HEALTH CARE/Joan Retsinas

Health Care Dives Down the Rabbit Hole

Lewis Carroll plunged Alice down a delightfully upside-down Rabbit Hole, where logic was illogical. A confluence of forces, political and economic, plunged the American populace down a scarier health care Rabbit Hole.

As in Alice’s hole, logic was upside down. Consider a syllogism. Premise one: The United States has wondrous medical care. If you are ill, this nation has the expertise, the tests, and the elixirs to help.

Premise two: The United States has a swathe of seriously ill and disabled people.

Conclusion: Those Americans – the sickest, the most disabled among us — benefit from our wondrous medical care.

Before last year’s passage of the Accountable Care Act, the conclusion did not follow. In Health Care USA, logic was illogical. The challenge for reformers has been to restore logic, to pull Alice from the rabbit hole.

Pre-reform, the dilemma was real: we had wondrous medical care, but the Americans who needed that care often could not pay for it. The system of care focused on keeping us healthy; insurance, a for-profit business, focused on profits. The two goals didn’t dovetail. And, not surprisingly, the latter trumped the former.

So insurers routinely limited their risks, using numerous strategies – all legal, all good business decisions.

First, they used disability and illness as key factors in setting rates for enrollees in the individual non-group market. Since people (under age 65) who are seriously ill or disabled are less likely to be employed full-time, they must enter the non-group market for insurance. In that market, premiums are higher. Once insurers factor illness and disability into their applicant’s “experience” rating, the premiums soar higher. The sicker the enrollee is, the higher the premium. Insurers could even reject an applicant as “uninsurable.”

Second, insurers instituted ‘pre-existing condition” exclusionary clauses – again, legal and good economic sense. Insurers refused to cover whatever a new enrollee suffered from for six months, a year, sometimes longer.

Alice would marvel at the idiocy: A person with cancer, hypertension, diabetes, arthritis (name a malady) is unemployed and, consequently, uninsured. Happily, the unemployed person lands a job with health insurance. But the policy won’t pay to treat the malady.

Third, the policies excluded coverage of complicated, lengthy, and expensive treatments. The “wellness” policy would cover preventive exams, immunizations, regular tests, maybe even eyeglasses, but not a liver transplant, open heart surgery, or rehabilitation after a stroke.

The Accountable Care Act took a goal that would have astonished the Mad Hatter: reformers wanted the people who needed the most care to get the most care. Towards that end, the Act axed pre-existing condition exclusionary clauses, took aim at the “maximum” spending caps, and required “essential health benefits” in policies. The “essential health benefit” will spell out what a policy “must” cover. We have always known what a policy “should” cover, but insurers have not been bound by those “shoulds.” So Americans’ policies have run the gamut, from comprehensive to spotty.

Under this Act, the Secretary of Health and Human Services is empowered to define coverage; age, illness, and disability – key predictors of rates and benefits in the Rabbit Hole – are no longer supposed to guide decisions.

The Act is now one year-old, a shaky toddler. Even as the Act is slowly pulling us out of the Rabbit Hole, some Americans are screaming “repeal.”

They want to return to the illogic of Health Care USA. They want insurers to prevail. They want exclusionary clauses, high rates for people who are ill or disabled, low caps on spending, and skeletal policies. Presumably the screamers fared well in the Rabbit Hole. Presumably they are healthy.

But I am optimistic that the shaky toddler of a law will grow stronger, more entrenched – much as Medicare did almost 50 years ago. Americans will look back at those years pre-reform with horror. In the not-so-distant future, when all Americans, even the sick and disabled, benefit from stellar care, we will wonder why we stayed so long in the Rabbit Hole.

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

From The Progressive Populist, May 1, 2011

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