One pragmatic reality of the soon-to-be resolved Presidential election regards our healthcare in the United States. For instance, what will happen if Hilary Clinton is elected President? What has she promised about her disposition toward the Affordable Care Act (ACA), pejoratively known as “Obamacare?” What if Donald Trump were to win this election? Along with every other Republican who ran for President, he is promising to get rid of “Obamacare.” Of course there are pros and cons to both approaches, but the day by day effect for most of us is, as Trump might say, “YUGE!” For instance, as Craig Klugman, PhD, notes in his blog on the matter,i Democrats believe that healthcare is a basic Human Right. Republicans believe we are individually responsible for our health and as a result the healthcare we may need to maintain it. So far I agree with both parties, but the complexities quickly pile up. Take insurance, for instance, and the so-called “Public Option.” What is the Public Option?ii And if Trump’s undoing of the ACA includes the insurance markets that have developed over the past few years, what will become of the policies for some 25 million of our families and neighbors? And what about those “Death Panels?” Will Clinton bring them back and force everyone to sit in front of a Death Panel only to be told how the Government wants us to die? When you cast your vote on November 8th how will healthcare influence the way you vote? Indeed, for many millions of us who work in the healthcare industry, we have an even more evident personal stake in the matter!
Let me illustrate some of the differences with two of the issues I mentioned above. The first regards Advance Healthcare Planning documents (often referred to as Advance Directives). The second regards insurance and how we pay for healthcare in America.
First, and with satire dripping from my mouth, thank you Sarah Palin for your knee jerk reaction to an early element of the reform we now call the ACA. The idea she helped squash was to enable our physicians to converse with patients and their families about what sort of healthcare they want toward the end of their life. For instance, a very specific and important question for families regards resuscitative efforts that might be used on your grandmother if and when she is hospitalized. Do you want your 93-year-old grandmother to have chest compressions if her heart stops when she is in the hospital for pneumonia? As it turns out cardio pulmonary resuscitation isn’t as successful as portrayed on television. And whether it is successful or not, she is likely to suffer multiple broken ribs and perhaps a collapsed lung if she undergoes chest compressions. Again, most healthcare professionals realize the need for having such difficult conversations with patients and families. But Medicare and Medicaid didn’t pay caregivers to have these conversations, so it was thought to be a useful part of the reform built into the ACA.
Somehow, Sarah Palin and others were offended that conversations with physicians about such matters would become a routine part of medicine. She reacted with her, now famous, “Death Panels” talk that President Obama was purportedly foisting upon us.iii Understand that every conversation you have with a physician takes time and physicians need to get paid for their time. So, in order for physicians to have conversations with patients and family about end-of-life care someone had to create standards for billing. Those paying for physician services (insurance companies, Medicare/Medicaid, or you in cash) had to create the billing methods to make this work. Physicians can’t just pull a price out of the sky and ask you to pay it. Over the years since Palin side-tracked our national conversation about end-of-life care, the Centers for Medicare/Medicaid (CMS) has managed to build these methods of billing. So now, if you need help from your physician to figure out what sort of healthcare you want as you die, he can get paid for his time to talk with you about it. This “method” I refer to means that CMS decides they will pay physicians for this service and they attach a billing code to the time.iv Insurance companies typically follow suit and if you are a “self-pay” patient (i.e. you pay cash) the physician now can cite a standardized fee for the bill.
So, one might expect that a Clinton administration would continue this CMS regulation for re-imbursement of discussions about advance healthcare planning. In my job as a clinical ethicist, I see the value of advance planning documents on almost a daily basis. Do you recall Terri Schiavo?v Do you remember the fact that the only real conflict was within her family? Her parents were fighting with their son-in-law, her husband, about what she would want. She had not filled out an Advance Directive even though her husband claimed to have discussed what she might want if she were ever to lose the ability to discuss her healthcare. And so they fought…and their fight embroiled our entire nation. Let me ask you, “Do you have an Advance Directive?” If not, fill one out TODAY! All you have to do is go to Google.com and type the name of your state and “advance directive.” It will pop up instantly. This is not hard stuff. But if you fail to provide direction, if you fail to have a conversation with your family and your caregiver, you fail. And it’s a big fail! I routinely see families drag themselves through bitter fights over end-of-life healthcare decisions because no one bothered to talk about it ahead of time. Do yourself a favor, talk about it now.
The second issue regards how we pay for healthcare. Finance is not something clinical ethicists have traditionally addressed. When does money become such an important issue that it can be deemed an “ethical” issue? Every clinical ethicist can recall tough cases where the expense of caring for a patient far exceeds the benefit that accrues to the patient and/or family. It is not unusual for patient’s bills to exceed the one-million-dollar mark, in sometimes desperate attempts to save the life of a loved one. Tragically, families struggle to let their loved ones die and we now have so many medical, technological, and pharmacological ways to extend the dying process that it can take months to unfold. In some cases, hospitals and caregivers are between a rock and a hard place. We want to honor and support grieving families but every day their loved one’s death is delayed, it costs them (and everyone) more money.vi In the Intensive Care Unit of most hospitals there is often a tenuous balance between harming and benefiting the patient.vii Many of the death-prolonging therapies that caregivers can use are felt to be harmful because they know these treatments are ultimately futile. But families often perceive them to be life-sustaining and often they want everything to be done while they await God’s miracle for their beloved. And please note the focus of my language about extending death, rather than supporting life. The American public needs to move beyond the idea that medicine saves peoples’ lives. It surely does that, but in millions of lives it can only extend the inevitable. Everyone dies.
Allow me to be more specific. Let’s say a patient has a $1,000,000.00 bill and see how it plays out:
-Patient on Medicare/Medicaid or Centers for Medicare/Medicaid (CMS): While it is sometimes difficult to figure out if someone “qualifies” for CMS money, once you qualify then you needn’t worry about your bills. By that I mean the hospital will get paid (eventually) by CMS so they don’t have to go after you for the money. The qualification process demands that you show the government you absolutely do not have the money to pay for it. There is no small measure of investigation involved here, with the government reaching back seven years to see if you and/or your family tried to hide your money so you would qualify.
-Patient paying cash: One might think this is fairly straightforward, but no. Hospital finance offices cut a deal with you if you pay cash; they give you a discount, sometimes as much as 80%. They know that they will receive only 30-40% of the amount billed. No doubt it is difficult to manage hospital finances without a full and complete knowledge of your income. Can you imagine trying to plan your own personal budget if you had a regular, full-time job but knew you would not get full pay for it? It is like knowing your yearly salary but you’re sure you won’t actually be paid all of it.
-Patient with Insurance: There is typically an “out of pocket” expense for everything. If there is a catastrophic event, families typically have a cap on the out of pocket expense so that they only have to pay thousands of dollars. But insurance companies have limits as well. In some cases of futile care (care that everyone knows is only extending death) the Insurance company will cut off payments after a certain number of months. But its more complicated yet….The large Insurance companies cut deals with hospital corporations so that an “adjustments” line shows up in the bill reducing it by as much as 50%. Hospitals and Insurance companies benefit in their overall financial planning if they can be assured of a certain volume, so they cut deals for each other. Given the American system of employment-based insurance coverage most of us get covered through group insurance policies with companies that cut these deals with hospitals.
The ACA moved us forward into a time when insurance companies are offering individual policies. Again, it’s complicated, managed state by state, and has been incredibly frustrating for millions of Americans. But millions more of us do have insurance. Keep in mind, however, that insurance companies exist to make money. They do not exist as altruistic, self-sacrificing organizations with a calling to rescue your family from medical/financial bankruptcy. Their legal obligation to benefit share-holders is on par with their legal obligation to follow the promises of the plan they sold you.
The Public Option in healthcare insurance was, like the payment for advance care planning, an early element of the ACA. But the insurance companies who depend upon market forces to remain profitable did not like the Public Option. They didn’t like it in the early stages and they don’t like it now. From the New York Times article cited above: “As they did before the Affordable Care Act was enacted, insurance lobbyists are mobilizing to kill the public option.” The idea of those supporting the Public Option is to offer private insurance through the government because they do not have to generate a profit and can thus keep costs contained better than for-profit insurance. For those die-hard, market-based business ideologues who believe that competition drives down costs, our American healthcare system certainly does not illustrate this supposed standard.
So, who will you vote for on November 8th and what ramifications to your healthcare coverage are you willing to gamble on? Regardless, I do hope you will actually go out and vote.
vii One recent position statement from a combined, multi-year study of medical societies involved in adult intensive care units is catching a lot of attention for the effort to draw clear lines of appropriate and inappropriate use of therapies available in the ICU. See an abstract and summary of the statement, “An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units” here: http://www.atsjournals.org/doi/abs/10.1164/rccm.201505-0924ST#.V_2bNfArK00
Mark F. Carr is an ordained minister and theological ethicist with experience as a pastor, pilot, commercial fisherman, professor, and now clinical ethicist. He writes from his home town of Anchorage, Alaska.
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