Utopia 20: The Hospital

The commitment I seek is not to outworn  views but to old values that will never wear out. Programs may sometimes  become obsolete, but the ideal of fairness always endures.  Circumstances may change, but the work of compassion must continue.

What we have in the United States is not so  much a health-care system as a disease-care system.

The more our feelings diverge, the more  deeply felt they are, the greater is our obligation to grant the  sincerity and essential decency of our fellow citizens on the other  side.–Sen Ted Kennedy

Utopia 20:  The Hospital

Jack  walked up to a console in the lobby. He touched the screen and entered  the letters of Andy’s name. The console showed him a room number and  then showed him an animated progression of the walk to Andy’s room.

Jack watched the animation twice to be sure he had it memorized and  would not need to consult a consoles further along.  Then he set out to  find Andy. He had no problem reaching the room but paused at the doorway  for a moment.  He had no idea what condition Andy would be in.  He  heard nothing at the door so he cautiously pushed the door open.

“Educant  Randall, you made it!” Jack jumped at the slightly squeaky male voice  with a prominent lisp welcomed him to the room.   Andy was actually  speaking to him, and in a rapid, excited tone.  “Come over and check out  my stitches.”  He continued with an element of pride.

Jack  could not help himself, he chuckled with relief. Andy was all boy.

Jack walked to Andy’s bedside and examined his leg.  His relief was  short lived.  Andy’s wound reached from just above the knee to the ankle  and the skin of his leg still had a sickly purple, puffy appearance.  Still he smiled at Andy, who seemed like his ordinary self.  “How you  feeling sport?” he signed as he sat on the edge of the bed.

Andy smiled, “I feel fine.” he squeaked.

Jack gave Andy a  serious expression.  “Have you texted your parents?”

“Will  emailed them when we got here.  They are on their way.  They should  arrive in the morning.  I got to email them while they were on the train  about an hour ago.”

“The doctor says he can go in a few days.”  Will added.  Jack had not noticed Will when he had entered the room.   Jack turned to look in his direction now.  He was sitting on a couch  along the side of the room looking very relaxed.

Jack thanked  Will for staying with Andy throughout the process and he insisted that  Will get something to eat in the cafeteria.  Jack sat with Andy while  Will took a well earned break.  Jack made himself comfortable on the  couch and sat as Andy chatted with him for a while and then fell asleep  shortly before Will’s return.  Then he asked Will about their time  apart.  

Will told Jack the hospital staff had been rather  upset that no other adult had come with Andy.  They had immediately  assigned a Hospital Liaison to the case who told Will that the doctors  needed the permission of his parents to do surgery immediately.  That  they needed to clean the wound made in the Desert.  With Will’s help the  Liaison had located Andy’s parents and the Liaison had helped Will to  tell them what had happened.  Jack winced at this.  He had known Andy’s  parents first.  Before he had even been assigned the rest of his  students.  He had let them down. He had failed to keep their son safe.   He could only imagine what a call from a hospital Liaison about your  son must be like.  Jack should have been the one to make that call.

There  had been a brief video conference with the doctor and Andy was whisked  off to surgery.

The Liaison had taken Will first to  breakfast and then to the room Andy would have when he was out of  surgery.  There he had called his own parents and spoken with them.   Again Jack felt the hollow feeling in the pit of his stomach.  

The  Liaison had suggested a game of chess while they waited and Will  suspected that the Liaison had let Will defeat him.  Andy had come out  of surgery and there was another call to Andy’s parents.  Then the  Liaison offered another game of chess but Will had sent him away saying  he needed some time to rest.  The Liaison had brought blankets and  pillows and shown Will how to make the couch into a bed but Will had  just wanted to be alone.  The Liaison had shown Will how to reach him  through the hospital computer and then he had left.

Andy  had awaken shortly afternoon and had stopped being groggy about dinner  time.  Will was about to set up the chess board again for Andy when Jack  had entered the room.

“You did well, Will.  Thank you.”   Jack looked at the young man with true appreciation.  Instead of Andy or  the liaison, Jack played the next game of chess with Will.  His heart  was not really in the game and Will beat him even though Jack had not  deliberately thrown the game.  Then they had watched some historic  documentary on TV while Will curled up on the couch.  The Liaison had  come to check on Will but found him with Jack.  The Liaison offered his  services to Jack but Jack declined any assistance and he soon left  again.

Jack sat on a comfortable high back chair and  watched a second documentary without hearing a word of it…

Dim  light was streaming in the window when someone shook him awake.  Jack  gazed up and recognition hit him.

“Mr. Clay!”  Jack  managed as he propped himself up in the chair.

“Educant.”   Ted Clay greeted Jack.  His voice was distant and Jack interpreted this  as worry about his son.

Andy’s mother was sitting on the  bed with a protective arm around her son.  She was hugging him and  kissing his forehead.  Tears were streaming down her face and Andy was  signing furiously trying to reassure her while rolling his eyes at the  scene she was making.

“Glad to see you made it here.”   Jack said and extended his hand.

Ted Clay looked down at  Jack’s hand and scowled.  Then he turned back to his wife and son.

Jack’s  arm hung in mid air a moment longer and then Will began to stir on the  couch.  Jack dropped his hand and let his eyelids slide closed for a  moment.  Then Jack just stood gazing at Andy and his mother.  He had  wanted to do exactly what she was doing several hours ago.  How was it  that women could be so free with their emotional lives?

Will  awoke and immediately stood.  “Hey, Mr. Clay, Mrs. Clay!”  

Andy,  who had only being making half hearted attempts to get his mother to  stop fawning over him, became more insistent with his best friend  watching.  Will seemed to take no notice at all.

“The  doctors said he is doing really great.  They think he can go home in a  couple of days.”  Will began, “When we get back to class…”

“He  won’t be going back to class.”  Ted interrupted through tight lips.

“But  there’s 2 more months of school left.  He’ll surely be well before  graduation.”  Will reassured them.

“We will provide  for his education.”  Ted said sternly.  Andy read his lips and looked on  with a shocked expression.

“But he’ll need…”  Will began.

“He won’t need a teacher!”

Silence  fell over the room.  Jack’s head snapped up to see Ted Clay glaring  directly at him.  Their eyes locked and Jack’s back stiffened.  He had  never been called a “teacher” to his face before.  Jack said nothing but  he refused to look away from Ted’s angry stare.  

Will  looked on wide eyed and even Mrs. Clay looked away from her son to her  husband.  Andy, who had not been able to see his father’s lips was  furiously trying to catch someone’s attention to find out what had  happened.  

Will recovered first, “Educant  Randell is not a teacher.” Out of habit he signed this as he  spoke, allowing Andy to catch up.  “He has always encouraged us to go  our own way, to think our own thoughts.  He’s never once even given us a  spelling list to memorize!”

“Will, please.”  Will looked  ready to continue the argument but Jack held up his hand.

Andy  was now signing furiously a similar protest but Jack took a step  forward and rested his hand on Andy’s good ankle to get his attention  and then shook his head.

“I’m sorry you and Kate feel that  way, Ted.  Andy is a good student and he shouldn‘t  be punished for something I did.  The other members of the class will  miss him and his insights.  Won’t you consider letting him complete the  year with his classmates?”

“You’re right.  He is bright.   He can complete the year at home.”  Ted’s voice was resolute.

Andy  was unable to find his words.  He was now furiously signing his  objections to this plan.  Will also began to object but Jack grabbed his  shoulder.  Now was not the time to have a rational conversation with  Andy’s father.  In truth, Jack could not even be angry with Ted.  Jack  could not think of how he would have responded if he were in Ted’s shoes  right now.

“It is of course your decision to make.”  Jack  said and then he turned to Andy, “I will miss your son deeply as I know  all of the class will.”

Andy stopped signing and looked  crestfallen.

The Concepts behind the Fiction:

1.   Hurrah for Health Care?

Well I admit that I am  surprised any health care bill at all got passed into law.  Only because  Americans did not forget that this was one of the key campaign points  did anything at all get passed.  It is a far cry from what Obama said he  wanted when he was campaigning, however.  And it is a big wet sloppy  kiss to the health insurance industry and big pharma.  So, for  those of you not sick to death of hearing about health care, here is the  good, the bad and the ugly of it.

2.  The  Good

*It reins in some of insurance companies most  egregious acts.  They can not cap how much they will pay over your  lifetime if you get sick with a chronic illness or a very expensive  acute illness.  They are prohibited from “rescission”, where insurance  companies review and nullify benefits after you make a claim based on  some irrelevant thing you did not tell them years ago, while keeping all  the money you gave them over those years.  If you pay the premium, they  must pay for the illness when it occurs.

*Insurance  companies are restricted from considering preexisting conditions before  they give you insurance.  Unfortunately this does not occur for the next  6 months for children and until 2014 for adults.

*Small  business owners will get a tax break immediately for providing  insurance to employees.  They will also be able to take advantage of  their own health insurance exchange in 2014.

*It increases spending on low income  community clinics.  Thank you Bernie Sanders, you old socialist  you.  No really, he ran and was elected as a socialist.

*Dental  health gets recognized as an integral part of health care in 2014 and  gets coverage.  No more  pulling your own teeth with pliers.  Children get more coverage  immediately.  Mental health and addiction therapy also get recognized as  real health care.

*It sets aside $500 million in seed  money to create a new government organization, “Patient-Centered  Outcomes Research Institute.”  This institution is supposed to compile  data on the best way to treat diseases.  The data can not be used to  deny coverage, however.  Normally I would be all for this, but history  tells us some interesting lessons about such care.  For example, all  care was based on studies of white men until the 80’s.  Then it was  discovered that the treatments that worked in white men often failed in  black men or women.  Even when the disease was not related to sex or  race, like high blood pressure or diabetes.  So some research can be  misleading for certain groups of people.  The more exclusive the group  the more likely this is to happen.  Also we know that drug companies are  able to design studies for drugs that make them appear effective even  when they are only minimally so.  Or they design a study to minimize the  ill effects of drugs.  These studies are compiled by the FDA but the  FDA has been fooled by these studies for years and drugs like Vioxx  and Phen-Fen  were allowed on the market because of this sort of lying with  statistics.

*Medicaid  will expand to cover people below 133% of the federal poverty level  (Around $14,000 annually for a single person and $29,327 for a family of  four.)  Never mind that it is much more expensive to live in some parts  of the country than in others and that the poverty line only takes into account the cost  of food and not housing.

*There is help for those  who make up to 4 times the poverty level in this country.  Buying health  insurance is a new expense for some people, and I fear that some of  them can not afford insurance.  The poverty level is calculated on food  alone and does not take into consideration housing or other costs.  Some  people barely make ends meet now adding this cost will force them to  break the law.  Unlike car insurance, which you must have if you drive,  there is no way out of this cost.  Theoretically if you can not afford  car insurance, you could not drive and take public transit or a bike  instead.

*It will allow nonprofit insurance co-ops  in 2012.  Remember though that this is how Blue Cross started, and look  where that ended up.  Currently states are restricted from participating  form this type of insurance by laws lobbied in by health insurance  companies.  Dennis Kucinich and  Bernie Sanders tried to undo these laws but failed.  California has  passed a law to create a state wide public option twice.  It was vetoed  by the Govenator,  twice.  There was some legislation on the internet  that has now been taken down about County public options.  If you are  interested in that contact me and I will put you in touch with the right  people.

*Would reduce the deficit…maybe.  So many  things could interfere with this I hesitate to even include it here and I  refuse to give you a number because that could change on a moment’s  notice.

*It funds SCHIP thru 2016.   This is the program that provides preventative health services to low  income children throughout the nation and I have absolutely nothing bad  or even catty to say about that.

If you are a  kid in college or just getting started, then you can stay on Mom and  Dad’s health insurance until age 26.

Strips banks of  the ability to originate student loans  in favor of a system of direct government lending.  Has nothing to do  with health care but happens to be the best part of the bill.  It helps  to prevent the start of life as a debt slave.

         

3.  The Bad

*As promised, if  you like your health care coverage, you get to keep it. Unfortunately,  if you don’t like your health care insurance, you also get to keep it.   In fact, it will be breaking the law to go without health care in  America after 2014.  The fine for doing so is $695.

*If  your employer didn‘t have health insurance  before, and you were having difficulty finding private insurance, there  will be exchanges of insurance set up for you to shop for insurance you  can afford.  It is estimated that 32 million people who were doing  without health care will now get some.  Of course this means all of  these people will now be paying homage to the God of Health Insurance.   Still this means that the number of uninsured will drop from 19% to 8%  by 2016 and there will still be 23 million uninsured by 2019!  We will  remain the only industrialized nation to fail to insure all of our  citizens.

*It pays for itself with some new  taxes.

• For one thing the insurance  itself is taxed.  The value of the insurance itself will be reported on  your W-2 if your employer has insurance for you.  That’s right you will  be taxed on something you paid for that is barely worth anything if you  really do get sick.
• Medicare Payroll tax on investment income  — Starting in 2012, the Medicare Payroll Tax will be expanded to  include unearned income. That will be a 3.8 percent tax on investment  income for families making more than $250,000 per year ($200,000 for  individuals).
• Excise Tax — Beginning in 2018, insurance  companies will pay a 40 percent excise tax on so-called “Cadillac”  high-end insurance plans worth over $27,500 for families ($10,200 for  individuals). Dental and vision plans are exempt and will not be counted  in the total cost of a family’s plan.
• Tanning Tax — 10 percent  excise tax on indoor tanning services.–   CBS
• Drug  manufacturers would pay the US a total of $16 billion between 2011 and  2019.
• Health insurers would pay $47 billion over the same  period.
• Medical device manufacturers would pay a 2.9 percent  excise tax on the sale of any of their wares, beginning Jan. 1, 2013.-Christian Science Monitor
  

Tanning  Tax?  Really?

*There is a tax credit to keep health care  affordable.  But it caps out at 2019.  That is it will cap out at 2019  if health care costs do not rise above standard of living cost increases  as they have done in the last 30 years.  In the wake of Anthem Blue  Cross raising its cost to consumers without explanation by 39% in a year  when their company saw record profit-well.

*HSA plans would  only be allowed $2500 a year of savings.  Not even enough to pay the  deductible on many plans.  Many people were using these plans for tax  deferred savings.  Apparently, even that small threat that a person  could become independent of health insurance if they were healthy  enough; long enough was too much of a threat.  So now the amount you can  contribute will be capped at $2500 after 2013.

*It  starts to close the Medicare prescription doughnut hole in 2011.  It  does not completely close the doughnut hole until 2020.  However it does  this by paying more to the drug companies.  There are still no  bargaining methods allowed with big pharma and  pharmaceutical companies continue to charge 30-50% more in the US than  abroad.  And the sky’s the limit for what they can charge!

4.   The Ugly

*About  87% of private insurance carriers currently offer paid abortion  coverage.  This bill complicates things by requiring all funds for  abortions to be separate from public funds.  A woman with insurance for  abortion will need to write two checks for the coverage.  Many insurance  carriers will stop funding abortions all together to avoid the  confusion of having two funds and possible fines.  Also states could  choose to opt out of abortion coverage by not allowing companies with  abortion services in their exchange.  This is in effect making abortion  so cumbersome that making it illegal is no longer necessary.

*It  prevents insurance companies from refusing to cover things like birth  control and pregnancy that are exclusive to women.  However, it allows  insurance companies to charge up to 50% more to women than to men.  They  can also choose to charge more to older patients.  This essentially  enshrines age and sex discrimination in our laws.  Imagine for a moment  if this law said that it was OK to charge a black man 50% more than a  white man and it did not cover sickle cell anemia, a disease that is  almost exclusively in people of African decent.  Even if there was some  logic to this (and statistically speaking there is) how do you feel  about this law then?  We have placed the cost of our health care on the  backs of women when women still earn less than men and the elderly who  earned less over a lifetime.

*It does nothing to  prevent insurance agencies, or for that matter to Medicare/Medicaid,  from reimbursing doctors who care for women or children at a lower rate  than those who care for the men exclusively or the population at large-a  long standing issue in this country.  The low reimbursements for women  and children centered medicine makes hospitals dump huge amounts of  money into cardiac cath labs while  virtually ignoring or even downgrading care in obstetrics or pediatric  units where the dollars actually result in much better outcomes instead  of marginally better outcomes.

*Well you  might not get to keep your insurance if you like it after all:

“Businesses are fined $2000 per FULL TIME  employee (FTE)  for not offering insurance. The first 30 employees are not counted in  the calculation, however, so the fine for not having insurance for a  company of 50 employees is $40,000, or about what they currently pay on 4  employees’ health insurance. In businesses that do not have to offer  insurance to remain competitive, this would be a major savings for the  business and force you into a public pool. If we take that business with  50 employees, it stacks up like this:

                      2009 with insurance          2014 if drops coverage     NET

EMPLOYER           $495,000                            $20,000               ($475,000)

The  average employee pays around $3500 for premiums in 2009. Under the new  plan, his premiums will cap at $4060, a $560 increase over current  payments. This may still be lower than what he would pay in 2014 if  costs continue to rise, but it also makes him a recipient of government  assistance (welfare for the middle class?). There is also a max for cost  sharing that is added on top of this. To get the credit, as a married  couple, you must file jointly.”  

“I also see employers, especially small  employers, having a great incentive to drop health care coverage and  allow the worker to pick up insurance elsewhere. Admittedly, without pre-existing  conditions, this will be much easier.”–Gregory

*Undocumented  workers continue to contribute to Medicare and other taxes but will not  be allowed to take advantage of health insurance.

*There  is no provision to help lower the cost of your health care.  In the  wake of Anthem Blue Cross raising its price a mere 39% to its California  customers without explanation in a year when it made record profits, I  find this hard to swallow.  Most of the cost savings are directed at  Medicare and Medicaid.  It cuts $500 Billion to Medicare payments in the  next 10 years.  In other words it is asking physicians and hospitals  who see elderly, disabled and low income patients to see them for less  money.  This is due to a formula called the Sustainable Growth Rate  which was adopted in 1977.  However, in 2001 the cost of health care  started to go up dramatically, not due to physician pay which was stable  but due to big pharma and the  insurance industry.  The formula indicated that physician reimbursement  should be cut dramatically.  Congress has overridden those cuts as doctors  opt out of Medicare but that only means that the reimbursement has been  stable for over 15 years while the price of seeing the patient has  increased.  It costs me a certain amount of money to rent an office and  pay for staff and supplies.  I can not tell the land lord or my staff  that they will not get more money from me for the next 10 years-their  cost of living is increasing too.  There is no such device restricting  what insurance companies or pharmaceutical companies make, so during the  last 15 years when physicians have made less and less, insurance and  big pharma  have made record profits.  For that reason, even if the drastic cuts to  physician salary had gone through; health care cost would have  continued to rise at the same rate.  The cuts are taking aim at the  wrong sector of health care.  When I left the job I recently left, it  was because the cost of doing medicine had outstripped the profits and  the group I worked for financially collapsed.  This is the second time I  have had that happen to me during my career.  When this happened the  group I was with did not take Medicare because the cost of seeing the  patient outstripped the reimbursement in that area.  Factoring in  inflation and the increasing cost of running a practice, the recent  Medicare cut is not 21.2 percent but a cumulative 83 percent over 2001  profits for physicians.  Texas Med  The group I joined is doing Medicare,  but in the wake of this bill it is now discussing dropping Medicare for  the same reason-it costs more to see the patient than it pays.  You can  see where this is going I am sure.  The question is whether these cuts  to Medicare will stay or be lobbied out of the bill in subsequent low  profile bills that get passed later.

*No public  option.  It is hard for me to get excited about this given that the  public option was so wimpy.  Less than 1% of Americans were going to be  able to take advantage of it.  Yet, even that wimpy public option could  not get through Congress and the thought that 1% of Americans might opt  for a government run vs a market driven health care system disturbed the  tea-baggers to  the the point of violence.  Still Rep Alan Grayson  has a bill that would allow people to buy into Medicare at cost.  (HR  4769 The Public Option Act)   Kind of a commercial version of Medicare.  The act already has 50  cosponsors.  You can encourage your representative to cosponsor the act here.

*Death threats  and threats of violence.  Really?  What in this bill could stir anyone’s  emotions to the point of violence?  At best this is a milk toast  reform.  Get a hold of yourself for God’s sake!

5.   Timeline for Health Care

If you are as confused  about the dates when things happen as I was you will probably find this  listing useful.

How the health  care bill shapes up

Here are effective  dates of major provisions of the health care bill:

Within  a year

• Would provide a $250  rebate this year to Medicare prescription drug beneficiaries whose  initial benefits run out.

Within 90  days after enactment

• Would  provide immediate access to high-risk pools for people with no insurance  because of pre-existing conditions.

Six months after enactment

• Would bar insurers from denying people  coverage when they get sick.

• Would  bar insurers from denying coverage to children with pre-existing  conditions.

• Would bar insurers from  imposing lifetime caps on coverage.

•  Would require insurers to allow people to stay on their parents’  policies until they turn 26.

2011

• Would require individual and small group market plans to spend  80% of premium dollars on medical services. Large group plans would have  to spend at least 85% on medical services.

2013

• Would increase the Medicare payroll tax and  expand it to dividend, interest and other unearned income for singles  earning more than $200,000 and joint filers making more than $250,000.

2014

• Would provide subsidies for families  earning up to 400% of poverty level, currently about $88,000 a year, to  purchase health insurance.

• Would  require most employers to provide coverage or face penalties.

• Would require most people to obtain  coverage or face penalties.

2018

• Would impose a 40% excise tax on high-end insurance policies.

2019

• Would expand health insurance coverage to  32 million people.

Sources:  Speaker of the House, Congressional Budget Office, Kaiser Family  Foundation; MCT.   Journal Sentinel

Another helpful link was thing  interactive website by Christian Science Monitor:

Health Care Reform 101

6.   Ode to Unwelcome Guests

As long time readers know I  am a fan of Lyn Gerry’s podcast Unwelcome Guests.  After 5 years  of broadcast and over 500 two hour shows, Unwelcome Guests has  gone silent recently.  I have been unable to find out why.  If anyone  knows what happened or if Lyn needs some assistance please contact me.  I  miss the show and I hope that she is well and will return eventually.