What's wrong with Colorado?

Let’s consider the case of Peggy Robertson, a resident of the Great State of Colorado. Ms. Robertson had given birth by Caesarean section. Because having one child by Caesarean section means a woman is more likely to have later children by Caesarean section, many insurers consider that a pre-existing condition. This means that when a woman who has had a Caesarean section applies for an individual health insurance policy (group policies usually work differently), the insurer will either exclude coverage for a Caesarean for some number of years or cover Caesareans but charge the woman a higher premium.

In 2007 Ms Robertson had individual health insurance coverage but was shopping for a better rate. She applied to the Golden Rule insurance company and was denied coverage. She was “mystified”. She contacted the Colorado Division of Insurance which contacted Golden Rule asking for an explanation of the denial. Golden Rule then wrote Ms. Robertson to explain their decision:

The plan you applied for is an association group plan and is medically underwritten. As a general rule, our underwriting guidelines require that we issue coverage with a rider excluding benefits for caesarean section delivery for three years. However, the Colorado Division of Insurance no longer allows us to place that rider. Without the rider, we have decided that we cannot provide any coverage for the individual. Unfortunately, we cannot collect sufficient premium to offset the risk of paying for a repeat C-section delivery during the first three years of coverage.

In order to consider coverage without a rider, we require that certain requirements be met. One requirement is that some form of sterilization has occurred since the caesarean section delivery. Also, women age 40 and over, who had their last child two or more years prior to applying for coverage, will not require a rider. Unfortunately, since you had not met either of these requirements, it would have been necessary to place the C-section rider.

Some people on the Left reported this as “woman was told to ‘get sterilized’ if she wants insurance.” This is, of course, not at all what the letter said but it made a handy stick with which to beat insurance companies. (I’m pretty sure that if Golden Rule had sent Ms. Robertson a letter without that second paragraph about sterilization and Ms. Robertson had had her tubes tied after her Caesarean section, those same people on the Left would have reported this as “sterilized women denied insurance because of previous Caesarean.”) In fact, the letter was a straightforward, professional response to a request for information.

Golden Rule was asked by its regulating agency to respond to Ms. Robertson’s complaint about being denied coverage. It did so and it explained the circumstances under which Ms. Robertson’s Caesarean section would not have caused her to be denied. It’s no different from an insurer turning down someone who was injured working at a high-risk job; explaining that they had to do so because they aren’t allowed to exclude coverage for injuries from the high-risk job or charge a higher rate for coverage because of the high-risk job; and stating that they would not have denied coverage if the applicant had taken safer employment since the accident. I don’t understand why, more than forty years after the founding of NOW, we’re arguing that women deserve special treatment and apparently accepting the idea that merely mentioning the world “sterilization” to a woman of child-bearing years causes her unbearable mental anguish.

But why, you’re wondering patiently, did I call this post, “What’s wrong with Colorado”? Because the real source of Ms. Robertson’s denial is not Golden Rule; Golden Rule would have been happy to write her an individual health insurance policy. The real source is the Colorado Division of Insurance which has got to be in the running for stupidest insurance regulator in the country. The CDI forbad Colorado insurance companies to exclude Caesarean sections from coverage: if an insurance company takes on a new customer, the insurance company must cover Caesarean sections beginning immediately. However, it obviously never even occurred to the CDI that this would mean insurance companies would simply start refusing to take on women who had had Caesarean sections. Not only did such an outcome never even cross the minds of the rule-makers at the CDI, it apparently also never occurred to them to actually ask insurance companies, “What would happen if we forbad you to exclude Caesarean sections from coverage for new policyholders?” I’m pretty sure that anyone who worked for an insurance company would have foreseen quite clearly that their company would simply stop writing policies for such women.

But perhaps it’s perfectly understandable that the CDI would never have asked an insurance company what the outcome of their new policy would be. After all, insurance companies are all the spawn of Satan whose only goal is to be mean to people who need insurance. None of their decisions have any rational basis, they just randomly do whatever is the most hurtful thing they can think of. The guys in government are smart enough to see through their dastardly plans and thwart them without having to pay any attention to what those monsters at insurance companies say about anything.

Way to go, stalwart members of the CDI. I’m sure Peggy Robertson appreciates your efforts on her behalf.

Look, I’m not sure insurance companies have a role in health care/insurance going forward. Their business model does not seem workable to me in an era when we can help sick people a lot more than we once could by spending a lot, lot more money than we once did; when people increasingly think health care is a God-given right; and when any hint of profit is considered the mark of the devil. This country spends about $8,000 per year on health care. If we accounted for our spending honestly, that would mean an insurance premium of $32,000 per year for a family of four. Darn few families could afford that. So the only route for insurance companies is to either raise premiums so high no one can afford them or do their best to weed out people who are actually sick. Neither one is sustainable in the long run. None of that means insurance companies are evil. It just means they are reality-based. It’s easy to rail about what insurance companies should be doing when you don’t have to meet an insurance company payroll or have enough in the bank to pay an insurance company’s claims. Dollars and cents, however, are not amenable to uninformed rhetoric.

We can try to regulate away the practices we don’t like but as Ms. Robertson can testify, reality cannot be regulated away. Of course Colorado can now turn around and require insurance companies to write individual policies with no exclusion of coverage and no higher premiums for women who have had Caesareans. The result would be that premiums for everyone with health insurance would go up. That’s a nice outcome for Ms. Robertson - everyone else is subsidizing her chance of having another Caesarean - but it’s not so nice for the other policy holders.

And, of course, States can require insurers to write standard individual polices not just for women who have had Caesareans but for people with diabetes and heart trouble, with cancer and multiple sclerosis, with any and all diseases and conditions you can think of. My State of New Jersey has basically done that. Our health insurance is very expensive and we may well be in that downward death spiral where regulators force insurers to cover everyone no matter how sick; insurers have to raise rates; fewer people can readily afford the rates so healthy people drop their health insurance; the people left in the health insurance pool are sicker on average; rates go up again; and the whole thing repeats until the only people with health insurance are those who are unlucky enough to be really sick but lucky enough to be pretty rich.

On the other hand, we can go down the path of the health bills passed by the House and Senate which somehow let us convince ourselves that we can cover 10 or 20 or 30 million more people without spending one more cent. Or down the path of single-payer where we can convince ourselves that health care is free because it will be paid for by taxes - and 95% of us will assume that the taxes will be assessed only on the other 5%.

Or we can finally admit that we can’t have everything for nothing and decide what we’re willing to pay for and what we’re willing to give up. Perhaps David Brooks is right and President Obama can become the leader who forces us to face up to those choices - or at least to realize the choices actually exist and can’t be wished away by everyone’s perfectly understandable desire to get what they want and leave someone else with the bill. It would be a great service to the nation and require an unflinching look at the reality of health care costs.

And that’s the reason I object so strongly to demonizing insurance companies: it’s just a way of pretending there are no choices to be made when it comes to health care. As long as we tell ourselves that all our health care woes are the result of rapacious insurance companies, we allow ourselves to refuse to look full on at why insurance companies really do what they do. That means we allow ourselves to refuse to acknowledge that money only goes so far, everything we want has to be paid for by someone, and the more we want the more it’s going to cost.

*****

Afterword:

I was going to write about Peggy Robertson when I first read about it last October but never got around to it. I decided to revisit it after Movin’ Meat put up a post about another example of how stupidly Colorado is regulating its insurance companies. I’m really sorry the Colorado Division of Insurance is incapable of doing a competent job but I don’t think that’s a very good argument for passing a massive overhaul of the entire nation’s health care/insurance.

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.

Swine flu vaccine

My doctor’s office has informed me they have received a limited amount of swine (H1N1) flu vaccine. They can only provide the swine flu vaccine to certain approved groups. Doctors must report each dose given to the State health department and explain why the person vaccinated was eligible to receive the vaccine. The approved groups are:

- pregnant women
- those caring for infants under 6 months old
- those 4 to 24 years old.

The vaccine is also recommended for children between 6 months and 4 years old but my doctor’s office has not yet received “an approved formulation” for those children.

I assume the eligible groups have been defined as people under 24 and those closely associated with them because viruses similar to H1N1 have turned up in the past and so the theory is that anyone over 24 probably has some immunity to the new variant.

May I just say I personally find that less than reassuring. My entire immune system was wiped out ten years ago - I had to be revaccinated for polio and so on - so I do not have any hope of being at all immune to H1N1. In addition I have a damaged lung which means it would be a really, really bad idea for me to get any serious respiratory illness.

Do I think the initial restrictions are wrong? No, not really. I’m all for protecting the young first. But I will be watching with a great deal of interest to see how much flexibility doctors have if the next release of swine flu vaccine is also inadequate to meet the demand. Will there come a point where supplies are still limited but doctors are allowed to exercise some discretion in deciding who gets the vaccine? I’m never going to fit into an endangered age group - I’m over 24 and under the 65 and over group that usually gets priority - so the only way I’m going to move up the list is if my doctor is allowed to use her knowledge of my health history to make a judgment call.

You see why the idea of having the entire health care system run by the government makes me nervous.

Figment and reality

Figment and Reality has commented on my earlier “Rape is a pre-existing condition” post. As so often seems to happen my response to him has grown to post length. I don’t disagree with what F&R has written - with one exception - so I suppose this is not technically a response to his comment. Rather his comment has provided a springboard for me to expand on some thoughts.

F&R writes:

If we follow the conclusion of the insurance company, it would be best if she bought the drugs on the black market to prevent being labelled with the pre-existing condition tag. Should she later discover she indeed contracted HIV, then since they did not know about it, they would be required to cover it. Instead, by being responsible, she is being penalized.

I agree wholeheartedly that this situation is - for both society and Susan - stupidly arranged. Obviously Susan should be able to take care of herself medically and clearly society is best served when people at risk of serious illnesses - particularly communicable ones - seek quick and aggressive treatment. The disconnect comes when people use this story to condemn the insurance industry. It is indeed in Susan’s best interest and in society’s best interest for Susan - anyone - to seek medical treatment without fear it will keep her from getting health insurance down the road. But by what logic is it an insurance company’s job to serve either Susan’s interest or that of society? Insurance companies are profit-making entities. They exist to serve their paying customers and - if they have them - their shareholders.

If society believes pre-existing conditions should never prevent someone from getting health insurance then society needs to assume the burden of making sure that happens. To force that burden onto private companies is stupid and short-sighted - unless the goal is to see the companies fail.

It is perfectly logical to use Susan’s case to demonstrate the need to rework our health care/insurance system so that pre-existing conditions do not prevent someone from obtaining health insurance and therefore top notch health care. However, to use Susan’s case to “prove” the insurance companies are the villains of health care or that the “bastards have brought [health insurance reform] upon themselves with their despicable practices” reflects either a total lack of understanding of the really rather simple realities of pre-existing conditions or a regrettable willingness to demonize an industry to achieve a political goal. Leaving aside the moral problems of demonizing companies - which are, after all, made up of living, breathing human beings just like you and me - the practical problem is that demonization does not lead us to figure out where the problems in the current system really lie. In fact, demonization virtually guarantees we will misidentify the problem; it is designed to do just that. And if we misidentify the problems we have virtually no hope of designing solutions which actually fix the problems.

F&R continues:

She had to go to a Doctor to get the prescription, he/she recommended the meds as Prophylactic care and she is now being told that her potential exposure is now a pre-existing condition and obviously did not have insurance at the time of the Rape.

Actually Susan did have health insurance at the time of the rape. The story specifically refers to her losing her health insurance and seeking new coverage. We don’t know why she lost her health insurance: she may have lost her job; she may have gotten insurance through her husband’s job and he lost his job or they were divorced; the premiums may have become too much for her to handle and she was looking for cheaper insurance; she may have had private insurance at the time of the rape and lost it when she moved to another State. All of which lead to Figment’s next point:

From what I read, the one very important part of any health plan discussion has to be true portability. With portability, pre-existing doesn't occur, as long as you don't have insurance lapses.

Yes, but. There is a problem with true portability for the insurance companies. JustOneMinute is suggesting a plan he calls “Once Covered, Always Covered”:

My Tough Love approach would be to rank insurance policies and legislate that anyone with, for example, a Class One coverage cannot be denied Class One coverage by another insurer at prevailing rates. In other words, people only have to pass through the door once; after that first insurance company covers them, they can buy coverage for life. People who take their chances and don't buy insurance when they are young face the risk of getting the Tough Love message (which will be as tough as that faced by the current uninsured, namely, emergency room and clinic care.)

This sounds very fair to those of us who buy health insurance: if we’ve faithfully paid premiums for years why should we be denied coverage for a “pre-existing” condition just because we now want to - or need to - buy insurance from a different company? That condition didn’t exist previous to our ever buying insurance; it just exists previous to our buying this particular health insurance. And that, of course, is the sticking point. If I’ve paid premiums for years to, say, United Health Care and now I’ve got diabetes why should Blue Cross Blue Shield have to cover me? It’s UHC that got all those premiums for all those years when I was perfectly healthy; why must BCBS take me on knowing my premiums couldn’t possible cover what I’ll cost them? Insurance companies are not fungible.

The counter-argument would be, I suppose, that this will all even out. But it won’t. I can easily envision a situation in which ABC Insurance has really low premiums but achieves that by paying health care providers as little as possible (resulting in very few who take their insurance) and by denying as many claims as possible. Meanwhile XYZ Insurance charges substantially higher premiums but pays health care providers very well (and has a huge network) and processes claims fairly. Why wouldn’t I enroll with ABC Insurance as long as I was well and switch to XYZ Insurance if I ever became seriously ill?

A similar situation arises if I live most of my life in a relatively poor State with relatively unsophisticated medical care. My insurance premiums are low. Then I become seriously ill; let’s say I have cancer. Now I move to New York or New Jersey to be near the world-class medical care available there; my insurance premiums are high. Why do the New Jersey insurance companies have to take me on? They haven’t seen a dime from me for 40 years and I’m going to cost them a fortune.

We can get around this, of course. We can write government regulations that make sure JOM’s Class One designation not only includes what a policy covers but also takes into account reimbursement rates and how many providers are in a network and the percentage of claims paid and whatever else an insurance company can do to make its policies more or less desirable plus some kind of weighting by State. (We have now re-invented the Bronze, Silver, Gold, Platinum designation in the proposed “Exchange” - which was itself a re-invention of the Federal Employee Health Benefits Plan. She nagged.) We could require an insurance company to cough up some money when one of their policy holders switches to another company: prorate it based on years covered or something like that. Of course both of these ideas mean Yet More Government MicroManagement and so we’ve circled back around to something I’ve said before: if insurance companies are going to become public utilities we might be better off just going with a straight government program. It removes a layer of bureaucracy and cost and it puts government on the firing line rather than letting it blame all the intractable problems of health insurance on those horrible insurance companies.

F&R points out:

That was the intent of COBRA but it does not work as applied when the premiums under COBRA exceed your unemployment check.

Yes, COBRA is an idea that resulted from an attempt to do good without being willing to ante up any money.

Finally, the part of F&R’s comment that I do disagree with:

As far as the media playing to their audience, what else can we expect? They are rewarded financially by having larger audiences and our world runs on money. The headline caught me, just like the rest of us in this blog. If they (or you) had changed the title, few would listen or read about it. There is truth to the theory that "if it bleeds, it leads" in the newroom. Profits are what keep the news companies running but it is unfortunate that opionions get confused with real news.

I can buy that argument for newspapers and television which must capture readers to sell advertisements to stay in business. I don’t like it but I can buy it. I can’t buy it for your basic blogger who is - I assume - blogging in an attempt to add value to the very serious discussion we should be having about how our current health system functions, what causes the problems we see in it, and what we can do to fix those problems. I first found this story - and headline - at a blog that has done some helpful writing on cost shifting and malpractice - including an objection to Ezra Klein’s “Pollyanna-ish belief that ‘if doctors were just better, we wouldn't have these lawsuits’” because it “betrays a lack of real-world experience actually delivering health care.” I expect more from such a thoughtful blog than “if health insurance companies weren’t such bastards, we wouldn’t have a problem with pre-existing conditions like Susan’s.”

*****

Reading:

Megan McArdle is explaining how the public option can drive reimbursements for health providers below sustainability. (I discussed this problem here although McArdle is of course doing so much more pithily.) McArdle is also wondering how health care providers will react to health reform that will be bad for their reimbursement rates.

I’ve recommended David Mamet’s piece before but I think it’s worth re-reading in the context of demonizing insurance companies.

Oregon Offers Terminal Patients Doctor-Assisted Suicide Instead of Medical Care

In July of 2009, RedState put up a story about Randy Stroup, a 53-year-old man with metastatic prostate cancer who applied to Oregon’s government-run Health Plan to pay for his treatment. The Plan refused to pay for the treatment but offered to pay for physician-assisted suicide. This, RedState tells us, is a look at “The Future in ... Barack Obama’s America”.

Well, not exactly. The RedState article lacked some important context. First, it did not explain that Oregon refused to pay for Mr. Stroup’s chemotherapy because:

Oregon doesn't cover life-prolonging treatment unless there is better than a 5 percent chance it will help the patients live for five more years

Back in the early 90s the State of Oregon established a tax-funded health plan to help the uninsured. This State health plan was intended to work within an established and limited budget while providing health care to as many needy people as possible. In order to do this the State figured out how much of the taxpayers’ money it was willing to spend on health care for the poor and uninsured. It then produced a list of treatments ordered by effectiveness. It determined how much each treatment would cost and estimated how many of each treatment it would have to provide. It calculated an extended price for each treatment on the ordered list, kept a running total, and drew a line when the total equaled the amount of money it had to spend. Everything above the list would be covered; everything below would not. It’s not clear that this approach succeeded: political pressures seem to have resulted in a rather small list of disallowed procedures and made the attempt to live within a set budget ineffective. One restriction that does survive is that the Oregon Health Plan will not pay for cancer treatment when there is less than 5% five-year survival rate. This is why Mr. Stroup’s treatment was not covered. (pdf; Prioritized List of Health Services, pp. 17-61)

There is another point about Mr. Stroup’s experience that was not made clear at RedState or at the Fox story RedState linked. The Oregon Health Plan does not offer terminally ill patients a choice between no medical care and State-paid physician-assisted suicide. Rather it offers terminally ill patients “comfort/palliative care” and - despite the title of my post (taken from the Fox story) - comfort/palliative care is medical care. Specifically, here’s what comfort and palliative care means under the Oregon Health Plan (same pdf; see page 93):

COMFORT/PALLIATIVE CARE

It is the intent of the Commission that comfort/palliative care treatments for patients with an illness with <5% expected 5 year survival be a covered service. Comfort/palliative care includes the provision of services or items that give comfort to and/or relieve symptoms for such patients. There is no intent to limit comfort/palliative care services according to the expected length of life (e.g., six months) for such patients, except as specified by Oregon Administrative Rules.

It is the intent of the Commission to not cover diagnostic or curative care for the primary illness or care focused on active treatment of the primary illness which are intended to prolong life or alter disease progression for patients with <5% expected 5 year survival.

Examples of comfort/palliative care include:
1) Medication for symptom control and/or pain relief;
2) In-home, day care services, and hospice services as defined by DMAP;
3) Medical equipment (such as wheelchairs or walkers) determined to be medically appropriate for completion of basic activities of daily living;
4) Medical supplies (such as bandages and catheters) determined to be medically appropriate for management of symptomatic complications or as required for symptom control; and
5) Services under ORS 127.800-127.897 (Oregon Death with Dignity Act), to include but not be limited to the attending physician visits, consulting physician confirmation, mental health evaluation and counseling, and prescription medications.

Examples of services which are not intended to be covered as comfort/palliative care include:
1) Chemotherapy or surgical interventions with the primary intent to prolong life or alter disease progression; and
2) Medical equipment or supplies which will not benefit the patient for a reasonable length of time.

Physician-assisted suicide is legal in Oregon and the State’s Health Plan offers it as one of a range of palliative options. Personally, I think legalizing physician-assisted suicide is a terrible idea; Ezekiel Emanuel’s 1997 Atlantic article makes the dangers inherent in such a policy quite clear. However the voters in Oregon have decided they want terminally ill people to have that option and since it is legal it is offered as one of the comfort and palliative care options. It is not, however, the only care option available to Mr. Stroup under Oregon’s Health Plan. The Plan is also willing to pay for Mr. Stroup to enter a hospice when his disease becomes more serious. If he prefers to die at home the Oregon Health Plan will pay for him to receive hospice care at home. The Plan will pay for him to receive pain medications. If he needs a wheelchair the Plan will pay for that. Mr. Stroup can choose from the full range of medical care usually consider comfort/palliative care.

The Oregon Health Plan is attempting to conserve a scarce resource: tax dollars available to fund health care for the poor and uninsured. The government of Oregon realizes that if agrees to pay for very expensive treatments with very little chance of success it will have to do one of two things: provide care to fewer poor and uninsured people or raise more money for the Health Plan through higher taxes. By focusing on physician-assisted suicide and failing to consider the broader offer of palliative care, the RedState story insures that anyone who reads Mr. Stroup’s story will insist the State should have paid for Mr. Stroup’s chemotherapy - and that their failure to do so is a condemnation of government-run health insurance.

Yet this formulation obscures the issue that is really at the heart of this story: are we willing to spend whatever amount of money it takes to make sure that everyone gets every possible treatment? Surely there must be cases like this under government programs where physician-assisted suicide is not an option, where the government has refused to pay for an expensive treatment that is likely to prove futile while offering to pay for all necessary comfort and palliative care. If we remove the option of physician-assisted suicide from our thinking, are we still prepared to argue that the government should have paid for Mr. Stroup’s chemotherapy? Are we prepared to argue that so long as there is any chance whatsoever that a treatment might save someone - or might prolong his life for a few months or might make his last few months more comfortable - we will pay whatever amount of money is required to provide him with that treatment?

If our answer is “Yes” then must understand what that means: higher taxes for all of us. If we are not willing to write a blank check for a government-run insurance plan then we need rules that tell the government how much we’re willing to spend and how we want that spending allocated. The Oregon Health Plan was designed to have a limited budget and allocates spending by covering some treatments and not others. If you flinch from this and believe everyone like Mr. Stroup should be given every possible treatment then we’re back to unlimited spending on health care and higher taxes. There is no magical third option.

Yes, you say, that’s a problem with government-run health insurance; people with private insurance don’t encounter the same problem.* Actually people with private insurance encounter exactly the same problem. In as nice a bit of sleight of hand as I’ve seen lately, ABC managed to report on the physician-assisted suicide issue in Oregon and turn it into a condemnation of insurance companies.

The ABC story begins with Barbara Wagner who also had metastatic cancer and who also was denied treatment by the Oregon Health Plan due to her poor prognosis. It took ABC eleven paragraphs of references to Ms. Wagner’s “insurance company” before it explained that the “insurance company” was actually “state-run”. After presenting Ms. Wagner’s case; briefly mentioning Mr. Stroup’s case; discussing the (undeniably) incredibly insensitive letter the Oregon Health Plan uses to deny care to the terminally ill**; and warning of the dangers of physician-assisted suicide in a cost-cutting setting, ABC goes on to discuss an executive who is fighting his insurance company to force them to pay for Sutent to treat his liver cancer. The executive is no different from Mr. Stroup except that the executive has a private insurer instead of a government one. But the private insurer faces the same dilemma as Oregon’s State-run Health Plan: the more extremely expensive treatments it covers the more premiums are going to rise. This will mean some people who could have afforded health insurance are not going to be able to do so and will become uninsured and -presumably - receive worse care. Just as is the case with Oregon’s government-run Health Plan, paying for every costly treatment available means either higher costs for everyone or fewer people covered or both.

The ABC story contains two quotes that make it clear people are unable or unwilling to see this reality. The first quote comes from the executive who wants his private insurance company to pay for Sutent:

Most of my objections are that some second rate guy on the staff of the insurance company is second-guessing one of the foremost authorities and trumping his judgment[.]

I’m pretty sure the guy on on the staff of the insurance company isn’t second-guessing the executive’s doctor’s medical judgment. I imagine that guy - whatever rate he is - believes absolutely what the executive’s foremost authority is saying: Sutent will cost $54,000 and might - might - extend the executive’s life by six months. However the insurance company guy also knows two other things: paying for Sutent was not something the insurance company included in its calculations when it set the executive’s premiums and if it starts paying for Sutent - and other drugs like Sutent - premiums are going to have to go up for everyone. It’s not the facts about what the drug might do that are in question; it’s whether the drug is worth the money it will cost. Understandably it’s worth any amount of money to the executive; if he had the money to pay for it himself he would. Equally understandably it’s not worth what it costs to the insurance company - and it may not be worth what it costs to the insurance company’s other policyholders.

The other quote that demonstrates an unwillingness to face the reality of the connection between more care and more money is this:

"[Ms. Wagner’s] case is hardly unique," said Michigan lawyer Geoffrey Fieger, who defended Dr. Jack Kevorkian's crusade to legalize physician-assisted deaths. "In the rest of the country insurance companies are making these decisions and are not paying for suicide," Fieger told ABCNews.com. "Involuntary choices are foisted on people all the time by virtue of denials."

"I am surprised there hasn't been a revolt in this country," he said. "It happens every day and people are helpless."

Let’s give Fieger the benefit of the doubt and assume he’s not suggesting revolt because insurance companies won’t pay for suicide. Then we have to ask: what would be the goal of his revolt? To force insurance companies to pay for every possible treatment? That doesn’t require a revolt; it just requires that subscribers be willing to pay higher premiums. To turn health insurance over to the government? That would simply transfer the problem from insurance companies denying treatment to the government denying treatment. And if we aren’t happy with that then we can force the government to pay for every possible treatment - so long as we’re willing to pay higher taxes instead of higher premiums. A revolt is not going to change the fact that if you want more care you have to pay more for it.

Like the dilemma of pre-existing conditions the conflict between our desire for all possible care and our desire to not bankrupt ourselves paying for it is a conflict inherent in the nature of health insurance. It is not an issue that arises only with private insurance companies or only with government-run health insurance. If we want private insurance and all possible care then we have to be prepared to pay higher premiums. If we want government health insurance and all possible care then we have to be prepared to pay higher taxes. If we’re not willing to pay higher sums to either private insurers or the government then we have to accept that someone, somewhere is going to have the power to decide that the treatment your doctor tells you might prolong your life, tells you might - if combined with a miracle - save your life, is simply not worth the money to your fellow taxpayers or your fellow subscribers.

I understand that most people want every possible chance at every possible moment of life. I stood where Ms. Wagner, Mr. Stroup, and that unnamed executive stood. My doctors went to bat for me and my private insurance company paid for me to get that less than 5% chance. That was ten years ago which means I got very, very lucky. If we as taxpayers or we as premium payers decide that we want everyone to have the chance I had, that’s our decision to make. But we have to realize the cost. And we have to stop kidding ourselves that if only we had private insurance instead of government-run or government-run insurance instead of private, the reality that more care costs more money would magically disappear. It won’t. Reality is stubborn that way.

*****

* It’s a charming bit of irony that a Right-leaning Website like RedState is up in arms over the Oregon Health Plan being unwilling to treat Sam when - as their own post makes clear - Sam was “Uninsured and unable to pay for expensive chemotherapy”. In other words, Oregon was at least willing to pay for comfort/palliative care for Sam; the private market was unwilling to pay for so much as an aspirin.

** The ABC story quoted an Oregon Health Plan official as saying the Plan intends to increase sensitivity by having someone from the Plan phone patients to deny them treatment and suggest comfort/palliative care. I cannot imagine anyone staying in that job for more than a week.

*****

Afterword

I have written about Randy Stroup and Barbara Wagner in the present tense. However both the Fox story about Mr. Stroup and the ABC story about Ms. Wagner appeared in the Summer of 2008 - more than a year ago. As the Fox story makes clear, the Oregon Health Plan eventually agreed to pay for Mr. Stroup’s chemotherapy. Although it made an exception for Mr. Stroup, Oregon apparently was not willing to make an exception for Ms. Wagner. However Ms. Wagner’s doctor appealed to Genentech, the pharmaceutical company that makes the medication she needed. Genentech agreed to supply a year’s worth of the drug free of charge.

Randy Stroup died July 16 of this year. He was 54. I have also read that Barbara Wagner died although the blog that reported this did not provide a source. I am terribly sorry that neither Mr. Stroup nor Ms. Wagner shared my luck.

Rape is a pre-existing condition

[Updated October 22, 2009, at 7:10pm: I fixed the Category. It should have been Med Stories.]

I hate stories like this. A woman (let’s call her Susan) believed she had been drugged and raped so she took anti-HIV meds to be on the safe side. When she applied for health insurance she was denied coverage because she had a pre-existing condition and told to try again in a few years if she was HIV-free.

What happened to Susan was terrible. She did the smart thing for herself medically by taking HIV meds and as a result she made herself uninsurable for three years. That certainly doesn’t seem fair.

However the reason I hate stories like this is that they rely solely on eliciting an emotional response and have no interest in the sort of long analysis that needs to be done to figure out what such stories are really telling us. In fact stories like this are intended specifically to keep us from doing any such analysis. The title of this post expresses this perfectly. It’s the title of the post at Movin’ Meat where I found this story; a Google search for that phrase plus “Susan’s” last name yields 800 hits. The title is certainly dramatic and enraging but is it accurate - or even defensible? No.

Let’s assume the insurance company is correct that it will be three years before Susan can know for sure whether she has contracted HIV. That is, latent HIV is a medically valid pre-existing condition. The insurance company has not made a medical error in its analysis of the situation. I do not know for certain that this is the case but Movin’ Meat didn’t argue otherwise so I’m taking it as a working assumption.

So Susan does have a pre-existing condition and the insurance company is treating it accordingly. It is not rape that is a pre-existing condition but latent HIV. Those who insist this is an example of rape being a pre-existing condition are saying that the insurance company was wrong to deny coverage to Susan since her exposure to HIV was a result of rape but would be perfectly justified in denying coverage to Susan if she had been exposed to HIV:

- as a result of one episode of consensual sex;

- through sharing a needle once;

- because she was a health care worker who treated a patient with HIV; or

- because she was a newborn whose mother was HIV positive.

So let’s talk about what these beliefs will look like when translated into health insurance legislation. We will forbid insurance companies to deny coverage to people whose pre-existing conditions were the result of rape. On the other hand, people whose pre-existing conditions were not the result of rape can be denied coverage.

Somehow I don’t think that anyone who is pushing the “rape is a pre-existing condition” line really wants that kind of legislation. Stories like this are not supposed to lead one to draw conclusions - or even to think them through. These stories are designed to make those who read them angry and sad and horrified at the villain of the piece - the insurance company - in order to achieve a goal - support for health insurance reform that is not in the interest of insurance companies. These stories do not lend themselves to careful consideration of exactly why we find them heart-wrenching which means they do not advance the cause of thinking through what we find objectionable in our current health care system. And they certainly don’t support attempts to consider what correcting the perceived horror will entail. They have no balance, no other side.

Susan’s story is not about rape. It is about - or should be about - how we want to handle pre-existing conditions. This in turn should lead us to a discussion of why insurance companies handle pre-existing conditions the way they do - because if they didn’t exclude people with pre-existing conditions they’d go out of business. From there we should consider whether we want to force insurance companies to accept people with pre-existing conditions. If we do then we have to realize that doing so will either drive health insurance premiums through the roof or put insurance companies out of business in short order. If we think putting health insurance companies out of business is a desirable outcome then we have to discuss how we’re going to handle health insurance instead. This almost certainly means some type of government intervention. The choices for government-run health insurance are the same as those for privately-run health insurance: everyone must buy in; buy-in is optional but pre-existing conditions get you excluded; or everyone who buys in is supporting those who wait to buy in until they’re sick.

On the other hand, if we want to avoid putting insurance companies out of business then we have to force everyone to buy health insurance from them. If we are not willing to do that then either we have to live with insurance companies denying coverage to people with pre-existing conditions or we have to live with sky-high premiums or we have to accept that government needs to provide health insurance in some way: either by taking it over completely or by providing health insurance for people with pre-existing conditions. If the former then we’re back to the same three choices: everyone must buy in; buy-in is optional but pre-existing conditions get you excluded; or everyone who buys in is supporting those who wait to buy in until they’re sick. If the latter then there is no choice: we all support those who wait to buy in until they’re sick.

Framing Susan’s story as “rape is a pre-existing condition” short-circuits that entire discussion. It makes it clear that the only decent responses to her story are to insist that no insurance company should be able to deny her coverage for her pre-existing condition and to accept that insurance companies are clearly rotten to the core. Only someone with ice in her veins would read Susan’s story and then point out that an insurance company needs to remain solvent and that providing coverage to someone who may have an extremely expensive pre-existing condition will make insurance more expensive for everyone else who buys it. And only a monster would point out that - whatever advantages government-run health insurance might have - it does not eliminate the relationship between required coverage and pre-existing conditions. A government-run plan that does not require everyone to enroll will face exactly the same issue: what to do about someone who is not enrolled in health insurance, who may have contracted HIV, and who now wants to sign up. Conversely if private insurance companies operated in a community where everyone was required to have insurance coverage this situation would never have arisen.

On paper the Baucus bill understands this relationship. It requires insurance companies to accept applicants with pre-existing conditions; this resolves situations like Susan’s. It balances this requirement with an individual mandate: everyone must buy health insurance. This gives insurance companies a big enough pool of healthy people to dilute the cost of covering those with pre-existing conditions. It also - and more importantly - means that there will no longer be people with pre-existing conditions who are not insured but want to become insured. So from that standpoint the Baucus bill looks reasonable.

There are reports, however, that the fines for the individual mandate are being decreased. If they are decreased to the point that they are no longer coercive or if they are not enforced we will have written exactly the kind of bill that Susan’s story could be expected to produce: one containing an emotional response to the problem of pre-existing conditions but lacking any understanding of the realities that cause that problem.