As of today, March 29, 2017, the ACA is still, to quote Paul Ryan, "the law of the land". Whether that will remain the case is unclear as, after a weekend of contemplating the ruins of their Repeal-Obamacare scheme, some Republicans are saying they'll try again. Separately Health and Human Services Secretary Tom Price, an avowed ACA opponent, is now hinting he will purposely do what he can to damage the functioning of the ACA. So we'll see.
But in the meantime, for people who might want to actually improve delivery of affordable healthcare to Americans, there are two fallacies I'd like to address:
- That people view healthcare like a consumer product.
- That people even have choices.
The Myth of the Healthcare as a Consumer Product
Some legislators, pundits, lobbyists and business leaders view healthcare as a consumer product, like a house or boat or car or microwave (or iPhone!), and they believe (or claim) that "people want more choice".
I don't know what planet these folks live on, but I can tell you right now I know of NO ONE who has any desire to spend their time comparing health plans. People do it because they have to, and they do it fearfully (i.e., "will I regret it if I go with the lower-premium higher-deductible plan?"). They read lists and descriptions of services and options and networks and providers. They confront levels and ratings and think about how sick/injured they are or were or weren't last year (ditto same re: their spouses, children) and try to predict what the year ahead will bring health-wise. At no time do they sit dreamily contemplating their future purchase. There's no "new car smell" to look forward to, no joy in the purchase, no sense of pleasurable acquisition. The best you can hope for is a feeling of security, which is enhanced if that security doesn't require painful sacrifices to afford. Medical insurance is a means to an end, period. No one goes window shopping for a healthcare plan.
But while "choice" in the healthcare market is seen as a necessary evil by the hands-tied "consumer", it is nevertheless preached loudly across the land. Why? Because it supports the existence of for-profit health insurance companies in the first place. The "choice" argument advances the idea that single-payer would obliterate "choice". People supposedly like "choice". Therefore, having a bunch of for-profit companies provides something people want and justifies all the other baggage such as excessively high costs and complexity.
In reality, the notion of choice with respect to healthcare isn't about benefitting "consumers" nearly as much as it is about justifying the existence of for-profit health insurance companies.
Now, since, at the moment, we still have a predominately for-profit health insurance system in America, there may be some truth to the notion that more choice encourages competition which is supposed to result in both lower prices and innovation. There may be some truth to that. But that's really just a way of trying to minimize or deflect from the simple fact that all this choice benefits insurers and their investors far more than the American people. Because, when all is said and done, health insurance companies do nothing more than process fees. They are not involved in any material way with delivery of medical services. Aetna and Cigna don't heal anyone. They don't save lives. They just take money in and send it out again. But, as institutions, they are vehicles for investments and all the financial machinations of any large company. And they employ a lot of people who essentially perform "make-work". So, you can say they provide jobs. And we need jobs in America. But that's really what we're all paying for through our premiums and through the tax dollars that are used to offset costs for individuals and employers — we're paying high prices so that a bunch of Americans can have jobs and a much smaller group of Americans can pad their investment portfolios.
The Myth of Individual Choice
The folks who view healthcare as a consumer product also seem to think people can treat their healthcare choices the way they treat their transportation choices (as an example). If you're rich you can take advantage of any and all forms of transportation, including those in the luxury class. As incomes go down, so do options. Middle-income folks buy or lease new cars at different price-points. They also buy used cars at different price-points. Lower-income folks drive older cars or opt to go without because they can't afford payments, insurance, etc. So, they may use public transportation, or walk, or ride bikes (weather permitting), etc. The point is, if they can't afford a car they don't have one. Lack of a car may result in any number of difficulties and inconveniences, but the key is, the person is theoretically able to adjust their transportation choices based on what they can afford. They will also, hopefully, survive.
Healthcare doesn't work like that. No one gets up one day and says, "Hmm, I'm feeling under the weather. I can't afford cancer right now so I'd better opt for something cheaper like a cold."
People get sick. People get hurt. Most of the time sickness or accidents are unexpected and unpredictable. And when medical help is required people are powerless when it comes to costs. They are at the mercy of one company and institution after another. The notion that people need to "have skin in the game" because it will cause them to be "better consumers" is nonsense. What are they supposed to do? Opt NOT to get the shot because it will add $25 or $250 or $2500 to their bill?
"Would you like to beat this infection Henry ($250) or suffer a high fever for another week and maybe die, but you'll save $250? Or, how about today's special, half a shot for $165? For an even $200 I can throw in some painkiller and one more IV drip."
Most people will do whatever their doctor recommends. They may get a second opinion, but the choice will not be about money, it will be about the potential efficacy of the treatment. People (with the exception of the true hypochondriacs) don't enjoy going to the doctor or clinic or hospital any more than they enjoy being sick or hurt. They want to get well and feel better and to expect them to forego treatments or drugs because some drug company decides it will charge exorbitant prices (because it can) is inhumane and sadistic.
The Path Forward
Bernie Sanders is introducing a Medicare-For-All proposal. Personally, I don't think his proposal will go anywhere at this time, but that doesn't mean we can't try. I think it will stall because people aren't really talking about the underlying issues. They recognize the for-profit focus of our system increases costs for everyone. But they don't talk about what it would mean to suddenly render obsolete several large publicly held companies. And it's not just the big insurers, its all the little packagers that make up the hundreds of insurance packages offered throughout the country. Also impacted would be all the medical equipment-related companies. And Big Pharma. And medical software developers. And doctors and hospitals. There's wages and profits encrusted throughout our system that flow into the pockets of many Americans. There's also predators and monopolies and tax shelters. (This story The Hidden Monopolies That Raise Drug Prices, describes one of host of predatory practices that infest our for-profit system which contribute to the insanely high prices Americans, directly or indirectly, pay to healthcare related companies.) The beneficiaries of the ACA will fight to keep their largesse.
So, the debates about for-profit and non-profit healthcare isn't really about what would better serve Americans with respect to health. That's the cover story. The real debate is about who's been making lots of money and should we stop them from making so much money or even any money? The ACA was a compromise that enabled people who were already making money to keep making it, even if they had to agree to make less. At least, ostensibly less. Less for a time. (Skilled business people can always find a way to make more money later on.)
To switch our healthcare system from for-profit to non-profit is another choice. A big choice. And maybe the folks who are empowered to decide what to do, theoretically on our behalf, can start being more honest about what these choices are really made of, and who benefits from them and who doesn't. The myth of choice in healthcare exists not to solve problems but to disguise problems. It's time for that to stop.