I learn from my patients every day about the benefits, limitations and contradictions of their health insurance. One charming 60-year-old with severe seasonal allergies insists on seeing me every few weeks this time of year, even though I tell her she doesn’t need to — her antihistamines and nasal spray treatment rarely changes. But she worries that her allergies could be hiding an infection, so I investigate her sinuses, throat, lungs and ears. I reassure her, and her insurance (which she buys through New York’s Obamacare exchange) covers the bill.
If she was responsible for more than a small co-payment for these visits, I’m sure I would see her less often.
We pride ourselves on being a compassionate society, and insurance companies use this to manipulate us into sharing the costs of other people’s excessive health care. Meanwhile, 5 percent of Americans generate more than 50 percent of health care expenses. Why shouldn’t a patient who continues to see me unnecessarily pay more?
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The government’s job is to maintain public health and safety. It should ensure that insurance plans include mandatory benefits like emergency, epidemic, vaccine and addiction coverage. The Republican bill would let states apply for waivers to define these benefits differently; it would be a big mistake to drop such coverage entirely. But Obamacare went well beyond these essentials, by mandating an overstuffed prix fixe meal filled with benefits like maternity and mental health coverage that drove smaller insurers with fewer options out of the market. The few that remain often have a monopoly, and premiums rise.
Speaking of compassion, how about some for the 20-something construction worker who can’t afford to pay his rent because his premiums help subsidize overusers like my allergy sufferer? Why shouldn’t a patient who is risk-averse pay more for coverage she might never need, while that construction worker be allowed to choose a cheaper insurance plan that might cover only the essentials?
In addition to limiting the menu of essential benefits, the House bill would let states create high-risk pools for patients with pre-existing conditions who had let their insurance coverage lapse, and who could then be charged premiums more in keeping with their health care needs. This is the only way to make insurance affordable for most consumers; pre-existing conditions will continue to drive up premiums if everyone is compelled to pay the same price.
These risk-pool premiums can and should be subsidized by the government. A recent report from the Kaiser Family Foundation found that high-risk pools can work, but have been historically underfunded. Trumpcare should change that — though it will cost more than the House bill’s $8 billion in additional funding. Drastic cuts to Medicaid should also be reversed, which could help the bill pass the Senate.
But the bill is on the right track. Americans believe that insurance provides access to care, when in fact it is the gatekeeper that often denies care. Many think Obamacare is generous, and yet I often have to fight for essential care for my patients. We need to be more pragmatic, and less emotional, about this issue.
Jimmy Kimmel’s contention this week that a child like his would not receive lifesaving surgery for his congenital heart problem without Obamacare may tug at the heartstrings, but it is neither fair nor accurate. Employer-based health insurance, which covers 170 million Americans, including, no doubt, Mr. Kimmel, would have paid for this infant’s needs with or without Obamacare. Even if the Republican plan replaced Obamacare, and even if the infant didn’t have employer-provided insurance, the treatment would still be covered, either through a traditional plan or a high-risk pool. And at the end of the day, a federal law, the Emergency Medical Treatment and Labor Act, guarantees this kind of treatment, whether we have Obamacare or Trumpcare.
The final question concerns the skyrocketing costs of innovation, and how one-size-fits-all insurance can possibly continue to pay for it. My 93-year-old father, a retired engineer, just received a $50,000 catheter-inserted aortic valve, which was covered by Medicare. But if all such high-tech devices are covered, it will be practically impossible for any insurance company not to go belly-up. The tax-free savings accounts that the House bill would expand and make more flexible are a far better way to pay for this kind of care. Shouldn’t my father and those like him be asked to save their own money for just this sort of rainy day?
Or should we continue to overload health insurance with all our fears and expectations?