Sunday, August 30, 2009

The quality of mercy

In response to an earlier post, commenter Mara quoted something I said and then talked about pre-existing conditions:

In particular, group insurance policies provided via large employers are good about this.

Yes, that's true, Elise. HIPPA (Health Insurance Portability and Accountability Act, written by Sen. Kennedy) requires that group insurance policies cover employees with pre-existing conditions. However, as you know, not everyone is covered by group insurance including the millions of folks who are self-employed, small business owners, the unemployed and those whose employers do not offer insurance. For them "pre-existing conditions" such as cancer, down syndrome, even pregnancy represent a costly if not insurmountable barrier to health coverage. You may be surprised to learn as I was that in a dozen or so states even women who have been victims of domestic abuse are deemed to have pre-exisiting conditions. It boggles one's sensibilities.

As for the details of the former Governor Palin's insurance coverage, I couldn't care one wit. I trust she'll continued to be covered by the State of Alaska as is the policy for most former state executives. My point is that I would have hoped she would care enough for all the families who have a down syndrome baby who already face discrimination. Ain't the first time nor the last that she'll disappoint.

I began writing a response to her comment and it turned into a post.

Actually HIPAA is not quite so straightforward with regard to pre-existing conditions:

Title I also limits restrictions that a group health plan can place on benefits for preexisting conditions. Group health plans may refuse to provide benefits relating to preexisting conditions for a period of 12 months after enrollment in the plan or 18 months in the case of late enrollment. However, individuals may reduce this exclusion period if they had group health plan coverage or health insurance prior to enrolling in the plan. Title I allows individuals to reduce the exclusion period by the amount of time that they had "creditable coverage" prior to enrolling in the plan and after any "significant breaks" in coverage. "Creditable coverage" is defined quite broadly and includes nearly all group and individual health plans, Medicare, and Medicaid. A "significant break" in coverage is defined as any 63 day period without any creditable coverage.

This 12-month exclusion is clearly intended to handle the problem of someone diagnosed with a high-cost illness who then seeks employment specifically in order to have coverage with a group health plan. And, yes, I did know someone who did this. Provided the illness is chronic rather than catastrophic or has a long latency period, this is a perfectly rational response to our current health care/insurance system. It is the pre-emptive strike version of continuing to work at a job you hate because you or your family need the health insurance.

That said, I certainly agree there are a lot of people who do not have jobs that include large group health insurance policies and can’t get such jobs. My preferred solution if we’re going to do a total overhaul of health care/insurance would be something along the lines of the Goldhill ideas I wrote about recently - which I think are very similar to what Singapore does. Goldhill’s plan is not fully fleshed out - the devil is always in the details - and I do not know all the ins and out of Singapore’s plan* but they both provide government assistance for those who need help paying while also requiring health care consumers to make choices about how they spend their money - whether they contribute it themselves or get government help. This seems to me to be the only way to restrain health care costs while making the government’s role in deciding what care will and will not be provided as small as possible. (As long as you have any government involvement that role cannot be non-existent.)

If we don’t want to do a complete system overhaul then I would like to see anyone who wants to be allowed to buy into the FEHP with the government subsidizing those who cannot afford it. (Actually, in my heart of hearts I’d like to see this - and a whole slew of other government functions - move to the State level - I don't think the less well off people of Alabama should have to subsidize New Jersey’s sky-high medical costs - but I’m talking realm of possibility here.)

Finally, I cannot begin to imagine the anguish of having a child who needs medical attention and not being able to provide it. I gather you don’t think much of Palin but it’s worth remembering that she does in fact have such a child and - unless you accept that she is a monster - must understand how parents who are not able to provide what she can provide would feel. This is why I would like to see her talk about what she thinks should be done for such children and their parents. Perhaps she truly is a monster who figures that since she and her family aren’t suffering, no one else matters. I don’t believe this but I’d be very interested in more information. (I’d also like some sources for your claim that State governors continue to get benefits once they leave office. If that’s true in NJ, my State legislators are going to hear from me.)

Many people seem to believe that once the government - especially the Federal government - provides a good that good can never be taken away. Thus people argue that if the government would just provide health care for all everyone would be set for life. I don’t believe that. I can remember my aunt’s anger over Social Security because, she said, her parents had been told by the government that if they would just pay this little bit of money then the government would provide fully for a comfortable retirement for them. Less personally the proposals to means test Social Security and Medicare; to raise the eligibility age; to change how increases in benefits are calculated are all examples of how a benefit once promised can be taken away. So is the proposal floated a while back that veterans’ own health insurance pay for some part of the care they needed as a result of being injured while on duty. The proposals make sense given the financial situation but that doesn’t change the fact that the government wants to change the rules and if it succeeds in doing so, those who counted on what the government told them will simply be out of luck. And if the rules aren’t changed voluntarily then we will run out of money at some point and the whole game will change. California is an example of what can happen when promise meets cost.

The Federal government is as capricious and ultimately as cost-constrained as any other entity and what is promised one day may be withheld the next either through choice or through necessity. I do not believe that is an argument that government should do nothing to help its citizens; indeed I’ve argued that to the extent a society can afford to do so it has a moral obligation to help those who cannot help themselves. It is, however, an argument to beware of putting ourselves in a position where government is the only source of a good. Sometimes there is no real choice about that: national security, for example. But if we have competing interests - both private and public - we are far less likely to find ourselves at the mercy of either.


* Singapore’s numbers - if accurate - are astonishing. According to the BBC and various Wikipedia references:

- Singapore spends 3.4% of its GDP on health care; Canada spends about 10-11%.
- Singapore spends about $1,228 per capita; Canada spends about $5,100.
- Singapore’s infant mortality rate is 2.1 per thousand live births; the CIA 2009 figures say 2.31 versus 5.04 for Canada; the UN says 3.0 versus 4.8 for Canada
- Life expectancy in Singapore is 79.7 years; the CIA 2009 figures say 81.98 years versus 81.23 years for Canada.

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