HEALTH CARE/Joan Retsinas

Nostalgia, or Careening Back to the Future

Full speed ahead! It is back to the future, at warp 10.

But what a future, health-wise!

As the good old days approach, they don’t look so good.

This Administration mourns the golden era when Uncle Sam stood back from the insurance marketplace, leaving private sector insurers free. The sin of Obamacare: it unleashed a heavy-footed Uncle Sam to clamp down on insurers with an exhaustive list of musts and mustn’ts.

Many in Congress want to slash that list. Insurance companies will be free at last, as they were in the good old days.

On the chopping block: “essential benefits.”

Once upon a pre-Trumpian time, you could buy a “lite” policy. Optional were: emergency room care, mental health, inpatient hospitalization, outpatient care, maternity care, newborn care, mental health and addiction treatment, lab tests, preventive care, medications, and/or pediatric care. One policy wouldn’t exclude everything – but could include a grab-bag of benefits. The obvious result? Cheaper premiums for people who bought cheap policies. The overlooked result? Hordes of “underinsured” Americans who went to their physician, heard a diagnosis, then learned that their insurer wouldn’t cover the cost of treatment.

Some policies bordered on the fraudulent; they offered few protections against the catastrophic costs of illness. Conservatives praised other policies as “Model Ts,” more affordable than “Mercedes” policies; but the analogy with cars was specious. Every car needs the basics, like engines, carburetors, pistons, tires, mufflers, seat belts (though maybe some in Congress would like to get rid of this requirement). Nevertheless, the lure of “lite” policies remains strong with insurers eager to market them, consumers eager for low premiums, employers eager to return to “mini-med” plans.

Obamacare did away with “lite” policies. The Affordable Care Act mandated 10 “essential benefits.” No matter the insurer, no matter the state (state requirements in the good old days allowed wide variation in policies), any policy had to include the basics.

Those “essential benefits” will now be optional, under the bill House Republicans passed. The ironies mount. We don’t easily allow abortion; we are making maternity care optional. We blame gun deaths on mental illness, not on easy access to guns; we are making mental health care optional. The states record an opioid epidemic; detox will be optional. In the ascendance of managed care decades ago, state legislatures were awash in bills to “mandate” emergency room care, alcoholism treatment, maternity care. Consumer-patients rebelled at same-day mastectomies, limited formularies, their insurers’ lists of “not covered.” We are rushing back to that future.

Throughout the debate over Trumpcare, the 56 million Americans insured through their workplaces have been complacent. The media has zeroed in on Medicaid, and on “pre-existing condition” exclusions in individual market policies. Yet these Americans will also go back to the future.

Proposed: optional insurance. In the good old days, employers could — or could not – offer insurance. The Affordable Care Act changed the rules: employers who did not insure their workers faced a fine. Republicans propose to drop the fine. Insurance once again will be optional. While large employers might continue to offer coverage, smaller and/or less-solvent ones might simply drop it.

Those policies will cost employees more. The Affordable Care Act was clear: employers had to offer “comprehensive” (think of the essential benefits) that were “affordable” to the employee. Uncle Sam was meddling in employer/employee relations, with a heavy hand.

No more meddling. While many economists predict that most employers will not modify their benefits (even though they could), those employers might rethink “affordable” as they, with impunity, raise co-payments and deductibles, require a larger premium from employees, and eliminate the annual caps (the Obamacare limits: $7,150 for an individual, $14,300 for a family).

Of course, the more limited the policy, the greater the burden on the employee. Consider: a policy that does not cover emergency room visits leaves a patient with a minor injury – a broken leg, for instance — with a four-figure bill. Physicians routinely recommend colonoscopies, mammograms, bone density test, MRIs; a patient would pay thousands out of pocket for them.

Evoking nostalgia for a past that was hardly rosy, conservative legislators are pushing us back to a grim future. But they won’t be living in the grimness: they have comprehensive affordable health insurance, courtesy of us, the taxpayers.

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

From The Progressive Populist, June 15, 2017

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