I have been fortunate to be able to afford health insurance coverage my entire life.
As a physician, I consider myself to be pretty savvy about navigating the health care world. But, it isn’t always easy to know what my own health insurance covers and which physicians I am “allowed” to see. There’s the copay, deductible, coverage limits for certain services, facility fees, in network/out of network physicians and facilities, etc.
I wish there was an easier way to sort through all of this.
I long for simpler times when the relationship was between the physician and the patient, with no insurance middleman. But some amount of health insurance coverage is a necessary evil because it is a way of managing risks. As in other insurance markets, when you buy health insurance, you transfer the cost of a potential loss to the insurance company in exchange for a fee (premium). Insurance companies invest the premiums securely, so it can grow, and pay out when there’s a claim.
In a Health Wise column last fall written by family physician Clint Carter, he described direct primary care (pay a monthly fee, much like a gym membership, to see your doctor). The monthly fee covers physician visits, unlimited access to the physician and a menu of in-office services. Direct primary care is certainly an option but not one that is affordable to those who live paycheck to paycheck, with competing everyday expenses for food, shelter, and transportation in the way.
But even in the direct primary care/concierge medicine model you still would need to maintain a health insurance plan to cover catastrophic hospitalizations. You still would need to know which hospital is preferred and hopefully all the physicians who see you during that unforeseen emergency are also in your insurance network.
So it’s complicated. And federal lawmakers have their hands full, with hundreds of special interests and think tanks all knocking at their doors.
The fundamental question we need to decide as a country is whether or not health care - a term that has become synonymous with health insurance - is a right that we all should pay for collectively.
When looking back at history, this has been debated for quite some time. Teddy Roosevelt ran on an election platform that included health insurance back in 1912. In 1945, Harry Truman envisioned national health insurance for all and failed. After a study came out that 56 percent of Americans over age 65 had no health insurance, John F. Kennedy fruitlessly attempted to push national health insurance for those 65 and older. In 1965, Lyndon B. Johnson signed legislation that started Medicare, a national health insurance program for those 65 and older that has about 50 million members today.
But with the advent of Medicare and Medicaid (insurance for the poor), health care spending has grown astronomically - largely due to expansion of coverage for previously uninsured individuals, but also due to a mix of complicated factors such as the rapid increase and utilization of advanced medical technologies and the growing epidemic of obesity-related chronic illnesses, to name a few.
In 1960 (pre-Medicare/Medicaid), the cost of medical goods and services accounted for 5 percent of gross domestic product. In 2013 it made up 17.4 percent.
In recent years the Affordable Care Act under Barack Obama was an attempt to increase health insurance access for all Americans and to control costs. And now we have the American Health Care Act as our country’s latest stab at tackling this difficult issue.
The truth is, with or without health insurance, your physicians, nurses, and hospital staff still take care of you in emergent situations. As physicians, we simply don’t get paid in many of those instances. In what other industry is it sustainable/tolerated for services to be provided and payment to be nonexistent, or at best delayed, and deeply reduced arbitrarily by insurance companies?
A colleague of mine remarked the other day, ”It’s like walking into a restaurant, ordering something to eat, and then leaving without paying. Or saying that the steak is listed for $20 but I will pay you $5 instead, and I will pay that $5 to you two months from now. Food is essential for our body’s survival. Emergent medical care is as well. But society turns a blind eye to all we do to care for the underserved every single day.”
I don’t have the right answer. I just know that our system is fundamentally broken.
Burnout is at epidemic levels among physicians nationwide, largely due to the requirements our federal, state and commercial health plans have imposed upon us (if we want to get paid under their insurance plans, that is).
Physicians did not go to medical school to become slaves to data entry into an electronic health record during (and mostly hours after) a patient encounter. Physicians did not pursue years of residency and fellowship training to argue with health plans about prescription drug choices and to jump through hoops to get medically necessary tests authorized for their patients. Physicians did not choose to have office visit times reduced to unrealistic 15-minute time slots. It is impossible to consistently provide thoughtful medical advice in that timeframe.
I love being a physician. I love caring for my patients. I just wish I could be left alone to do just that.
Li-Yu Mitchell, MD, is a mother of 3, a family physician and wound care specialist, president of the Smith County Medical Society, a board member of NETPHD, and delegate for the Rose Chapter of the Texas Academy of Family Physicians.