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Sometimes God Wants Angels

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Stories from thirty years of being a physician.  This is one.

José was a Certified Surgical Assistant (CSA) who helped me with Cesarean sections. He was a big guy with a little white in the scruffy black stubble on his face, and a man of few words.  I usually had to ask him to repeat the occasional amusing quip because, unlike the nurses whose hearing was far more acute, all I heard was a low rumble.  José always thought I should sew the abdominal muscles back together after we did a Cesarean.  I didn’t see any reason—sewing muscle is like sticking a needle through a stick of butter—but I didn’t see any harm. I’d give him the needle holder after I’d closed the peritoneum. He would neatly bring the pyramidalis and rectus muscles together with the same care one would use embroidering a shirt.

One evening Maria came to the hospital from the office. Her doctor couldn’t find the baby’s heartbeat, and an ultrasound confirmed the baby had died. Her first baby, a girl, had died from a brain hemorrhage when she was 11 months old. She had two boys at home, both delivered by Cesarean section. Sadly, this turned out to be another girl.

She insisted she’d felt the baby moving on her way to the hospital and repeatedly asked if there was some mistake.  We checked again with a bedside ultrasound exam, found no movement and no heartbeat, and her tears finally began to flow. I felt a little useless because she spoke no English (and I only know a little German), but her nurse, Molly, spoke fluent Spanish and gently consoled Maria.

I explained another Cesarean section would be the best way to deliver. We gave her the option of waiting until the morning but she didn’t want the baby inside her any longer than necessary.  We waited for her family arrive and gave everyone time to grieve, and then took her to the operating room. The anesthetist made her comfortable with a spinal and we prepped her for surgery.

It took about 5 minutes to open the uterus. The odor coming from the amniotic fluid indicated the baby had died a few days earlier.  We found a large clot in the umbilical cord where it entered the baby and a very tight constriction in the cord farther down near the placenta.

She began sobbing again as she felt the baby leave her body.  José leaned over the drape talked to her in the low, quiet voice.  I couldn’t follow what he was saying, but I caught “Dios”, Spanish for God.  We finished the operation in near silence.  We moved her to a regular bed after dressing the incision and took her back to her room.  I sat on a stool in the hallway because my back was aching; José came out of the operating room a moment later.

I asked, “So, what did you say to her?”

He replied, “Sometimes God wants angels, too.”  He paused, weary.  “This is tough for us; I can’t imagine what they go through.  Even when your kids are grown, you worry about them and don’t want them to die before you do.”

I thought I saw a faint glimmer of tears in his eyes, but my own tears obscured my vision.

What Does The CBO Say?

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Last week the Congressional Budget Office released “The Budget and Economic Outlook: 2014-2024.” Conservatives and the right-wing media got an instant woody over Appendix C – Labor Market Effects of the Affordable Care Act: Updated Estimates. The ACA would kill 2.5 million jobs, take away the incentive to work and put millions more on the dole.

The White House, predictably, embraced the report as a victory of sorts for the beleaguered American wage slaves who have been worried they will die chained to their desks.  Meanwhile, Politico accuses both sides of “cherry-picking” the data in the report.

(C) Can Stock Photo

(C) Can Stock Photo

So what to make of all this?  Here’s my take.

First, CBO’s projections are educated guesses about the future based on current data and realities that are likely to change, requiring further analysis and adjustments.  Indeed, the CBO admitted:

“…estimate(s) of the ACA’s impact on labor markets (are) subject to substantial uncertainty, which arises in part because many of the ACA’s provisions have never been implemented on such a broad scale and in part because available estimates of many key responses vary considerably. CBO seeks to provide estimates that lie in the middle of the distribution of potential outcomes, but the actual effects could differ notably from those estimates…”

The claim that there will be 2.5 million fewer jobs by 2024 can be blamed on conservative animosity towards the ACA, aided by the CBO’s authors’ poor choice of words.  The report forecast workers voluntarily reducing their labor by 2.5 million full-time equivalent hours. That will likely happen mostly among low wage workers, amounting to 1.5 percent to 2.0 percent of total hours worked.

“…The estimated reduction stems almost entirely from a net decline in the amount of labor that workers choose to supply, rather than from a net drop in businesses’ demand for labor, so it will appear almost entirely as a reduction in labor force participation and in hours worked relative to what would have occurred otherwise rather than as an increase in unemployment (that is, more workers seeking but not finding jobs) or underemployment (such as part-time workers who would prefer to work more hours per week)…”

Those workers are NOT quitting altogether to go on the dole. Some may go to part-time jobs; others may retire early. There are 10,000 Baby Boomers retiring every day through 2031; their exit from the workplace could potentially create job openings for younger, qualified currently unemployed workers.

However, any potential job changes come with trade-offs.

Full-time employees whose income is more than 400% of the Federal Poverty Level (FPL) or whose employers offer health insurance are not eligible for subsidies for health insurance purchased through the exchanges. So they will either continue to work full-time, switch to a different full-time job, or go to part-time jobs and purchase their own insurance, especially if the net result is working fewer hours while maintaining their desired standard of living.

Employees whose income is less than 400% FLP or whose employer does not offer insurance can obtain insurance through the exchange, and they are eligible for tax credits and subsidies, which decrease as income increases. They might work less to avoid crossing the FLP threshold which means losing their subsidies and credits while effectively hiking their taxes. But then again, they might decide the extra income is worth the tax bite

People living in states that agreed to expand Medicaid are now eligible for Medicaid benefits if their income is less than 138% FLP. If they earn more, they’ll be eligible for insurance subsidies, ensuring they won’t lose coverage. People living in states that did not expand Medicaid, however, can only get insurance subsidies, not Medicaid.

I think the real issue is: conservatives and their corporate overlords hate losing the leverage that health insurance once gave them over workers.  How many people have endured “job lock,” staying in a thankless job, working more hours for less pay, working for condescending employers who’ve made it abundantly clear employees are unimportant, easily replaced, but a necessary evil?  Have you ever been told, “Bend over and like it because there are ten other people out there waiting for your job?”

Employers might be a little more considerate now that health insurance isn’t always tied to the job. I’m not holding my breath.

Coca-Cola vs the Wretched Refuse

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In 1971, Coca-Cola produced the multicultural (and overly saccharine) “I’d Like To Teach The World To Sing” commercial and no one said anything.Coke hilltop7

In 1979, Coca-Cola jerked our heartstrings with the inter-racial Mean Joe Green ad, and in 2009 used Troy Polamalu in the parody hawking Coke Zero.  It wasn’t a big deal.coke-mean-joe

In 1990, Coke resurrected the 1971 Hilltop ad, this time with the original singers and their families.  Some of us groaned after hearing “that song” again, but no one complained.

In 2014, Coke aired a beautiful multi-lingual version of America the Beautiful.  And the right wing knuckle-draggers went ape shit, saying that singing “our national anthem” in anything but English was a travesty.Coke 2014

What the hell is the matter with you people? First, our national anthem is The Star-Spangled Banner and the tune is To Anacreon in Heaven ,an English drinking song.  Second, Katharine Lee Bates, who wrote America the Beautiful after hiking to the top of Pikes Peak, also wrote a collections of sonnets for her lover, Katharine Coman.

English may be the predominant language in the U.S., but it is not the official language. Unless your ancestors came from England, they spoke French, German, Dutch, Russian, Yiddish, Spanish, Portuguese, Norwegian, Swedish, Finnish, Chinese, Japanese, Gaelic, and whatever passes for English in Scotland. And the native tongue was anything BUT English if your ancestors were here before Columbus.

And when did we become the United States of Exclusively White People?  Which white people? The Irish were once scorned, partly for being Roman Catholic.  In 1889, the Bennett Law tried to make English the official language in Wisconsin, pissing off the Germans and Norwegians. So we’ve all been shunned at one time or another.

I live in the Chicago suburbs and we love our multicultural heritage. There are Asian, African-American, Hispanic, South Asian and Middle Eastern families within three blocks of my house. The son of the old Pakistani man drives a big-ass Dodge Ram pickup with a Chicago Bears sticker in the rear window.

Chicago has arguably the largest Polish population in the country and in a month we’ll be celebrating Fat Tuesday with P?czki (pronounced POHNCH-kee), a jelly doughnut on steroids. paczki The city has ethnic festivals all summer long: Italian, Greek, Chinese, Thai, German, Hispanic, Irish, African, and Korean. There are African-American, gay, St. Patrick’s Day, Southside Irish, Northwest Side Irish, Chinese, Greek, Mexican, Polish and Puerto Rican parades every year.

No one is “shoving multiculturalism down our throats.”  It’s been here as long as we have.  No one says you have to participate, but you do have to tolerate it just as they tolerate you. I realize some of you resent having to sharing the pie, but that’s the price you pay for living in the melting pot. The Pledge of Allegiance reads, “…liberty and justice for all,” not “for some privileged people.” If you don’t believe me, maybe John Winger can convince you

“We’re all very different people. We’re not Watusi. We’re not Spartans. We’re Americans, with a capital ‘A’, huh? You know what that means? Do ya? That means that our forefathers were kicked out of every decent country in the world. We are the wretched refuse. We’re the underdog. We’re mutts!”

Oh, and for those of you boycotting Coke, Pepsico backs gay rights and its CEO and Chair is Indra K. Nooyi, an Indian-American woman.  Just thought you should know.

The Difference Between Auto and Health Insurance

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If anyone still wonders why health insurance is far more expensive than auto or homeowner’s insurance, here’s a simple explanation:

IF CAR INSURANCE WAS LIKE CONTEMPORARY HEALTH INSURANCE

  • Employers would provide auto insurance as a benefit in lieu of higher wages
  • Employers would either be self-insured or pay whatever rates they could negotiation with third party auto insurance companies, guaranteeing outrageous prices because “that is what the market will bear.”
  • A run through the diagnostics and an oil change would be covered, but, like an annual exam and Pap smear, would be priced at $250.  You could only have one oil change a year; if you needed more, you’d pay $250 out of pocket, unless you had the Federal Employees Auto Insurance Benefits, in which case you could have an oil change every week, subsidized by the taxpayers.
  • Like dental coverage, your car would be eligible for professional detailing twice a year, at participating detailers.
  • Like optical coverage, your car could get a new set of headlights and taillights every year, whether or not it needed them. Or, better yet, a new set of tires every year.
  • Like pharmaceuticals, you’d have a $10 co-pay for a tank of regular gas, $20 for midrange gas and $35 for premium, but that tank would have to last a month.  Your Auto Fuel Benefit Manager, however, would be arguing with the oil companies who would be charging $200, $500, or $5000*per tank to cover their “R&D” costs, which would be half of their marketing and advertising budget.
  • If you were self-employed, unemployed, or lost your coverage because of “downsizing” or illness, you’d have to pay $250 for that oil change, a minimum $200/month for a tank of gas, or walk to work.
  • If you were poor, you might qualify for Car-aid, but few gas stations or repair shops would accept your coverage and those that did would look down on you as a low-life draining the system, even though all you want to do is get to work and buy food without walking 16 miles in a blizzard, up hill, both ways.
  • When you reached 62 or 65, you’d qualify for Car-care, which would cover repair and maintenance at the same rate, whether you owned an Escalade or a Prius.  Your repair shop would be prohibited from providing any extra or discretionary work on your car, even if you could afford it, and be subject to fines and/or imprisonment.
  • However, since you no longer had Auto Fuel coverage, you’d be back to paying $200 for a tank of gas, unless you had Car-care Gap Coverage, hawked by Mr. Bluewrench, dressed in knit coveralls, standing by the waiting room in a homey garage “for only $9.99 a month and you CAN’T be rejected.”

A Short History of Health Insurance-Part 2

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I discussed the origins of our health insurance benefits in my last post.  This is how it all fell apart.

OOP Spending 1960-2014

Out Of Pocket Health Care Spending 1960-2014

By 1960 employer-sponsored health insurance plans covered 142 million people just waiting to be exploited. Congress and the states mandated coverage for health conditions, procedures and products, often because of lobbying efforts, not medical necessity. Out-of-pocket spending dropped from 48% of all health care costs in 1960s to 11.5% by 2009.  Annual health care expenditures rose every year, outpacing general inflation. We spent $27 billion in 1960, $888 billion in 1993 and $2.8 trillion in 2012. Everyone was happy playing with someone else’s money.

But there is only so much money to go around.

Medicare financing concerns surfaced early. In 1967, the House Ways and Means Committee predicted Medicare would cost $12 billion by 1990, an estimate 10 times too low.  Medicare expenditures were $98-110 billion by then (depending on who you ask), rising to $536 billion by 2012.

In 1992, the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) switched to the Resource Based Relative Value Scale (RBRVS) payment schedule, reimbursing hospitals a set amount based on Diagnosis-Related Groups (DRGs) rather than on length of stay or charges. Commercial insurers followed.  No one wanted to lose money so physicians discharged patients “quicker and sicker” than before. But the rate of growth in health care costs dipped only slightly before rising once again; insurance premiums quickly followed.

(c) 2009 Bob Conroy

(c) 2009 Bob Conroy

Health Maintenance Organizations (HMOs) attracted employers with large groups of mostly healthy workers, promising to control health care costs with “managed care.”  The reality, “managed cost,” created obstacles to potentially costly care with pre-authorizations, denials, and penalties for using “out-of-network” providers. The primary care physician became the beleaguered and much resented “gatekeeper,” pressured to forestall referrals or deny care outright. Patients and physicians rebelled, often resorting to litigation or ugly media campaigns forcing HMO administrators to approve payments for just about anything, including in-vitro fertilization.*

Private insurers eventually relented as well, but covered their losses by raising premiums every year. Employers who could afford to reluctantly went along; those who balked lost employees to other companies. Employers with a strong union presence—Pittston Coal, NYNEX, General Electric—faced expensive strikes over health care benefits.  Employees didn’t care as long as premium hikes or the full cost of benefits weren’t coming out of their pockets.  Large companies began to self-insure, taking their employees out of existing risk pools. Smaller firms dropped their policies, or in many cases, insurers dropped them.

The biggest blow to employer-sponsored health care benefits came in 1990 when the Financial Accounting Standards Board (FASB) ruled that, beginning in 1992, retiree health care liabilities had to be on corporate balance sheets, effectively reducing company assets and driving down share prices. The percentage of mid-sized and large firms offering retirees health care benefits went from 85.6% in 1980 to 37.1% in 2000.

KFF average premiums 1999-2013

Average Health Insurance Premiums 1999-2013
Source: Kaiser Family Foundation-kff.org

The dot-com bust in the late 1990s didn’t help.  Employers reduced benefit packages, increased the employees’ share of their premium contribution, or dropped coverage altogether as the economy suffered.  The percentage of employers offering health care benefits dropped from 80% in 1989 to 61% in 2013. Every year forty to fifty million people lacked health insurance. Health care premiums for a family policy almost tripled between 1999 and 2013, rising from $5,791 to $16,351. People expected health insurance to cover everything because it was so expensive.  Health insurance was expensive because people expected it to cover everything.

So how do we fix it?

*In 1998 the Supreme Court’s ruling on Bragdon v. Abbott that being HIV positive constituted a disability and inferred that infertility was also a disability since, at the time, HIV positive women were advised against becoming pregnant.  A similar ruling cost the City of Chicago $1.5 million to settle a class-action lawsuit brought by city workers demanding reimbursement for fertility treatments.