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insure-18_0I recently wrote a story for the state wide news website opinion page (published today) about 3 simple things Alabamians could do to raise our health ranking as a state from just above Mississippi to near Missouri. The solutions, from a set of policy recommendations put forward in the  Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) were, I thought, motherhood and apple pie. They included: Prevention of road injuries through enhanced enforcement; Implement diabetes treatment programs through expansion of primary care coverage and improvement in care delivery; and Reducing sexually risky behavior through targeting those most at risk (teenagers, not politicians).

To do this we will need to think about illness differently. We will need to focus on fixing a broken system. We will have to exhibit a collective resolve, state agencies will need to partner with other care providers and community leaders, and we will have a slight reduction in individual freedom. I don’t know if Alabama is ready for this, yet. I suspect that many Alabamians would prefer to see other’s personal responsibility  amped up instead. Why collectively try to fix a problem when we can blame the individual next door.

In Remedy and Reaction, Paul Starr describes our system as it exists until 2014

The United States took the critical steps in the formation of its health care financing system in the two post-World War II decades, when it turned decisively towards private, employer-based insurance and created separate programs for the elderly and for the poor. These were the years when the United States ensnared itself in a policy trap—a costly, extraordinarily complicated system which nonetheless protected enough of the public to make the system resistant to change.

Today, for those lucky enough to have a job that provides “good” insurance their illness care involves a lot of invasive testing and “machines that go ping.” For people who are uninsured, if they are lucky enough to roll their care, they will be rapidly transport via EMS to the nearest trauma center where they will, in addition to getting their wounds treated, get tested for diabetes. The motivation is not to keep the car from rolling or to prevent the diabetes.

In 2014, theoretically,the world (at least for Americans) change and everyone gets skin in the game. That is the crux of the Affordable Care Act. Health insurance will be “guaranteed issue” meaning that everyone gets it no matter what their “pre-existing condition” status is. The policy will be based on number of people covered, age, and smoking status. importantly for this discussion, it will also include a “geographic rating.” This will reflect, it seems, the cost of care and the number of sick people in the Metropolitan Service Area (MSA). The more uncontrolled diabetics, costly car accidents, or preterm births we have in our town, the more we will have to pay.

It appears to me that we will be required to take individual responsibility (the individual mandate). We are also going to have to take collective responsibility for our regional costs as well. Maybe we will become our brother’s keeper after all.

I’m giving a talk tomorrow to the first year medical students about financing health care. This is a talk I give every year, takes about an hour and a half, and it will be all of the information they get on this topic from our medical school for the next 3 1/2 years. The talk tracks health care financing from no insurance to the development of private “insurance,” public payment,and proceeds to the system as it is evolving as a consequence of the Affordable Care Act.

If you’re interested in why things are as crazy as they are, I refer you to The Social Transformation of American Medicine. This book, written in the 1980’s, is still the best resource for this subject matter. Written with attention to context, Paul Starr discusses the transition from a cottage industry which relied on patients paying cash (or other medium of exchange) into, well,  a cottage industry where large swaths of the population did not have access to care. For those who were not independently wealthy, it became clear early on that they would need to pool their money so that when the odd really bad thing happened, there was sufficient money from those to whom bad things had not happened to cover the costs. This was how private insurance came about. For some reason, major population groups were given access to alternative types of care (veterans, railroad employees).

The elderly were a special case. It was clear that every elderly person would need the service (at the time of Medicare’s passage 1 in 6 elderly went into the hospital on an annual basis) and they voted. Congress reported more mail on the subject of elderly access to health care than any other subject. The AMA, according to Mr Starr, was loath to give up the cottage industry aspect for this population. As a consequence, the law accommodated the needs of the elderly (access) and the desires of organized medicine (maintenance of the status quo) for this group. I refer you to the CMS website if you want to see the convoluted consequences of these compromises.

The poor were also a special case. Under the cottage industry model, the poor were the responsibility of the community. Care was delivered in public hospitals, by religious orders, by physicians delivering charity care, or more likely not delivered at all. Congress felt that the care was needed but was unwilling to take total control away from the states. As a consequence, Medicaid developed with a minimum level of services but allowed states to provide more services. Payment was a state-federal partnership. Medicaid thus has no long-term constituency (no one sees themselves as poor forever although many see themselves as old forever) and tends to be targeted for cuts by every governor, regardless of political affiliation.

All of these programs were tweaked over the intervening half century. Medicaid began to focus more on children and mothers-to-be in most states. As more illness moved outside of the hospital and the elderly couldn’t afford the medications, prescription drug coverage was added to Medicare. Cost containment has been a problem from the start, both in government programs as well as the private programs.

The New Republic has an amazing series about how the sausage was made to put together the Affordable Care Act, found here (subscription required). It turns out it was no different from the passage of Medicare or Medicaid—with one notable exception. When Medicare was being considered, the elderly were mobilized to assure its passage. The Affordable Care Act, by contrast, is focused on those who currently have no coverage and are unlikely to vote. It is disliked by seniors, possibly due to deliberate mis-information, and they vote. Interestingly, despite a rough start 45 years later Medicare is very popular and performs very well (although somewhat more expensively than it needs to). It may be that once the smell and taste of sausage is in the air the Affordable Care Act will be popular as well.

When I give the talk to the students, they politely listen. Although I am not old enough to have cared for sick elderly folks that were hidden in the attic for fear of exposing the family to medical bankruptcy, I am old enough to have cared for elderly  folks who were hospitalized because they could not afford life-saving medication. I still care for folks who have no insurance, and I have to game the system to get them needed care. I don’t know that the students appreciate how much easier Robert Kennedy and Lyndon Johnson (Medicare, Medicaid), George W. Bush (Medicare prescription coverage, expansion of the Community Health Centers) and Barack Obama (Affordable Care Act) have made their lives.

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