Lakeside Medical Musings

Obamacare is Not THE Answer

Ruth and I have been married for 30 years.  For the first 28 years, she was an addict.  Together, we handled her “problem” well during those years, but we both agree that it did interfere, to some extent, with our daily lives.  More often than I like to admit, we went to some mighty seedy places for her to get her “stuff.”  I often sat in the car outside a 7-11 or other type of convenience store while she went inside to score.  (So you weren’t born yesterday, and you know there’s a “gotcha!” in here someplace…)  My dear wife’s addiction was to Diet Coke, and she knew the location of every place in every city we lived where Diet Coke  — never Diet Pepsi – was sold in a giant refillable fountain cup with ice — never in bottles or cans.  And we often drove far off our intended route so Ruth could buy her Diet Coke at one of her favorite stores where she knew the names of all the front counter employees, as the actual  purchase of her Big Gulp was not all that happened during these twice-daily visits.   Her interactions were not limited to the usual hello, thank you, and goodbye to the store’s employees, as most people’s are in those situations.  My wife got to know them, brought them homemade cookies, admired cell phone photos of their children, wrote emails to store management to praise their friendliness and unsung work habits, but above all, she heard their stories.  As I am a “hello, thank you, goodbye” kind of shopper in any kind of store, it always amazes me how Ruth gets people to talk to her, how they tell her about their lives, their hopes, their dreams, and their problems, in a visit that encompasses two minutes for people like me, but takes my wife ten minutes.  Her getting to know people, all people, everywhere,  is a gift.  This is a story that is framed around one of these people my wife talked to, and a political/personal dilemma that I am trying to reconcile in my own head.

As my readers can tell, I am a Democrat.  The recent election was a disappointment to me, but I am used to the violent swings of the electorate, and I know that in two years, there will be another election.  The 2014 fears of Ebola or ISIS will be replaced with some other 2016 fears.  Fox News and MSNBC will rile up their political bases with misleading and biased facts accompanied by outraged shouting and pounding of fists on Lucite anchor desks.  Fear mongering, negative advertising, and truth stretching (or ignoring) is the political modus operandi of both parties, and it is what keeps cable news alive, kicking, and shouting. I don’t have a lot of respect for either our corruptible political process or the majority of our contemptible politicians, as it seems their main objective is raising money for the next election, while the art of governing and looking after the best interests of the country are pretty far down on their lists of priorities.  But this last election season, especially, upset me, and that distress came from my pre-election discussions with friends and relatives.  I have had energetic political arguments for years with people, never changing anyone’s mind, and I always enjoyed the verbal joust.  Differences of opinions about both the causes of — and potential solutions for — social, financial, and political issues of the day are important and engaging, and I generally enjoy the intellectual chess match.

But this year was different. What I encountered this year was a lot of very intelligent people who truly believe that the majority of people living in poverty are poor by choice or are just lazy and enjoy the life they’ve chosen, a life of living off the largess of the government.   They believe that if people truly want to escape poverty, they can do it.  These peers of mine feel that if poor people have made bad choices, well, too bad, people have to live with the results of those choices. They tell me that they are sick and tired of paying taxes that help poor people sit home and eat potato chips and watch soap operas on their big screen TVs while they go out and earn a living to pay those taxes that produce welfare checks.

I just don’t believe that is a true picture of what it means to be poor in America.  Research and statistics clearly show that how you end up in life is very dependent on where you start out. Nobody gets to pick either their parents or their community.  I know that I have been successful in large part because I inherited intelligence and was nurtured in an upper middle class environment with two parents and a secure roof over my head, and I never, ever went to bed hungry.  I had the advantage of an excellent education, and it didn’t hurt that I was both white and male.  I screwed up plenty in high school, but I had the benefit of a supportive family, and they got me through those difficult, life-turns-on-a-dime kind of times. How different would my life be today if I had been born with below average intelligence, or in a single parent household, or in a poor neighborhood with the worst schools in the city?  I certainly might have ended up as a physician with a good wife, three children I was able to send to college, a house, and financial security, but statistically speaking, that is a less likely outcome.  The old argument that poor people just want to take government handouts because living in poverty on food stamps and a meager welfare check is the bomb just doesn’t make sense. But the story below, brought to me courtesy of my now Diet Coke-free wife, is where the rubber meets the road.

Last week, Ruth and I went grocery shopping at our local Walmart, the only grocery store near our home.  I went to find batteries for our smoke detectors, and Ruth went to the deli counter to get supplies for our sandwiches for the week.  Fifteen minutes later, Ruth came looking for me and asked me to come to the deli with her and talk to the counterwoman whom she had just met over slicing deli meat.  In just three or four minutes, Ruth had asked the right questions and gotten her to talk about her life.  Turns out she’s 50 years old, has been a Type I diabetic since she was 27, and has worked full time her whole life since graduating from high school, and has been employed at Walmart for a number of years.  She told Ruth that on her income of $16,000/year, she could not afford the medical insurance that Walmart offered,  so she had signed up on healthcare.gov for an “Obamacare” policy.  Unfortunately, the cost for that policy was $110/ month and it carried a high deductible of $6,000. Until she met her yearly deductible, the policy didn’t cover much of anything for her diabetes.  She couldn’t afford the premium for the policy and pay for the insulin — which she took four times a day — as well as needles, and blood sugar monitoring strips. So, after the first month of insurance coverage, she stopped paying her premiums and returned to being uninsured.  Ruth asked me if I would talk to her and see if, as a trained Affordable Care Act Navigator, I could help her find health coverage she could afford.

I spoke with this woman and was surprised that her Obamacare premium, after the government subsidy, was as high as $100 each month .  Apparently, she was given bad advice during the last sign up period, and she purchased a Gold plan.  I explained to her that if she had selected a Silver plan, she would have not only paid much less for her premium, but she also would have had a marked reduction in both her maximum out-of-pocket expenses and her deductible.  I told her exactly what steps she needed to take during this upcoming open enrollment period — which begins on November 15 — and that I could help her further, if she needed.  She was so grateful and so appreciative of our help, but I certainly noticed that her vocabulary and speech was not that of someone with much education.  I was happy that Obamacare would most likely be able to help this hard-working woman afford both her insulin and necessary doctor visits.

What I did next surprised even me.  I walked around Walmart using the life-long techniques I’d observed from my wife.  I stopped for a few minutes here and there and just chatted with people who worked in the store.  I did this to see if I could guess what type of career they might be able to handle if they didn’t work at Walmart.  There was one manager who seemed quite sharp and could probably have done a good number of things, but there were many people that I wondered if they could work at any higher level of employment than minimum wage, people who were stocking shelves, greeting customers, operating cash registers, and bagging groceries.

Did the people working for such low wages at Walmart stay there by choice? Could they, indeed, have been lawyers, doctors, or entrepreneurs earning  a significantly better income?  Could they become accountants or managers, if they chose?  Were they lazy or just plain obstinate? And if they could have, at one time, done some of those higher-paying jobs, had too much time elapsed now?  What options does a 50-year-old, whose total work experience is in the deli section of Walmart, have at this stage in her life?  If you were hiring someone for a job in your company, what position would you offer her? Even with her lovely, outgoing, friendly manner and excellent work history, would you offer her a position that would pay her a wage on which she could not just survive, but thrive, as you have?

So here is what I ask of my “pull yourself up by your own bootstraps” friends…   What should we do to make healthcare affordable and possible for someone who works full time, forty hours each week, at a place like Walmart and earns $16,000 a year?  Walmart insurance would cost her $100 per paycheck, $2,600 a year. Do you really think that’s affordable on a salary of $16,000? On top of the premiums, there are deductibles and co-payments.  This woman is unmarried and lives alone.  As she’s thin as a rail, and her diabetes is Type I, she’s no more responsible for her medical condition than you are for the hypertension or the rheumatoid arthritis that you suffer from that require doctor visits and medications to control.  She is the epitome of the “working poor,” the people who are all around us, working two and three jobs trying to earn enough money to put food on the table for their families.  Do we just say, “Too bad for you?”  “Decide for yourself if you want healthcare, or food and housing.”  Do we say, “Go get a better job?”  I doubt she could.  Do we say, “You have made decisions that leave you with a poor paying job?  You can’t afford health insurance, and it is your own fault?” “If you’d gone to college and gotten a business degree, you wouldn’t be working in the Walmart deli?”  And by the way, if we believe that, and if everyone did go to college, and incurred enormous student loan debt, who then would work these jobs in the groceries and the laundries and the day care centers that really are essential to our way of life and our economy?

Do we close our eyes and not look in her direction so we don’t know she exists? Do we hurry through our encounters with her so we don’t have to hear her story?  Do we continue to sit in our nice living rooms with our giant screen televisions and declare that she is not our problem? I worry that is what too many people in this country do. Obamacare is certainly not THE answer to providing healthcare to those for whom healthcare is unaffordable, but it is AN answer.  It’s a start. Like every start, it needs a chance to work and a chance to work out. I am open to hearing other real solutions to providing healthcare for our working poor and our poor who cannot work or cannot find work.  And please, let us all remember that for every person who does make it out of a poverty-ridden environment, many more do not.  I am not open to just hearing party-line platitudes. If you have answers, let’s hear them, but let’s be realistic, honest, and compassionate and realize that the health of our country, our whole country, is at stake.

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7 thoughts on “Obamacare is Not THE Answer

  1. johnadams1782

    John, Thanks so much for your current blog. The title says it all, so far as I am concerned. From my perspective, the only thing that ACA has accomplished besides getting a pitifully few uninsured people coverage, is to “get the ball rolling.”
    This country operates (good or bad) by political opinion. So what are the opinions regarding ACA?
    1. We do not want preexisting clauses and want reasonably priced coverage for all.
    2. We do no want any lifetime or annual maximums on benefits from healthcare.
    3. We do not want to go back to healthcare as it existed before ACA.
    4. We feel that deductibles are too high.
    5. We feel that anyone not receiving a subsidy (or welfare through Medicaid) is paying too much.
    6. We do not want individual mandates requiring us to buy something we may not want.
    7. We do not like or trust insurance companies
    8. We think that imposing a tax on medical devices is inflating costs rather than containing them.
    9. We think that taking funds from Medicare to put into ACA is nothing but “smoke and mirrors”.
    10. We want to make our own choices of doctors and hospitals
    11. As it presently stands, we do not and probably never will like ACA.
    Almost all of the sane politicians of my party (Republican) agree that ACA will not ever be repealed. The others are simply politically grandstanding to rally their rather small base of extremists. Even they know that attempts to repeal ACA are as frivilous as our President’s tentative agreement with China over climate control or a proposed nuclear arms deal with Iran.
    Before I go on, let me digress to a different matter. (I will try and tie it into my thinking in a minute.) As much as many of us do not like government intrusion into our lives, we have it and will have more of it in the future. We have an immigration problem. It is getting worse. We will never control it until or unless we have a verifiable national I D system. The immigration system, in my opinion is straining our economy including health care.
    Now, back to my original topic. Universal health care for every legal resident of this country should be attainable and would definitely be popular. The current hybrid system was created out of fear that the government could not function to manage a complex health care delivery system. The despised insurance companies love it. So do the pharmaceutical companies. High deductibles are intended to assist with cost containment but miss the boat since many people will never exceed them and therefore figure that they are paying for nothing. Your example of the Walmart employee is a perfect example. I believe that it is important for everyone to have some skin in the game, so I propose a reasonable co-payment with each use of medical care of any type. If someone has an ongoing problem like your example, then there should be an annual maximum of out of pocket expense.
    Back to my national I D card thing. As an aside, wouldn’t a national I D card solve almost all the nonsense about voter I D laws?. With my concept of national health care, everyone would have it, (if here legally). You go to your provider of care and pay your small deductible and get care. The provider submits his accounting to the government monthly and is reimbursed for the charges other than the co-payments. To avoid the co-payments, many people would simply go to an emergency room for a runny nose or a rash. The rules regarding care unpaid care at emergency rooms needs to be changed so that only potentially life threatening situations are allowed. Accordingly, use of emergency rooms by those paying the co-payments would be sharply reduced because emergency room costs far exceed clinic costs for treatment of, for example, the common cold.
    I believe your Walmart employee would be happy to pay 15 % of her daily costs for diabetes supplies and other care. If her costs exceeded some level, to be determined, she would file for a refund along with her income tax.
    Not to leave out the beloved (sarcasm) insurance companies, supplemental coverage could be sold by them to cover the co-payments..
    Health provider fraud should be a Federal crime to be deal with by mandatory prison terms.
    Such a program would replace: Medicare, Medicaid, V A healthcare and ACA but it could still be called ACA. Some wil undoubtedly say, the street people won’t be able to afford the co-payments. I would agree but would not amend my ideas. If the public want a welfare program to fill in the co-payment doughnut hole, then pass such a law – separately.
    Oops, I haven’t gotten around to the hard part – how do we pay for it. I favor a separate, stand alone (by law) I V A tax of all consumer goods and services. Not being a statistician, and dealing with what I perceive to be the confusing figures of annual consumer spending, I would think that approximately a 12 % tax would be sufficient. The law should be written so that the tax is amended annually so that the program is fully funded. the tax is collected by the sellers, or providers, so that it is paid to the government on the basis of gross receipts.
    Under ordinary circumstances, I would say that my ideas or those of someone someone elss, would never see the light of day. However, since the inept writers of the law wrote it so that only State exchanges could receive subsidies, if the Supreme Court does not make law but interprets it literally, then ACA goes into a rapid tailspin. Then, it will be necessary to either rewrite the unpopular law to include Federal exchanges or to substantially modify ACA as it presently exists. Being pragmatic about the new complexion of Congress, I would say that the former just won’t happen. Therefore the opportunity to have a national healthcare system that works is possible.
    These are my ideas John where am I wrong?

    1. John Post author

      I think the major thing that was done as a compromise to the Republicans and big business was to keep insurance companies in the game and not have a government program. The government isn’t allowed to negotiate with drug companies to reduce the cost of medications for medicare part D and this has to change. I like all of your ideas for a national healthcare system similar to the way you have described it. It would do all of the things that would protect the people who can’t afford health care. I am not sure about your way of funding this, but there are a lot of options there and your suggestion could certainly be part of the solution. This won’t happen any time soon, but I will be there with you trying to get the ball rolling.

      1. johnadams1782

        John, Thanks for your reply (and for reading through my long and windy comment. My reason for suggestion of the separate IVA tax was to go along with my ideas that everybody would be paying something – no favorites. Certainly the wealthy will spend more that the poor in consumable goods. I want to keep it simple and make it transparent so that the true costs are in bold faced print and not subject to “political interpretation”, if you know what I mean.

  2. Sarah

    Thank you. Your essays are antidotes to “libertarian” (widdle-aged white male) survival-of-the-fittest way of thinking–many of these folks love to give excess pantry items to food banks, then call it a day. Or we like to tip lavishly the underemployed. Making sense of government remedies like Affordable Care can flummox the most educated among us. Democrats can frustrate the most party-line Democrats. I like to think we are all doing our best in life–but the current climate is, on many levels, depressing and enervating. Especially here in Alamance County, so red. But we are slowly bringing in some new School Board and County Commissioner members! Baby steps.

  3. John Post author

    Mark, thanks for reading and commenting. Pre ACA we had about 18% of our population uninsured If you are saying we can get 80% of those insured but the last 20% might be more difficult, I say, “That is a great start”. It will be expensive to get everyone covered especially if we don’t make any fundamental changes to the costs of our health care. I also agree that there will be abuses in any system and we should do what we can to minimize those. Most other industrial nations have a nationalized health care program that covers everyone. There certainly are cracks in their system, but the percentage of GDP those countries spend on health care for everyone is less than we spend on health care with large number of people outside of the safety net. Again this is because of a structural “flaw” in our system. The more healthcare that is given, regardless of necessity, the more money is paid.

    I am not sure that enough people would change their shopping habits, if they knew about how a company pays their employees, to change a companies practices. Other than Costco, most grocery store chains pay poorly with poor benefits. To really improve access to health care and health insurance we probably need to separate this from employment. Again, thanks for commenting.

  4. Mark

    John, I agree with you that not everyone has the aptitude or ability or opportunity to bootstrap themselves to a better life. So much of anyone’s life, good and bad, can be ascribed to circumstances beyond their control.

    Those “pull yourself up by your own bootstraps” friends you describe have offered an overly simplified “solution” to the problem of being poor, IF the problem is defined as getting *everyone* to the point of being self-sufficient and capable of earning a livable wage. Of course that bootstrap approach works for some. If those friends think that all people in poverty can do that, well, maybe we can call that naivete on their part. Not everyone can do it, plain and simple.

    And I believe it is equally naive to expect that any social system we construct, healthcare or otherwise, will not have leaks, and holes, and inefficiencies, and to some extent ineptitude and corruption – all of which leads to some portion of the intended population falling through the cracks, and some portion of the population at large taking advantage of the system in illegal ways.

    The reality is that there always will be a baseline of the population who are poor and trapped, whether by their own action or inaction or circumstance. And some of those will be under served by the social system in which they find themselves. No social program is perfect, nor should we expect them to be. Assuming we could even devise a system that served 100% of the population, I think our experience tells us that not everyone would be served sufficiently. And the 80/20 rule suggests that striving to serve the last 20% effectively will require an enormous amount of resources. That’s our reality.

    In terms of the working poor, let’s turn transparency. Like health inspector scores or calorie counts for food offerings, why not have a sign on every business that rates how well they pay their non-management employees. And let’s say stores that pay only minimum wage (no tips, no benefits, etc.) get the lowest score: F. And then let’s decide only to do business with stores that score above a certain level. Aside from the social pressure, maybe voting with our pocketbooks would stimulate higher wages, even if that meant higher prices. One way or another we will have to pay to lift out of poverty those who can be lifted.

    I bet Walmart would score a D.

Discussion