Monday, February 8, 2010

Take what you want, says God - and pay for it

On February 4, at a Democratic National Committee fundraiser in Washington, President Obama referred to an Obama campaign supporter who died of breast cancer:

She didn’t have insurance. She couldn’t afford it, so she had put off having the kind of exams that she needed. And she had fought a tough battle for four years. All through the campaign she was fighting it, but finally she succumbed to it.

JustOneMinute has done yeoman work in pulling together the details of this woman’s illness and death beginning with a detail Obama omitted: her name was Melanie Shouse. JOM wrote further about Ms. Shouse when he outlined the inconsistencies in her timeline. Those don’t bother me: if you deal with a serious illness for years, what happened exactly when gets very blurry. JOM also clarifies her insurance situation and the details about her insurance provider or providers’ refusal to pay for Avastin. And today JOM sums up with:

It's a very sad story but the takeaway is more complicated than "she had no insurance".

Based on JOM’s information, here’s my understanding of the timeline of Ms. Shouse’s illness:

- Sometime in 2004 she went deeply into debt to open a store. As a result she could only afford an insurance policy with an extremely high deductible ($5,000) and significant co-payments (an additional $3,000 to $5,000 maximum per year).

The timeline gets a little murky but it appears that a year elapsed between when Ms. Shouse began to feel ill and found a lump in her breast and when she was diagnosed. Since it seems clear she was diagnosed in October of 2005, the timeline would presumably be:

- In the Fall of 2004, Ms. Shouse began to feel ill and found a lump in her breast. She chose to ignore her symptoms because she could not afford to have them checked.

- In October of 2005, Ms. Shouse was diagnosed with Stage 4 breast cancer

Now Ms. Shouse was seriously ill so she could not switch to a policy with a lower deductible and co-payment.* She was, however, eligible for the Missouri Medicaid program.** She was treated from October 2005 until September 2009, covered under Medicaid and eventually under Medicare. In September 2009 her “insurance provider” refused to pay for any further treatment with Avastin. The assumption among those who support Ms. Shouse’s stand on universal health care is that the “insurance provider” in question was her private insurance company, Wellpoint. However, apparently neither Missouri Medicaid nor the Federal Medicare program would pay for it either. It is not clear whether anyone was willing to pay for further conventional treatment like chemotherapy.

So to sum up: Ms. Shouse decided to expand her business and went deeply into debt to do so. As a result she could only afford catastrophic health care insurance and did not have the money to pay the deductibles and co-payments necessary before insurance kicked in. She thus decided to ignore a serious health problem until she became so sick she could no longer do so. Once she was diagnosed as being seriously ill, State and Federal insurance paid for her treatment for at least four years. Finally, no insurance provider - private, State, or Federal - would pay for additional treatment with a particular drug and she died.

The only part of this story that could possible have any bearing on the type of universal health insurance proposed in the House and Senate bills (hereinafter “Obamacare”) is the beginning of the story: because she chose to purchase catastrophic health insurance while not having the money to cover the resulting out of pocket obligation, she put off getting medical treatment for her illness in its early stages. As Ms. Shouse put it:

I had to take the ultimate risk with my health in order to chase the American Dream, like so many small business owners in America today.

This was Ms. Shouse’s choice. She knew she was gambling her health - her very life - in order to expand her business. She was not forced to make this choice; from all accounts she was a dynamic, intelligent woman who could have found a job with excellent health insurance or a job that paid enough for her to purchase her own excellent health insurance. Instead she chose - freely and willingly - to spend her money elsewhere.

Now, it may be that we as a country don’t want people to have to make that choice. Perhaps we prefer that everyone should be able to spend their money as they please without thinking for one minute about whether that means they can’t afford health insurance or health care. That’s certainly a decision we can make and - given my own disinclination to work for someone else - I can see the advantages.

However, I would point out that under Obamacare, the constraints on Ms. Shouse would not be any different. Obamacare is not going to give anyone health care for free. Rather Ms. Shouse would have been required to purchase health care. If Obamacare even allows a catastrophic plan, we have to assume that is the plan Ms. Shouse would have selected: her finances did not and would not have permitted her to do otherwise. If Obamacare allows only health insurance policies with lower deductibles and co-payments, then Ms. Shouse would have been forced to spend her money for such a policy and would not have been able to expand her business. Yes, Obamacare will subsidize those who cannot afford health insurance but I find it hard to believe that someone who could lay her hands on $30,000 would qualify for such a subsidy.

In other words, under Obamacare Ms. Shouse would have made the same choice she actually made: choosing to risk her life to expand her business. Or she would have been denied the chance to make that choice and would have good health insurance but no expanded business. Not even Obamacare could have afforded Ms. Shouse the opportunity to do what she wanted without paying for it one way or the other.

Ms. Shouse’s story is a very sad one and for Ms. Shouse herself, her family, friends, and loved ones I have nothing but the deepest sympathy. However, we cannot make policy based on heart-rending anecdotes - from either side. Instead we must make policy with a clear understanding of what we want - and what we're prepared to pay for it.


* Yes, the evil pre-existing conditions exclusion. It doesn’t mean that insurance companies are the spawn of the Devil; it means that someone who is betting her life she won’t get seriously ill can’t shift that the cost to other policy-holders when she loses the toss.

** JOM asks, reasonably, why Ms. Shouse wasn’t eligible for Missouri Medicaid when she first found the breast lump. Based on this story from September 2009, I believe it’s because she only became eligible when she “became too ill to work.” Note that the references to Stage 4 cancer being a “jackpot” disease for eligibility apparently pertain to Medicare.

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