I’m not here to debate whether Trump is the worst President in history. Almost certainly history will bear that out. And I’m not here to say Trump isn’t doing bigly harm to our health care every single day. He is. But the unfortunate reality is that “Obamacare” was a hopeless mess from the start. We talk about how reckless the Republicans were in writing the tax bill. Certainly Democrats used a more open, deliberate process in writing the ACA. But it is still terrible legislation — and terrible legislation that makes a wreck of 17% of the American economy.
I am simply not persuaded by an argument such as “OK the ACA is seriously flawed, but it is helping some people — and it is a whole lot better than doing nothing.”
Yes, it is better for some people. But we blew our generational chance on a solution that could only survive if there was a friendly administration willing to play a lot of bureaucratic games and keep throwing huge amounts of money at what is a fundamentally broken industry.
It is absolutely tragic, considering that almost all of us have either first- or second-hand experience with Medicare: a system that is very successful and competitive with our global peers. But in his “9-dimensional chess” wisdom, Obama decided that is was better to exclude any consideration of a public option or any restraint on a pharmaceutical industry that increasingly behaves like the worst racketeers in history.
Some StipulationsI will stipulate that the ACA is providing (at enormous cost) some life-saving services, and has saved thousands of lives — maybe hundreds of thousands by now. But it has done so by perpetuating a for-profit cost model that is easily double what any other nation pays for health care better than ours.
And I will stipulate that in some markets, the ACA exchanges may still be working more or less as envisioned by the Romneycare team that formed most of this legislation. But frankly, it just doesn’t help me if one of my friends in Fresno or Hoboken has access to a decent policy under the exchange.
The Realistic ResultsUnderstand the system is broken in major parts of the country. And the key point is that the system was designed to fail. It was failing before the Republicans had control of the government. Indeed, there is a good argument that this dumpster fire of a law was a primary reason — if not THE primary reason — that Trump was able to walk into the White House. This was not just lousy legislation. it was brain-dead politics, and it has robbed us of a chance to have globally competitive health care for another generation or more.
Some ParticularsI am fortunate. So far, this dumpster fire has “only” cost me $35,000 or so. I have had the good fortune of no serious health issues. I take care of myself and live a healthy lifestyle, but it still is a matter of luck, and I know that luck can change at any time. My purpose for writing is to bring a dose of reality to those who just cannot understand why so many people have been angry about this legislation. And I won’t hide any agendas here. Enough of this BS for-profit stuff. Health care is too important to sell it to the highest bidder in a profit-driven market. We must insist that every Democrat stand up and demand that America solve these problems.
Drug costsAbsolutely nothing happened in the ACA to deal with this. Obama basically made a deal with Big Pharma that he wouldn’t put a glove on them if they would stay out of the debate. In other words, the American citizen was sold out — again. I am fortunate that I don’t have many medications. But I have daily medicines for lipids and those run over $100/month — well over twice the cost of the same compounds in Canada. And I must use eye drops that cost over $1.00 per drop. Yes, I can afford $4.00 per day, but that is $1500 per year and 4 times what they cost in Canada. And so on.
Trading one pile of junk for anotherWe all talked about “junk policies” as if the ACA was going to end that. The ACA did (in theory) eliminate the abuses of pre-existing conditions and lifetime caps. But the reality is that the legislation is complicated and full of loopholes the for-profit insurance companies are able and eager to exploit. I will give two examples, and I am certain there are many more where these came from.
The Obama administration crowed about all the preventive coverage that was mandated by the ACA. Bah-low-ney !!! It took the for-profit insurance companies almost no time to figure out how to get around that. You see, the “gotcha” comes down to one word: “screening”. There are a few — and I mean a very small number of very specific items — that actually must be covered by the ACA policies. For example, I had an annual physical. The physician fees must be covered. But the Doc ordered a battery of blood tests that he felt were appropriate for a person of my age (early 60s). The tests were $500, and a reasonable person would consider all of them “screening tests”. I had never had any diagnoses in any area that would have been indicated by those tests. The Doc just felt it was medically appropriate, and I am glad he did. Again, I reiterate I am very fortunate that they did not reveal anything of concern. But that is why we do screenings regularly.
However, according to this dumpster fire of a law, the insurance companies are able to deny payment for everything except a cholesterol test. And the cholesterol is part of a $120 lipid panel that was always covered by my pre-ACA insurance. Under the ACA, these companies don’t have to cover the entire lipid panel — only the $35 part that is specifically identified as HDL-LDL levels. Diabetes screening? Sorry it was not included in the law.
Likewise, these companies play the same games on colonoscopy procedures. If the Doc can find a polyp or hemorrhoid, no matter how small or benign, it is no longer a “screening test.” I think the Docs get reimbursed at a higher rate if they can get the charges upgraded, so there are perverse incentives. When my father has the procedure under Medicare, he pays nothing. When I have it, it is $3000 or more. And part of that comes from other loopholes, such as being able to separate out the anesthesia from the screening. And lately the favorite trick is to rent expensive operating suites by the hour because the “facility costs” can be excluded, even in a screening test. In my area, these “separate facilities” are typically owned by LLCs made up of the same Docs who send the business to these facilities. Talk about gaming the system. They look upon the colonoscopy as a loss leader.
This just plain sucks. If a car dealer plays games like this, I can walk out of the dealership and not buy the car. We simply don’t have those same options in HC. We never get the real picture until after the procedure is done. The system is set up this way deliberately. That’s how it got to be 17% of the economy.
Nothing but Junk Companies on the ExchangeMy first year on the ACA, there were at least two companies I had heard of before (Anthem and UHC). I didn’t like paying the high prices (I don’t qualify for any subsidy — did I mention I know I am fortunate?) but at least these companies aren’t completely fly-by-night operators. For 2017, there were only 2 companies on the exchange in my area and both are generic no-mane companies cobbled together evidently to scam the system.
I mentioned the blood tests above. My company denied all payment for these tests on the basis that it was out of network. It was not out of network. I explicitly checked this before signing up — which is another of the great flaws of this legislation. It is virtually impossible for the average person to perform due diligence because you simply have no idea in advance what corporate entity will be charging for some of your services.
It took me 8 months of weekly calls to get the insurance company to acknowledge their error and actually process the bill properly. And they only did that after I filed a formal complaint with the state insurance commission. In the end, they only covered $35 of the $500, and evidently they are on solid ground under the ACA (see above.)
I know many people have much bigger problems than me, and I will not go bankrupt paying $17,000 a year in premiums for two people who end up getting a total of $400 benefit a year on average. But this is part of why people are so angry.
The people left outMuch has been said and written about the working poor who were cut out of the system. They made too much money to quality for Medicaid, but not enough to get any help from the ACA. That is horrible. But I want to point out there are millions of people in my situation that planned for a retirement a few years early. We aren’t ultra wealthy. We planned to maintain a frugal lifestyle. Many of us are in the position that our financial plans depended on the orderly conversion of 401K money during these years before social Security and Medicare. When you convert 401K money, it looks like you have a whole lot of income when you actually have no income at all. But that puts me in the range where I get no subsidies.
This is just lousy policy. My insurance costs have gone up thousands of dollars each year under ACA. Why am I personally paying twice as much as it costs to provide health care for a citizen of France or Cuba, or three times what it costs to have health care for a Japanese citizen? We didn’t solve anything, and we should stop talking as if we did.
I will end this rant with what is the scariest part of the story to me. For 2018, the scam company I described above has left he exchange. There are two new companies on the exchange, but they are once again, complete no-name companies. And the premiums would be another $3000 higher for 2 people. If it were Anthem or UHC, I would have paid the money. But I will be damned if I am going to pay that kind of money to companies that cannot be trusted to operate with even the slightest but of responsibility.
So I bought a non-ACA policy from a company that offers a faith-based exception. Of course, that exception is no longer needed after the GOP eliminated the mandate. But because the mandate was in effect throughout the open enrollment period, there were no “real insurance companies” offering policies off the exchange. My selected company does not cover any pre-existing conditions. I can manage that because my conditions are not overly expensive. The big problem is that this company refuses to take any responsibility for any new diagnosis of cancer during the first 12 months the policy is in force. So I had to buy a special cancer policy (that has a $120,000 limit) to help with costs if I were to get a diagnosis. If I do develop cancer this year, I can only hope that: a) it doesn’t cost a million bucks of treatments this year, and b) the GOP hasn’t succeeded in finishing off the ACA by 2019 because I can’t go on Medicate until 2020.
The Bottom LineIf anybody is still here at the end of this chronicle, I can only thank you for listening. I hope some of this has been an insight for people who may not really understand just how fouled up our system is. Honestly, I did not mean for this to be about me. I am way more fortunate than most and I think I will be OK. I just felt the need to provide information about which I had personal knowledge.
Bottom line. Our HC system is a mess and I am convinced we lost more than we gained in the process of getting the ACA. I believe we need to stop defending the ACA (should have stopped that a long time ago) and need to put our entire energy toward solutions that will actually solve some of the problems. That will be both good policy and good politics.
