I’ve never really understood how we got where we are with health care in this country. It always surprised me that the major conduit for the provision of health care was an employer. Really – what does an employer have to do with health care? When I was a kid, I thought perhaps this was based on some civil policy that you somehow had to merit health care. Yet that didn’t make sense to me either – the coal miner’s widow, orphans, retirees, and the disabled were among the many exceptions that came to mind. So I struggled with the question that as a society, how do you care for the basic human need for health care that we all have? I lost touch with this question as I moved through life. I guess I assumed we would evolve to a place where there would be an answer to this question in my lifetime. So far, it’s not looking so good.
In my early years, I was surprised to learn that provision of health care through employers was not the result of some deeply thought through social policy, but came about because employers such as General Motors wanted to attract and retain skilled workers and offered health insurance as an employment incentive. Other employers soon followed suit either through a desire to compete for labor or as a result of union pressure and the practice quickly became the custom in the United States. What resulted was the provision of health insurance that varied widely in coverage based on the contract terms that were negotiated between thousands of individual employers and their providers. Health insurance benefits were entirely voluntary and many small businesses could not carry the cost. So if you were not employed or employed by a company that did not provide this benefit, health insurance for you and your family was not yet a reality. This was the status of health care as I came to know it as an adult.
When my wife and I had our first child we had no health insurance, but the cost was manageable – less than a semester at Penn State in the 70s. We paid our doctor and hospital bills out-of-pocket on a monthly payment plan until they were paid in full. We often joked with our daughter that we got her on an installment plan. By the time our second daughter came to us, we had insurance coverage through an employer and it was fortunate indeed since she was born with a small hole in her heart that would eventually require surgery. However, when I changed jobs, health insurance ended with the old employer and began with a different provider through the new employer and the pre-existing condition clause kicked in. We were again fortunate that surgery occurred shortly after the pre-existing condition clause timed out. Throughout this period, even with insurance coverage, my wife became a gladiator who did battle with insurance company representatives who would deny payment or coverage without reason or logic. This patchwork of health care coverage and at times arbitrary interpretation was exasperating. This system didn’t seem to me to correspond with the world-class view we have of American institutions.
As years progressed, medical and insurance costs increased dramatically. Employers responded by changing providers and joining larger consortiums in the hope of gaining some negotiating leverage, but cost increases continued beyond their control. Employers don’t typically have any direct control over medical costs – they deal with the insurance company and not the doctors, hospitals or pharmaceutical companies. Their ability to control health care cost drivers essentially doesn’t exist at the employer level and it comes as no surprise that many employers just stopped trying – after all, they are in the business of baking bread, building houses, or manufacturing furniture and health care is not their focus. The inevitable result is that their capacity to absorb costs topped out and costs were passed on to the employees in the form of shared premiums, co-pays and reduced coverage. That incentive that GM nurtured long ago has now become a burden for many businesses and the trend seems to be to push more and more of the cost onward to the employee. The handwriting is on the wall. When it comes to the provision of health insurance it seems that employers are in a race to the bottom where health insurance costs will be fully borne by the employee. And then where will we be? At that point, employers will become no more than an administrative conduit. Imagine that – thousands upon thousands of employers, with little or no capacity or incentive for cost control, acting as purchasers and providers of health insurance who may each have different contract and coverage terms.
I believe that it is time to de-couple the provision of health insurance from employers. Their hearts are no longer in it and it is a distraction from their core business mission. Instead I believe it is time, indeed past time, for universal coverage through a single payer system – like every other advanced nation has put in place.
We also have to get passed the ideological disruptions associated with this issue. Whether it is as the result of a masterful public relations strategy or happenstance, we have been fighting among ourselves rather than focusing on the root problem: our health care costs are out of control. Our fight should not be about who gets health care coverage, but about why the coverage costs so much.
We should be wondering why the cost of some medical procedures vary widely among hospitals in the same region or why the cost of pharmaceuticals is so high in the US compared with other countries. It is to me unconscionable that a major cost control strategy proposed by some is to simply deny coverage to fellow citizens. We can certainly argue about the details, but at present I fear that we have no goal – we just argue and push/pull health care coverage and conditions in an ideological tug of war. But if we are at war ideologically, what is it we are fighting for? What is the stated goal?
In my view, if we are to live up to the promise and responsibility of a compassionate society, we should start with a simple goal:
All citizens of the United States will be provided with health care.
We can work from there.
KEVIN DEENY – A lifelong resident of Levittown, PA