The Morass of Healthcare in the United States
Divorce to Protect Your Family from Healthcare Costs
Reading through the litany of challenges in healthcare on a daily basis is depressing. That is unless you are in one of the fortunate groups that have healthcare coverage that actually pays those bills and doesn’t cost so much to be unaffordable.
So who manages to get medical insurance that’s affordable in this country – well the obvious group is those employed but that’s only if you work for a large enough company that is required to provide insurance or if lucky enough to work for a company that provides it because they see it as a necessity or a basic form of humanity. But in many cases, the cost shift has long been in progress as Jane Sarasohn-Khan (@HealthyThinker) has detailed in her blog and recent book HealthConsuming: From Health Consumer to Health Citizen. The US population is rapidly sinking into debt with “High Deductible Plans” and unable to pay these high deductibles as their savings are less than the amount of their deductible. And even if you are covered your healthcare insurance company is often not working to keep costs down on your behalf.
My feeling is we should stop referencing them as such and call them what they are Self Insurance Plans.
For government employees, there is the Federal Employees Health Benefits Program (FEHB) which provides a wide range of choices and options to all federal employees and includes retirees with a range of provisions that I don’t doubt there are many experts around in determining how long you need to be employed to be able to access this medical insurance for life
Then there is the military system that has the active duty military healthcare that is provided to all active duty “free” (nothing is ever free and they pay with their commitment to service and some with their lives) and for those who retire or are discharged the Veterans Administration (VA) if they have served their minimum commitment variable but for many a minimum of 24 months.
There are other less well-known healthcare options that include lifetime access to group medical insurance schemes from health systems, educational institutions and beyond. These are often only available to more senior individuals although I have no good data on this.
For the remainder of the workforce that is self-employed – somewhere of the order of 10% or ~14 Million people, the choices are stark. Your choices vary widely by the state you live in and the availability of the healthcare exchange which are so wide and varied, confusing and filled with unaffordable healthcare choices. It is as confusing as trying to compare bundled televisions and internet plans or cell phone provider service options but has a lasting impact.
The lower the cost of the plan the more it really is a version of self-insurance where you are responsible for all of the costs until you reach a high level of outgoings at which time insurance starts paying but oftentimes not all the costs are billed. It comes with terms like copayment and co-insurance that make you liable for varying amounts and is very confusing. In theory, plans have a maximum liability, your out-of-pocket maximum but this assumes that the service you got was covered which oftentimes requires you to be “in-network” (and the choices in the low-cost plan networks are think pickings). But if you get taken to a facility that’s out-of-network you are likely in for a terrible surprise with a bill your insurance refuses to pay and the hospital or health system will demand payment from you, plenty of examples and the Zuckerberg San Francisco General a frequent offender (at least in the reports). Even if you are in the network you may find yourself stuck with a bill thanks to “balance billing” where the hospital or clinician may bill you for the difference between the insurance allowed (read discounted of the rack-rate) amount and what they originally bill with no limits.
Divorce
So with the above background, I found the following message intriguing
I had no idea so many people get divorced as they’re dying bc otherwise their spouse will be burdened with massive medical debt. Our healthcare system is just so heartbreaking and messed up https://t.co/2jIOCQEao9
— Colleen Farrell, MD (@colleenmfarrell) May 6, 2019
A “hack” of healthcare that attempts to disconnect a dying spouse’s medical insolvency and allow the remaining family to say farewell without watching everything they built together be taken away in the name of healthcare treatments. As you read in the comments it does not apply in all states and depends on the rules on divorce for that state but just seeing this as a position statement is nothing short of a disgrace IMHO.
I’ve made my position clear – my life is not worth crippling my family and destroying their future life. There is also the rarely discussed topic of death with dignity and the importance of understanding the probabilities relative to the disease in question and importantly the economics. As I discussed a previous post – Doctors Die Differently because we make these assessments based on a better understanding of the reality of the disease and its likely outcome.
That said my resistance to care is a whole lot higher here, to the extent that I’d have to be unconscious to allow anyone to call an ambulance for me. I carry around a card with questions to ask at the facility or doctor that I see about the charges associated with care. Not a card to allow me to focus on learning about my disease or coping with the many medical conditions but rather an economically driven set of questions that need to be answered before any kind of care begins.
Ironically as I was writing this piece Dr Jayne piles on with her excellent article (Curbside Consult 5/13/19) reviewing the JAMA Does Employment-Based Insurance Make the US Medical Care System Unfair and Inefficient, which covers the history to how we got into this mess. If you want a deeper dive into the path to our current healthcare Self Insurance Plans I’d recommend Dan Munro’s book “Casino Healthcare” that details this history and as he still features in his pinned tweet the toxic nature of our system so succinctly captured in one chart
"Single-payer" healthcare is politically toxic b/c it's easy 2 defeat as "socialized medicine." It's also unnecessary b/c the big economic lever is price, not who pays – and (spoiler alert) the delivery mechanism 4 single pricing is universal *coverage.*https://t.co/0i09y6Ckn6 pic.twitter.com/a66I2zvYi6
— Dan Munro (@DanMunro) April 4, 2019
Dr Jayne makes some great points which resonate with me having experienced other healthcare systems, all imperfect, but in my experience better on many levels. As pointed out
“the interests of high-income individuals dominate decisions about what medical care is offered and how it is financed. The result is a less efficient and less equitable medical care system than in other high-income countries.”
Which explains a lot of the discrepancy – if the people designing the systems and working hard to lobby the status quo don’t have the slightest notion of the pain, suffering, and insolvency experienced by the other 95% they hardly have the right material or inputs to make any changes the address or combat the failing system. And as for innovation and happiness – I agree with Dr Jayne
I often see people trapped in jobs they don’t like or aren’t suited for because they are afraid of losing their insurance coverage. I see people staying in dysfunctional marriages or domestic partnerships because of the insurance issue.
The US Healthcare is killing people, productivity, happiness because of the historical link to employer-based insurance and the inability to see past the confusion between single payer vs universal coverage
Incremental Steps to Healthcare Insolvency
So my primary incremental step on the path out of this morass is pricing transparency.
Pricing transparency and the cost of care is an essential element for everyone and the recurrent push back by the industry and even some commentators that this is not desired important is wrong for all the people in the category of self-insured. And for all the others, the way the system is going I am willing to bet they will be desperate for price transparency in short order.
The other clear incremental step IMO is the need to move away from employer-based insurance systems disconnecting employment from healthcare insurance but I recognize this is not so much of an incremental step but a bigger reach.
