The complexity of the Pre-Existing Condition Problem

I have several pre-existing conditions which are not covered by my insurance. I am signed up with Medi-Share, a health coverage co-op which is allowed to impose such restrictions. When I applied for the coverage I was told that my knees were not covered due my history of injuries and potential need for surgeries in the future. My anxiety disorder was also excluded. I signed up anyway.

I signed up because my private work-based "cover everything" Blue Shield plan cost $1800 a month for full family coverage. It also had a deductible of $3000 a month, which meant I would spend over $24,000 a year before I had any true health benefit. The Medi-share plan, in part because it restricts pre-existing conditions, cost $480 a month for a $5000 deductible. I decided that the $16,000 of premium savings a year was worth the risk of paying cash for future treatment on my knees.

I confidently made this bet because my pre-existing conditions do not require ongoing care. Unlike diabetics, cancer patients and patients with congenital conditions, I can go years without paying anything for my knees. In the event I do need such care it will not be urgent and I can re-enroll in another plan to get better coverage. If I need a knee replacement I can game the system and enroll in an ObamaCare plan in November, have the surgery in January, and disenroll in February. 

I am not the only person who has figured out that delayed enrollment may be the best financial option. Many healthy Americans are choosing to forego insurance completely. Because they know that they can wait until they get sick to buy insurance, or in the case of emergency know that emergency care will be given regardless of their ability to pay, they roll the dice and do not sign up for coverage. They pay cash for the occasional sick visit and save thousands of dollars a year. 

While this no-insurance decision is beneficial for these individual families it is devastating to the insurance industry and the health care system. All insurance industry profits come from healthy patients. As more and more of these patients drop out of the insurance pool insurers are increasingly struggling to cover expenses. The only option they have is to further raise their premiums, which causes more healthy patients to opt out. Patients with pre-exiting conditions, especially chronic diseases, do not have such a choice. They have to pay the higher premiums.

(I have heard many people say that the solution is to eliminate insurance company profits. As appealing as this option may seem, it will do nothing to solve the problem. The insurance industry’s profit margin is about 3%. Cutting this to zero would take only $30 a month off of a family’s $1000 premium. This is not the answer.)

The current system is designed to fail. Millions of Americans have health coverage through their employer. This is incentivized by a tax policy that makes this type of coverage a deduction to the employer and tax free to the employee. Individuals purchasing insurance on the individual market get no such benefit. When people with chronic illnesses leave their jobs they take their pre-existing conditions with them. When they try to buy insurance on the individual market they find insurance difficult to get and expensive.

ObamaCare attempted to address this by forcing insurers to cover pre-existing conditions. While this seemed nice, lawmakers ignored the reality that the money has to come from somewhere and that somewhere is from healthy patients. This has caused sky rocketing premiums in the individual market. Faced with such high premiums many healthy patients opt out of the system, resulting in even higher premiums.

The reason this failure is predictable is that this system results in the financial burden falling on healthy people regardless of income. Younger people are on average the healthiest people but they are not the wealthiest. The current law limits the ability of insurance companies to charge higher premiums based on age so the young and healthy are effectively subsidizing the health costs of older, sicker and oftentimes wealthier people.

ObamaCare attempted to address this by trying to force all people to buy insurance. Uninsured Americans are faced with penalties if they do not purchase coverage. Since the cost of the penalty is far less than the cost of insurance and is essentially uncollectable, this part of the law has been ineffective. Too many healthy individuals do the math and opt out.

Left out of all of the current laws and proposals is an important reality. All of the proposals I have read expect all healthy people to pay the same, regardless of income. This seems fair on its face, but is no longer feasible. Health care costs have reached the point where many families simply cannot afford the premiums. I am reluctantly left with the conclusion that we need a system in which contributions to health care costs are based more on income than they are on health. As people are not likely to do this on their own, I expect the ultimate solution will come as a result of a government program or tax.

As unpalatable as this is, if the remaining option is to limit insurance to only those who can afford it, it is a pill we will all need to swallow.

Bart

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The Stupidity of American Healthcare

I have watched in fascination this week as our broken political system has churned out yet another foolish creation, the passage by the House of Representatives of a useless healthcare bill that has no chance of becoming law. Dysfunction is bipartisan, as Republicans gathered at the White House to celebrate their lack of accomplishments and Democrats gleefully hung on to the sinking Titanic of Obamacare. Neither side offers a viable solution and the American people suffer.

How did we end up with such a mess? The answer is simple. We voted for it.

Conservatives crow about getting the government out of Medicine, stupidly ignoring the reality that 132 million Americans are covered under government insurance already (58 million Medicare and 74 million Medicaid). That amounts to 40% of Americans. I hate to be the bearer of bad news Republicans, but we will never get the government out of medicine. That ship has sailed.

Democrats ignore the failures of Government medicine, which is expensive, inefficient and for the 74 million Americans on MediCaid, of remarkably low quality. A large majority of the 180 million Americans who are not covered by the government rightfully fear the quality of their health care will decrease if they lose their private insurance.

Both parties seem to be angling for a solution that caters to enough people to keep them in power instead of a solution that addresses the fundamental problems that plague our healthcare system.

Republicans need to address the reality that health insurance is increasingly out of the reach of the typical American family. It is not uncommon for health costs to consume a massive portion of a family’s income. In Huntington Beach a family of four making $80,000 a year will pay $13,000 a year for health insurance. Rent is $30,000 a year and state and federal income taxes are $10,000. Basic math says that after taxes and rent, one-third of the family’s remaining income is health insurance! The average American family simply cannot afford coverage.

Conservative “solutions” such as allowing insurance to be purchased across state lines are farcical. The savings achieved will be so small as to be irrelevant. They hate to hear it, but the only way to lower costs is by lowering coverage in the form of higher deductibles and limited benefits. Wealthy families can afford to take such risks in a way that lower income families cannot.

Democrats need to address the poor quality care and service rendered under many government programs. Medicaid pays hospitals and physicians so poorly that access to care is severely limited. This limited access increases the use of emergency rooms for routine care, driving up costs. In many parts of the country, ObamaCare is failing. Iowa is down to one insurance provider and it is threatening to leave the state. Doing nothing is not an option.

Both parties stay on their side of the aisle and holler at the other, accusing them of abandoning the American people, ignorant that they are all to blame. Their refusal to work together to accomplish things for the people they were elected to serve is the reason we have an orange president.

Bart

Medical Advice from Vin Scully

Her life was at a crossroads. At the age of 27 she was barely making ends meet. She was working two jobs, at Disneyland and at an office, making just enough to pay her portion of the rent for the 2 bedroom apartment she shared with a roommate. With only a high school education she did not think she would be able to afford Orange County living much longer. She was debating moving back to her family home in New England. She did not have a job there, but she had family and a lower cost of living.

I asked her if she was going to school or had considered it. Her reply surprised and saddened me.

“I don’t have much self confidence,” she said, “I am afraid that I will not do well in school.”

It wasn’t just the reality of her low self worth that bothered me, it was the fact that her sense of worth was tied more to academic achievements and professional accomplishments than it was to who she was as a person. This attitude, when combined with her anxiety disorder, was paralyzing her. She felt badly about herself and she wasn't sure her fragile sense of self could withstand the threat of failure she associated with college.

I thought of how I could encourage her. I gained inspiration from an unexpected source. What came to mind were words I had heard Vin Scully, the great announcer for the Dodgers, say during a baseball game many years ago. The Dodgers had fallen behind after a fielder had dropped a ball. After commenting how the game would have been different if the ball had been caught, he said, “The saddest words of tongue or pen are those that read, ‘What might have been.’”

I shared the story with her, that regret at previous mistakes need not consume her, and that fear of future failings not lead to lifetime of regret, how sad it would be if later in life she found herself wondering how her life would have been different if she had only tried going to school. I encouraged her to consider counseling to help her overcome here low self-esteem, anxiety and fear.

I shared with her that I had similar self doubt when I started college. I thought I was smart enough for college but I was certain that I was no where near intelligent enough to pursue a career in medicine. I was interested in health care and, thinking I could be a registered nurse, signed up for a course in anatomy and physiology. The class included two weekly physiology lectures and a Wednesday evening anatomy lab course.

Each week in the lab included a quiz on the previous week’s instruction. To my surprise, I went 11 weeks in a row without missing a question. The professor recognized my potential and each week asked me, “Are you going to go to medical school?”

Each week I answered, “I can’t go to medical school.”

Each time he answered back, “You should go to medical school.”

His words stuck. A year later, after Lisa and I had been married for about 6 months, I found myself wondering, “Could I go to medical school?” The words of Vin Scully gave me motivation. I did not want my future self to look back wondering what might I been. I decided that I had to try. I feared failure, but I faced those fears.

I encouraged her to think about trying. It seems to me that failing to try is worse than trying and failing.

Bart

It was the Patient's Fault

Doctor House was right. Everybody lies. Well, almost everybody.

She was a poorly controlled asthmatic.  Perfectly controlled asthmatics can often make do with one inhaler a year. She consistently used 200 puffs a month. She was not doing well.

I had quizzed her on her need for inhalers at multiple previous visits. Over and over that she was doing everything I had asked her to do. She had gotten rid of her cat and avoided triggers. She was taking her medications exactly as prescribed. Her recurrent asthma attacks were a mystery it took me months to solve out. In the end the answer was simple- She was lying to me.

Her secret was revealed to me as I drove the mile from my office to visit my grandmother in her assisted living facility. As I waited at a light I saw my patient standing on the corner waiting to cross the street. In her right hand was the smoking gun, a smoking cigarette. 

I drove through the intersection and pulled over, waiting for her to cross the intersection to where I was. As she approached I got out of my car. She did not look happy to see me. “You are so busted!” was my less than tactful greeting.

She was visibly embarrassed. She lowered the cigarette, trying to hide it from my view behind her leg.  “This is my first cigarette,” she proclaimed, “I have been under a lot of stress lately!”

“So throw it away then,” I replied. She did, apologizing profusely and telling me that she was not going to smoke anymore.

She was lying again.

I found out two days later when my nurse saw her at another intersection, again with a cigarette again in her hand. At her next visit I was finally able to address the real reason for her asthma problems. Sine then, her need for inhalers has decreased dramatically.

Her story reminds me of a basic truth in medicine. Doctors are only as good as the information we get from our patients. Patients who lie get poor care.

Doctor House was right.

Bart

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Happy Easter! Or Not.

People hedge their bets.

I do this as a doctor. Often when I give a diagnosis, I give several alternatives, so that if the first diagnosis isn’t correct I don’t come across as a complete fool when I am proven wrong.

“Based on the location of the pain in your knee, the mechanism of injury, and the tenderness on exam, I believe you have torn your medical meniscus. Either that or it is a sprain. Or arthritis. Or a rare parasitic infection.”

I feel like someone who bets on every horse in the Kentucky Derby so when the race is over I can tell everyone that I picked the winner.

We are all like that. No one wants to be proven wrong, no one wants to be embarrassed, so we avoid all or none statements. We like to have options.

This may be comfortable, but it is not always possible. Some things in life are either true or they are not. Some questions have only one answer.

The question of Easter is a one answer question. Either Jesus of Nazareth rose from the dead, or he didn’t. The claims of the Christian faith are valid or they are not. There is no room in the middle. People have to pick a side.

No one understood this better than the Apostle Paul, the Jewish Rabbi who became the greatest missionary of the early Christian church.

Paul based his entire life on his belief that Jesus had risen from the dead. His commitment to Christianity cost him his faith, his career and ultimately his life. His investment was either incredibly wise or terribly foolish. There is no middle ground.

This dichotomy was not lost on Paul. He himself expressed this reality in a letter he wrote to fellow believers in the Ancient Grecian city of Corinth, saying, “If Christ has not been raised, our preaching is useless and so is your faith.”

Paul’s words are no less true today. Everything about the Christian faith hinges on a single event on a single day almost 2000 years ago. An event that either happened, or it didn't.

Christians proclaim that Jesus was not just a man, that he was actually God become man, that he lived a perfect life and then allowed himself to be put to death in a brutal fashion as payment for “sins”, rebellious acts against God, committed by every person who ever lived. As evidence for these remarkable claims Christians offer a single proof, Jesus’ resurrection from the dead. This is a risky position.

If Jesus did not rise from the dead then he is not the Son of God. His words are no more valuable or meaningful than any other moral teacher. People like Paul who make tremendous sacrifices for their faith are fools, complete, total and pathetically deluded fools.

If the resurrection of Jesus isdisproven, then all of Christianity comes crumbling down. Yet, if Jesus did rise from the dead, then He is everything Christians claim he is to be.

Given the profound implications, it seems that thoughtful, prudent people would take the time to explore the evidence put forth in support of the Christian teaching on the resurrection of Jesus. The matter is too important, the consequences too significant, to be dismissed out of hand. The question, “Did Jesus really live, die and rise again?” May be the most important any of us will ever answer.

Something to think about on Easter. 

- Bart

Thanks for reading and commenting. Questions are always welcomed.