I have waited a bit till the dust settled on the Supreme Court decision of last month to ask some questions of about healthcare, and more specifically Health Insurance. I waited because this is neither a political blog, nor a legal blog. I want to leave the political commentary and questions to others, and let the legal types parse the Constitutional questions.
My questions are more personal and directed to us who are consumers of health care, especially about Insurance and how we pay for healthcare than healthcare itself. It is also about the high costs of healthcare.
While we may all wish to blame others (HMOs, hospitals, doctors, government et al.) is it not also possible that we all share some of the blame for the “off the hook” costs of medical care and for the Insurance debacle we in?
I would like to state a few questions and ask your feedback because a lot of the Health Insurance landscape is puzzling to me.
1. Let’s start with the concept of insurance. Most of us have several kinds of insurance: Car insurance, homeowners insurance and medical insurance. And yet the word “insurance” with reference to healthcare has taken on a vastly different meaning than any other kind of insurance.
Insurance is normally used to cover catastrophic, or at least significant costs. When I need new tires, I do not call my car insurance company. When I need an oil change or a 30,ooo mile checkup I pay for these things out of pocket. Same with homeowners insurance. We do not ask or demand our insurer to pay for new light bulbs, or even more expensive things like a new roof or HVAC system. No, Insurance is for catastrophic losses.
So why, when it comes to medical “Insurance” do we demand that every little pill, every doctor’s visit, every medical device be almost wholly paid by “insurers?” How did this system evolve? Is it necessarily reasonable for us to expect third parties to pay for everything when it comes to healthcare?
2. You may say, “But Father, if money were a consideration, many might neglect their health.” And this may be true. Although many do that now. But this leads to my next question.
3. Are Medical prices artificially high because third parties pay the bills? On the patient side there is inelastic demand. We run to the doctor with almost no thought to the cost. But on the supplier side why should an x-ray cost $1,100? Why should a night in the hospital cost thousands? Why should a 15 minute office visit to the doctor or specialist be $90-180? I wonder if market forces had predominated all along, would prices would be this high?
4. When did prices start going out of range? I vaguely remember as a child in the early 1960s that my mother paid the doctor cash when we visited. Only later did insurance start picking up the tab. At one time a doctor visit was considered affordable. My Grandfather, who was a doctor, surely did have some patients who could not pay, and I know he still saw them, but most could afford a visit a few times a year.
5. What role does technology play in costs? I realize that in the old days there was far less expensive equipment either available or used. Technology is expensive to be sure, but in other areas where market forces predominate, technology is still affordable. Very sophisticated computers, TVs and electronic devices that start out expensive, become affordable to the average person quickly, when market forces kick in. Is medical technology really all that different? Has the lack of a natural market due to third party payers meant that things have remained overpriced?
6. Malpractice Insurance is surely a huge factor. Is there anything we can do to limit frivolous lawsuits or limit the damages that must be paid? Can we stop suing each other so much?
7. What part has insisting that employers and government (more third parties) cover healthcare insurance played in driving up costs? Would insurance be more affordable if we all had to personally write the check every month? Would insurance companies compete more for our business? Would they have more incentive to help keep costs low?
8. I am personally happy to see “urgent care centers” beginning to spring up. So many these days run to hospital emergency rooms for what is not really an emergency, it is just urgent. They are not bleeding out, having a heart attack, or trouble breathing. They are not unconscious. They just have a headache that won’t quit, or have turned their ankle and fear it may be broken, or have a severe cold. Perhaps their doctor is away or it is a weekend or holiday. Urgent care centers perhaps with a doctor and several trained nurses may be a less expensive alternative. Can we develop more creative solutions like this?
Please understand these are real questions I am asking, not rhetorical points.
At the moral level I do think it is important for all of us to ask if we have not personally contributed to the high cost and increasingly unmanageable nature of the healthcare system. We don’t care what it costs, we don’t even ask what it costs. Our demand for unlimited care seems itself to be unlimited. We are part of the forces that have driven costs up.
I realize that healthcare decisions can get complicated. How long should I wait before I see the doctor? Is my ankle just twisted or is it broken and do I risk permanent injury if I don’t attend to it? These are not always easy things to answer, and most of us err on the side of caution. Maybe we should. But is cost never to be a factor?
Our even recent ancestors suffered through things we barely tolerate for a minute. In the old days when you went to the doctor with bad knees he’d hand you a cane and say “No more tennis for you.” We on the other hand demand knee replacement surgery and that others pay for it. Perhaps that is OK, but are there no limits? What part have we played in driving up costs by insisting that everything has to be fixed with no share in the cost other than our premium? And when the premium or co-pay goes up, we nearly hit the roof and scoff at the high price of medical care.
I want to say that decent healthcare available for all is certainly a pillar of Catholic Social teaching. But are there no limits to be accepted? Is it never legitimate to try and reign in the costs? Are there any limits of what others owe me in terms of medical care or at least in what I expect them to pay?
And a final bevy of questions:
- – Why do people demand that contraceptives and things like Viagra be paid for by me or others.
- – And why is Viagra $15 a pill?
- – What is truly urgent care that must be extended, and what can wait and be diverted to non-emergency settings?
- – Is there anything that can be done to walk back the medical system from an entirely third-party payer system and reintroduce market forces such as competition to drive down the cost?
- – Is there anything that can be done to make ordinary medical care affordable again and keep insurance for the catastrophic and big stuff?
Again, I am interested in your thoughts. I am not writing this post as an expert of any sort. I am asking questions as I try to formulate a moral point of view on the need to provide healthcare coverage to all but also to recognize necessary and reasonable limits.
I am also trying to start a discussion around the idea that we may have ALL had a role to play in driving up costs, and thus may have a role to play in bringing those costs down.
This video illustrates how third-party payments relate to escalating costs: