My feelings about healthcare reform and how to fix our medical system have evolved over time. I've heard some of the proposed replacement solutions for the ACA as it currently exists.
I used to be a strong advocate for HSAs and healthcare choice. I can't say that I have abandoned them completely, there are some people for whom an HSA may be an ideal solution. Of course, the point of an HSA plan is to have lower premiums on a high deductible plan, which is almost unheard of right now (when I had an HSA/high deductible plan, my premium was nearly that of a standard plan, so it wasn't really worth it).
As to interstate competition for insurance plans: the reason insurance companies aren't allowed to currently sell plans in other states is because they used to do that, and people in New York would find themselves with an Alabama plan that did not was not accepted by any of their local providers, making the coverage essentially useless to them.
This isn't meant to be a wonky piece with all sorts of details and numbers, so if you're looking for that, I'm sorry. This is a piece about why I have come to support universal health coverage (Medicare for all).
I'm going to give you the story of a patient. It could be anyone you know. It's happened to me as a physician more times than I care to count.
About a month ago, a patient walks in to my office with a chief complaint of "I have cancer."
Just over 2 years ago, she got a free mammogram through a breast cancer awareness program. She had an area that was recommended to be removed. She went to a surgeon who, as she put it, treated her like garbage because she didn't have insurance. (In fairness, I don't know that the surgeon was bad to her or not, I just know that is how she felt she was treated by the surgeon and his staff.)
Either way, she could not afford the surgery to do the lumpectomy, and since no one directed her toward any sort of social work intervention or charity care program, she walked out of that appointment in 2015 and did not return.
A couple of months ago, she discovered that one of the local hospitals has a mammogram assistance program, and here's where I entered her story. She can't get the free mammogram unless she has a doctor to order it. Since our office visits only cost $69, she shows up here just asking for a mammogram order. She doesn't want a physical, she doesn't want blood work, she doesn't want anything else. She just wants a mammogram order.
I tell her I'd at least like to do an examination (check her vital signs, listen to her heart and lungs, do a breast and abdominal exam, check her skin, etc). She says I don't need to, but fine, if that's what it takes.
She has a 6 cm mass in her breast. Two and a half inches.
I sign her mammogram order, as well as the orders for the additional views that they no doubt will request and an ultrasound, in case they might want one.
Now, every few days I get a faxed report:
A mammogram report showing a malignancy, she needs a biopsy.
A biopsy report saying that 3 samples were taken, and pathology results are pending.
Pathology results describe her cancer, she needs a referral to surgery and oncology.
Notes from a surgeon.
Notes from a cancer specialist (oncologist).
The notes all end with the same discussion: she is very concerned about the cost of her care. She is afraid she will be homeless while on chemotherapy for cancer. She doesn't think she can afford the prescriptions at the pharmacy for the nausea.
And I am angry about this situation.
I'm not angry that she has cancer.
I'm not angry that she might not be able to afford the treatment.
I am furious that 2 years ago, she could have had a surgery that was both biopsy and treatment. She could have had a surgery that would probably have saved her life. But she could not afford it because her job offered no benefits.
She worked full time.
She made okay money.
She isn't poor.
She is certainly not wealthy.
The severity of her illness means that now she will probably qualify for disability. This means that she'll end up on Medicare/Medicaid, and we'll all be paying for her treatment, which is now more expensive and intense than it would have been 2 years ago.
I'd like to say that this is an unusual case. It's not. For the last 16 years I've seen so many patients who defer, delay or deny themselves the simple interventions that they need because of the cost and because they have no insurance. Those patients invariably get worse until their issues become too big to ignore and require more intense and expensive intervention, and we all wind up paying for it.
Other examples I've seen:
A 30 year old with with severe fatigue who showed up in the ER needing transfusion of 5 units of blood, due to a bleeding ulcer he'd been ignoring for 8 months. A reaction to the blood transfusion led to almost a week in the hospital.
A 28 year old with a permanent elbow deformity after she fell at work and fractured her elbow. Her manager fired her when she tried to file a workman's compensation claim. She literally wrapped her arm in masking tape because she could not afford to get an xray or see an orthopedist.
A 40 year old who needed knee replacement for severe arthritis, but can't afford the surgery, so in order to keep working, she takes 120 oxycodone per month ($25/month with a coupon vs $45,000 average cost for knee replacement in the US).
A 58 year old with advanced colon cancer, who couldn't afford colonoscopy after a positive test in the office that was positive for blood in the stool.
A 37 year old with a long history of asthma who can't afford the steroid inhalers that prevent her flares, and so she winds up in the ER every couple of months and is admitted to the hospital once a year for severe asthma attacks.
So, no, I don't think HSAs are going to solve this. No, I don't think that selling insurance plans from Alabama to people living in New York will solve this. No, I don't think the ACA, as it currently is, will solve this.
Giving everyone access to coverage through a public health service is the closest we're going to get to prevent the working poor from slipping through the cracks and giving them the care that they need.