By Robert Needlman, M.D.
The (Cleveland) Plain Dealer, March 8, 2017
I am proud to be a pediatrician at MetroHealth Medical Center. I think a lot about health and health care. I’m an educated person, with undergraduate and medical degrees from Yale. And yet I can’t really get a grasp on how health care financing in this country works! I read articles, get confused, scratch my head, drink more coffee.
Then I fall back on my personal experience:
Under the Affordable Care Act (Obamacare), my 27-year-old daughter was able to stay on our family’s health plan until age 26, just in time for her to get her first full-time job with benefits (hurrah!).
But a close friend, who is self-employed, hasn’t been able to find an insurance plan under the ACA that is anything other than, well, outrageous, with sky-high premiums and deductibles to match.
So I get that something has to change.
But I just can’t figure out how the changes being talked about could possibly lower prices without cutting people off. And by “people,” I mean people I care about and take care of every day.
The new Republican proposals to give tax credits based on family income sound OK to me, but only if the credits are large enough to actually allow people to purchase decent health insurance. With proposed credits of only about $2,000 per year for a person under age 30, they aren’t.
Replacing existing subsidies with tax credits does save the government money, but only if the credits are less than the subsidies. Getting even less help with insurance bills isn’t going to make it any easier for my friends or my patients to get health care.
Under the new proposal, people who benefited from Medicaid expansion would continue to have good insurance coverage, but only until 2020. After that, who knows? When you’re my age, three years goes by really fast!
On the plus side, it sounds like the new proposals would keep the ACA protection for people with pre-existing conditions. That’s great. But I haven’t heard where the money would come from.
By taking away the requirement that everyone get insurance (the “individual mandate”), the new proposals would reduce the number of healthy people who purchase insurance. But the premiums paid by healthy people provide the money for the medical care used by sick people. Take away the healthy people, and the money goes away too.
The government could try to solve this problem by making people with pre-existing conditions get their care from a high-risk pool. But the money for the high-risk pool would still have to come from somewhere; and if the pool were capped, that would mean that some people with cancer or diabetes, say, might not get the care they need.
And the process for deciding who qualifies as high-risk is murky. Would “high risk” mean my patients whose chronic asthma lands them in the emergency room now and then? Or my patients with ADHD who take expensive medicine? Or the parents who have Lupus, or chronic depression, or colon cancer? Who makes these decisions?
So, with all my degrees, I’m left scratching my head.
But one thing is clear: We spend an enormous amount of money in the United States paying insurance companies to run a health insurance system which is too complicated for us mortals to understand!
In July 2016, for example, just one company (UnitedHealth) reported quarterly revenues of $46.5 billion. (You can look it up yourself; just google “health insurance company profits.”)
In countries like Canada and the United Kingdom, where there is universal health care, big insurance companies play a much smaller role, and take a much smaller cut. Everyone gets a baseline level of health insurance, and people who can afford more can buy it if they want it. Single-payer plans like Canada’s get criticized for being “socialized medicine.” But that’s just name-calling. What these plans are is reasonable, fair, and understandable. Even by someone like me.
Dr. Robert Needlman practices and teaches developmental and behavioral pediatrics at MetroHealth Medical Center and is a professor of pediatrics at Case Western Reserve University. He is the co-founder of Reach Out and Read and the author of “Dr. Spock’s Baby Basics,” and co-author of “Dr. Spock’s Baby and Child Care.” The views expressed in this op-ed are solely his own, not those of the institutions with which he is affiliated.