Jumping through hoops for lifesaving treatment
Your recent story “Hope for devastating child disease comes at a cost: $750,000 a year” (Page A1, March 28), about parents of children with spinal muscular atrophy battling to get the coverage their children need, is an example of our health care system gone wrong.
It’s outrageous that the insurer refused to cover the medical treatment these families needed for their children, especially since the Food and Drug Administration had approved it for the medical condition.
As the executive director of the New England Hemophilia Association, and as a patient with a rare bleeding disorder myself, I know firsthand the challenges facing those with diseases who have expensive treatments. In my experience, and in my role, I have seen patients with hemophilia forced to jump through unnecessary insurer hoops, such as prior-authorization process, due to the cost of their intravenous treatment. This leads directly to delay or disruption in the delivery of care to the patient. For someone with hemophilia, this is unacceptable and can lead to death.
People buy insurance so that they don’t face situations like these families are facing. The role of health insurers is to cover the cost of medically necessary medications. We don’t buy it with the caveat: “Except if I get hemophilia, then I’ll let you off the hook.”
Sharing both the risk and the cost
While the Republican Party was divided on just how draconian their health care plan should be toward the elderly and the poor, it seemed united on removing any mandates to purchase insurance by those less likely to file a claim, i.e., the younger, healthier segment of the population. This misguided approach flies in the face of basic insurance principles and would have accelerated the collapse of health care coverage in this country.
No insurance plan is sustainable if you exempt those less likely to use it from participating. If there is no penalty for not participating, or the penalty is not high enough, as in Obamacare, the risk pool will become quickly skewed toward those who are most likely to file a claim. In that environment, it stands to reason that one or all of the following will happen: (1) Insurance companies will pull out of markets that are not economically sustainable, (2) premiums will rise precipitously for those high-risk customers who remain covered, and (3) deductibles will rise so that insurance companies do not bear the entire risk of claims.
Apply this same principle to auto insurance, which we are required to purchase without much fanfare. If only those with a high propensity for auto accidents purchased insurance, how high do you think your auto insurance rates and deductibles would be? And how many companies would limit coverage or pull out of markets where they would have to insure only those most likely to have an accident?
The health care primer,
for Donald Trump
Lesson 1: Without individual and employer mandates to buy health insurance, there will be too many people without insurance, and the population will be starkly divided between insurance “haves and have-nots.” As we know from many research studies, the insurance have-nots will be sicker and will die younger.
Lesson 2: The Hill-Burton Act, which states that hospital emergency rooms cannot turn people away who need care. Surely your plan gives folks “freedom to choose,” and many will choose not to buy insurance. When these people get sick, they usually go to emergency rooms for care, but use of the ER is not health care; it is emergency care. Moreover, emergency care (and hospital care) comes at full price, whether the person has insurance or not, meaning that the patient is charged the full rate for the care. If the person cannot pay, it usually ends up as the hospital’s bad debt. Overuse of the ER by the uninsured will result in hospital closures. This would particularly happen in low-income areas of the country.
Lesson 3: The government must help with financial subsidies for individuals to buy insurance; otherwise people will be forced to choose between food, clothing, heat, etc., and health care. You promised health coverage for everyone that would be better and cheaper. If we want everyone covered in a system that will work for all, subsidies on a sliding scale make sense.
Don’t forget President Obama’s last words on the Affordable Care Act as he left office:
“Do try to make it better and let me know how it works out.”
Retired visiting nurse and founder of Haiti Projects
Professor emeritus of medicine and nutrition, Tufts University
A Health Care Act 2.0 that improves health and reins in costs
What SHOULD happen now is that Congress cap insurance payments for doctors, hospitals, and drugs at national Medicare levels, and Congress requires all US residents to contribute equally to their health. Insurance companies would continue to manage health care (for capped remuneration), and they would continue to prosper from increased business. Unfortunately the GOP isn’t likely to do this, even though we would all pay lower taxes.
There are still some inexpensive ways to improve the delivery of health care to everyone. One is to pay doctors and hospitals a fixed and adequate amount to see all US residents once a year, free of charge. This kind of comprehensive and prospective health care would sharply improve our national health and rein in long term costs. The costs are not open-ended, even though the benefits are open-ended. This could happen quickly, with a united Congress.