I was not planning to make another post this weekend, but my New York Times this morning includes an op-ed by a physician and medical school professor named Marc K. Siegel. [Don't miss the post on Trump and Andrew Jackson, below.] Dr. Siegel ran into an ambush when his thoughts reached my eyes, because he said something in simple, clear language, which had already occurred to me as the dirty secret of the Republican health care bill in general and the issue of "pre-existing conditions." This is what he said.
"In addition to limiting the menu of essential benefits, the House bill
would let states create high-risk pools for patients with pre-existing
conditions who had let their insurance coverage lapse, and who could
then be charged premiums more in keeping with their health care needs.
This is the only way to make insurance affordable for most consumers;
pre-existing conditions will continue to drive up premiums if everyone
is compelled to pay the same price."
Now my idea of health insurance is that we all pay into it because we will all become sick from time to time, and we may become very seriously ill. Many of us will never need extremely expensive treatments, but many will, and we can't tell who they will be. Thus our investment is very bit as reasonable as our investment in fire insurance. But Dr. Siegel has a very different view.
What, in fewer syllabus, as a "patient with a pre-existing condition?" Answer: a sick patient, one who needs treatment right now, and may need it for a long time. Alternatively, it may be someone whose medical history substantially increases the likelihood that they will get sick and need treatment in the future. And I had realized as I read a news story about the House bill last week that this was the key to debate. The insurance industry, bless their hearts, loves insuring healthy people but hates insuring sick people. Like just about every other corporation in America they are focused on their bottom line, which healthy people improve and sick people make worse. Somewhere in the course of his medical career Dr. Siegel seems to have forgotten the point of health insurance: to pay for treatment when people need it. He doesn't think that healthy people's premiums ought to be high enough to pay for treatment for people who are actually sick. [Incidentally, Dr. Siegel, if this post comes to your attention and you want to reply to it here, you can have all the space you want.)
I have heard other stories over the years about the insurance industry's point of view. A dear friend of mine who co-owned a thriving small business got cancer many years ago, and needed an expensive procedure. The procedure was an unqualified success in the short and medium run, and he survived for 8 years of happy and productive life as a result. But no sooner had he initially gotten well, than the insurance company that provided a group plan for his business (of a couple of dozen employees) hit the company with a tremendous increase in its premium. Now that he had turned out actually to need the insurance, they wanted him and the company, in effect, to pay the claim. Fortunately he was able to get insurance through his spouse instead, which solved the company's problem.
Now, of course, if people waited, as many do, to seek insurance until they are already sick, that's a problem about which insurers have the right to complain. One solution is a mandate requiring them to buy it, which Obamacare includes but the new Republican bill does not. A second solution which the Obama administration did not try to adopt is the Medicare solution in which payroll taxes (or conceivably other taxes) fund the health care system. But the idea of "high risk pools," even if they work--which they generally have failed to do--is in my opinion a travesty that ignores the whole point of health insurance, by separating those who really need it from the rest of us.
It is quite possible that the Obamacare premium increases over the last couple of years reflected the need to include sick people, as well as the end of some payments to make such coverage more affordable that apparently ended after 2014. And it is certain that health insurance is too expensive because of problems inherent in American medicine that Dr. Siegel also mentions, such as the cost of new devices. (He does not mention overdiagnosis and overtreatment, or the enormous amounts spent on end-of-life care.) Attacking those problems should have come next on our list. But the fantasy that we can solve the health insurance problem by taking sick people out of the normal health care system needs to be abandoned. It is unworthy of a civilized society.