HEALTH CARE/Joan Retsinas

Back to the Future

In the year 2058, a high school history teacher assigns the topic: health insurance. In 2058 every American has a Medicare card. Twenty years previously a president whose last name wasn’t Bush or Clinton—students can’t recall her name (50 years from now, students are no more historically-literate than today)—made Medicare universal. Octogenarians hazily recall the time when our country’s pastiche of private, public and employer-sponsored insurance ended.

Students must explain the transition, searching in long-ago newspaper archives for a clue. What propelled Congress and the president to act? Did any events in 2008 presage the end, pointing to inherent flaws that would eventually topple the system? Back in 2008, the electorate, while distressed at the 47 million Americans who were uninsured—a number that was creeping up—hesitated to scrap the system. Republicans and Democrats divided along the schism. Many Americans accepted the status quo, admitting it was not ideal, but shied from a major overhaul.

What early warning articles did students unearth?

Here are three.

1) Hospitals’ decision to sell the revenue stream of debt-collections. (Hospitals Put Patients’ Debt Up for Auction, Sarah Rubenstein, Wall Street Journal, June 3, 2008).

In 2008, hospital debt grew to a point where collecting became a major business. Although hospitals tried to demand payment upfront, before treatment, uninsured patients still ended up in hospitals, still needed surgeries, nursing care, and rehabilitation. But middle-income patients could not pay: major surgery cost two years salary for a teacher. As the number of uninsured patients rose, so did hospitals’ debt.

Over time, the growing popularity of high-deductible catastrophic policies also bolstered hospitals’ debt. Many Americans grabbed these policies: they were perfect for healthy enrollees. Then those healthy enrollees got sick. They got treated, but they couldn’t pay the deductibles.

In 2008 a seer might have seen the start of a trend. By 2038 collection agencies had become a dominant, profitable health care industry. Investors bought securitized bundles of hospitals’ bad debt. Soon hospitals were racking up more debt than revenue.

2) Insurers’ decision to deny coverage to women who had had a Caesarean section. (Denise Grady, New York Times, June 1, 2008)

This decision presaged the end of the individual insurance market in the United States. Those insurers selectively underwrote. They charged higher premiums, or denied coverage, to high-risk applicants. A person who was HIV positive or who had multiple sclerosis struggled to find an affordable policy–indeed, to find any policy. Many insurers shunned this market. Although a few states created “high risk” pools for people considered “uninsurable” (strange concepts for students in 2058), those premiums were exorbitant.

People insured through their workplaces didn’t face exclusion: in a small pool, a sick enrollee would raise premiums for everybody, but the employer could not easily drop that one sick person. Yet as more employers turned to part-time, temporary and contract employees, usually to avoid putting them on the company insurance rolls, more people sought out “individual market” insurance.

In 2008 the individual market filled a crucial niche for healthy Americans who couldn’t get insurance through their workplace.

The decision to ban women who had had a Caesarean (30% of American women in 2008 had had Caesareans), however, spurred more denials. Soon afterward insurers said no to women who had had positive breast biopsies, and women whose weight, cholesterol or blood pressure exceeded normal. Eventually insurers extended threshold exclusions to men, adding prostate scores into the mix.

A seer would have seen the trend. By 2038 the “individual market” for insurance had disappeared.

3) A swathe of Americans married for health insurance. (“Getting married for health insurance,” Ricardo Alonso-Zaldivar, Los Angeles Times, April 29, 2008)

Forget love. Forget lust. Forget the desire for a family. In 2008, a Kaiser Survey found that 7% of Americans married, or knew someone who married, to get onto a spouse’s policy.

Americans had always seen insurance as a key benefit of work; many Americans stayed in jobs solely for the health insurance. Yet in 2008 some Americans found insurance a benefit of marriage. By 2038 people searching for love via internet matchmakers routinely listed not just their age, hobbies, and occupation, but their insurance status too.

The nation expanded Medicare when the private system collapsed. By 2038 more than half of Americans had no insurance. Hospitals, barely solvent, hounded insolvent patients to despair. The lovelorn married for insurance.

So it was no surprise when President what’s-her-name signed an executive order, making Medicare universal. A seer, reading the articles from 2008, would have wondered: What took them so long?

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, August 1, 2008

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