• Small fixes for enormous problems

    Two quick anecdotes.

    (1) In the thick of the health care reform battle, in January of 2010, when Sen. Brown was elected and no one knew what was going to happen, I was home one night after dinner ranting (as I am wont to do) to my wife. At the time, this was all I could focus on. I was on radio quite a bit talking about health care reform, I was writing like a madman about health care reform, I was speaking about health care reform, I was going on TV to talk about health care reform. I read about it all day, I watched TV shows debating it at night, I listened to experts scream about it in the car. I thought it was all anyone cared about.

    And then my wife interrupted me to ask, “what’s a public option?”

    (2) Just a week ago, my mother called me early in the morning. My parents live on the west coast, so I knew something was wrong. When I answered the phone, she told me she’s been up all night worrying because she’d been told, by people she trusts, that Medicare will be gone by the time she turns 65 in two years. I had to talk her down and convince her that there’s not a single person in elected office who would let that happen.

    ———————————————————

    These are highly educated, smart people. They have both worked in the medical field. One of them lives in the same house as me. And yet, their grasp of what I (and many of you) would consider a basic part of health care policy is not close to complete.

    And why should it be? They have plenty of other things to do, and in their areas of expertise, I am equally limited. Why do we think everyone gets this?

    One of my good friends is in commercial real estate. I have no idea how that works. When he starts talking about buildings and deals and how regulations impact his company, I shut up and listen.  Another friend runs some B2B aspects of a large trucking company. He’s probably laughing right now at how I’ve mangled that description. Another owns a number of pizza stores. I don’t even begin to grasp the million facts and timetables he’s juggling at any one time.

    I’m not an expert in those areas, nor do I have the time to be. I can buy pizza, I can live in a house, and I’m happy when the truck delivers my package, but I don’t know the inner workings of how those things happen. That’s not because I’m stupid. It’s because I’m a busy guy, and learning how those things work is complicated, hard, and would take the time of, well, a full-time job.

    Yet we somehow believe that everyone should be expert in health policy. They’re not. So many people have no idea of the intricacies of insurance, how reform might affect them, and how it will all hold together. Moreover, when trying to approach the media for information, they’re treated to a “one side said this/other side said that” feast that mostly focuses on politics and not on substance. So it’s no wonder that my own wife can get frustrated and check out of the whole process, and my own mother can become so confused that she thinks her Medicare might be taken away in two years.

    And that is why I can’t get too excited about a nutrition label for health insurance. Go and look at the full version and tell me how anyone is going to actually use this. At my own job, the other doctors with whom I work don’t even understand  the much simpler versions we are offered each year for our own insurance.

    We in the health policy bubble believe that everyone understands this stuff. We believe that everyone cares about this stuff. I’m not sure they do. Things are pretty rough out there, and they’ve got plenty of other things to worry about. This is just my opinion, and I’m willing to be swayed by evidence, but I just don’t think that these kind of small fixes are going to do anything about a huge problem. I think they comfort those of us in the bubble, but they’ll do nothing for the vast majority of people out there.

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    • Aaron
      This resonates so well on two fronts:

      1) Identical encounters with my folks and family. I assume they get this stuff when I prattle on. They dont.

      2) Knowing what we know about health literacy, and folks basic capacity to understand instructions on prescription drug use for example, one wonders whether this is all a Sisyphean effort. It needs to be done, but will only make a small difference. KHN referenced HHS’s piloting of the prototypes, but I would really want to know more, mainly, in real world situation will they use this data. Heck, who reads mutual fund data (same problem). Very few.

      Brad

    • Just a week ago, my mother called me early in the morning. My parents live on the west coast, so I knew something was wrong. When I answered the phone, she told me she’s been up all night worrying because she’d been told, by people she trusts, that Medicare will be gone by the time she turns 65 in two years. I had to talk her down and convince her that there’s not a single person in elected office who would let that happen.

      IMO people are excessively fearful about lack of health insurance. I used to think like that but now I think that it is not that bad. Much of the most important health care is not that expensive and much of the expensive stuff is quixotic attempts to keep people going.

      The fear of not having insurance is similar to the fear of “death panels” and for the same reason.

      An anecdote follows but I think that this not all that uncommon. A friend had poor circulation in his legs and he had trouble getting started in the morning but he had no insurance and so never even had it checked out but once he became eligible for medicare he went to the doctors in hope. the doctor diagnosed an aneurysm but before he would operate on it he said his heart was too weak so he did a heart bypass then months later operated on the aneurysm. The result he walk less well now he never completely recovered from the heart bypass and he has incontinence problems and con now not do what he used to. He would have been better off without medicare.

      I am sure that health insurance generally nets out positive but not by a huge margin.

    • Another factor is willful ignorance. People want to believe that company health plans are provided for free through the benevolence of employers. People want to believe that high-quality health care should be free — paid for by insurers with little cost-sharing. People want to believe future generations will be so much richer than ours that they can afford the $89 trillion unfunded liability for Medicare. But of course, health care is not free — it consumes 1/6th of our economy. As such it displaces other areas of our consumption. But people don’t understand what that means because they prefer to believe otherwise.

    • Amen. Most of the docs and nurses I employ have little idea what is in their health insurance package. Heck, most of my patients dont remember what medicines they take or what kind of surgeries they have had. Health policy needs to acknowledge the ways people really behave. While it may be possible for people to change and become more involved with the financial side of their health care, I dont think it is an assumption we can make without evidence.

      Steve

    • My path to following the health care debate and discussion had its genesis in a nursing home in Troy, OH. I am a musician by trade and have earned my living by entertaining long term care patients in facilities all over SW Ohio.

      One day a patient I’ve sung to for several years came up after a show, teary eyed and said she didn’t know if she’d still be around when I came back next month. I asked her why? She said her Son, heard on Sean Hannity’s program that President Obama was trying to kill off all the old people…and that he was going to get away with it.

      I told her that her son had gotten bad info from Hannity’s program. I reassured her that President Obama wasn’t going to kill old people. She was relieved when I saw her th8e next month and the next month and the next month.

      It infuriated me that a basically decent person could be victimized by the trash from a guy like Hanntiy. I decided that day I would learn as much as I possibly could about the ACA, the problems in our HC system and how other places handle it. Its hard to keep up with a lot of people on this blog, but I think I know more than the average guy walkign down the street.

      I follow it every day…

    • Just an excellent comment and post.

      This explains why the elected officials have to be smart, knowledgeable and have the political integrity to support and vote for the best system. That is the key to a successful representative democracy.

      For all politicians, but mostly for Conservatives if the opportunity comes to “misrepresent” positions in return for electoral success, they will take the electoral success and make the misrepresentations.

      I don’t think anyone would describe our current situation as a “successful” representative democracy.

    • I’m not convinced that this is a fundamentally different problem than those that confront anyone buying life insurance, engaging in litigation, purchasing a home, filing our taxes, etc, etc, etc.

      In virtually every case where making a transaction requires expertise that we don’t have, we pay an expert who *does* have the knowledge and experience necessary to evaluate all of the options to either help us or do it for us.

      There’s nothing fundamentally different about health insurance. If it were bought and sold like any other kind of insurance, this would be a non-problem that one could easily overcome by seeking out an agent if one wanted one.

      For that matter, this is true of virtually everything that we buy and sell. I don’t know how to repair the valve cover gaskets on my truck and would probably do a bad job if I tried. Ditto for removing my own wisdom teeth, or wiring my house.

      We specialize and exchange. Once again – non problem. At least in those markets where people, rather than their employers, make these decisions….

      • JayB- In many ways it is fundamentally different. If someone does a bad job wiring your house, you can have it redone. Same with your truck valves. Your heart valves? If that is screwed up, you dont even make it off of the OR table. You may not be able to repair a valve if it has problems and/or the heart may be permanently damaged. If your internist misses a diagnosis, or your radiologist misreads an X-ray, you may progress too far too fast to have a cure.

        Health insurance is complex enough, that you may find that you cannot get the care you really need, when you thought you had paid for it. Referrals in and out of network are difficult to keep track of, even when you are in the trade.

        Steve

      • Steve stole most of my thunder. Let’s just say the impact of a poor choice of health care treatments/providers is far more reaching than buying a flat screen tv or a piece of real estate…

    • @Aaron:

      “And that is why I can’t get too excited about a nutrition label for health insurance. Go and look at the full version and tell me how anyone is going to actually use this.”

      It’s a start as part of the erosion of chronic managed-care misrepresentation. We must not forget that the “nutrition label” is for insurance as primarily regulated by the states. It is not for the more than 50 million covered under employer-sponsored “self-insured” plans, since the Affordable Care Act (unfortunately) doesn’t reach them yet. The self-insured plans are defined by ERISA as noninsurance, leaving those millions without any protections from state or federal government oversight.