly (and will be calling my Senators), and I encourage everyone else to as well. Your representative will never directly respond to you, and you will just be a tally mark on some staffer’s notepad. However, they will at least know people care enough about the issue to act. That is very important. I hope this has persuaded you to do so.
Thanks for reading to the end.

No comments:

 
2003-2016 Michael Battalio (michael[at]battalio.com)