According to a survey by Gallup and Healthways, Texas has more people in need of health insurance than any other state. Last year, 26.8 percent of Texans needed a health plan and that deteriorated to 27.2 percent, or nearly 6.3 million Texans, in the first half of 2011. Since Gallup and Healthways started tracking uninsured rates in 2008, Texas has trailed the nation in managing health care costs.
You may have heard Texas Governor Rick Perry describing how his state has created 37 percent of the country’s new jobs since 2009, but have you heard him explain how Texans are paying for health care? People are known to dial 911 in emergencies. Ambulances still send paramedics and emergency rooms still treat people in critical condition. That’s the most expensive form of health care, yet it’s also the last resort for people who don’t have health insurance.
Would you be surprised if hospitals raised rates for services when they had a lot of unpaid accounts? Would you be surprised if insurance companies raised premiums when hospital charges got more expensive? Ambulances, emergency medical technicians and E.R. staff cost money and it’s unrealistic to think that unpaid charges are always written off as charity.
Texas Health Insurance Coverage Is Not Covered By Many Jobs
Part of the problem is that Texas has a high number of retail and service jobs, which are typically the industries least likely to cover employees with health care benefits. Texas can have a low unemployment rate, and still have too many working people who can’t afford Texas health insurance coverage.
According to a survey by the Kaiser Family Foundation, 71 percent of the uninsured in Texas are members of families that include someone who is working a full-time job. Almost 63 percent of uninsured Texans have a job that doesn’t provide health insurance. Texas officials tend to stick with the federally-mandated minimums for Medicaid so Texans are less likely to get help with health care through Medicaid in Texas than in certain other states.
Change Comes To Texas Health Insurance
When it comes to regulating TX health insurance rates, you won’t find a lot of state government enthusiasm, either. However, federal action has made a significant change in health insurance for Texas. You won’t see it in any plan you may have purchased prior to health care reform, but the plans that are now available have an important difference from older coverage. Even the least expensive Texas health insurance plans no longer require policyholders to pay for all of their own health care until the plan’s deductible has been met.
The U.S. Preventive Task Force looked at examples of health care that were seen to prevent the need for serious, and costly, forms of medical intervention. By requiring Texas health insurance plans to pay for more health care that could prevent disease, federal policy makers have backed away from relying heavily on late interventions that can’t always save patients and invested more in upfront treatments that can help patients and keep medical costs low.
Who will benefit from this expanded coverage in Texas health insurance policies? People who could only afford plans with the highest deductibles can now get recommended health care without having to come up with cash for co-pay or co-insurance charges or having to spend enough to meet the plan’s deductible. Health care providers should see a decrease in the need for emergency care as preventive health care reduces the need for last ditch efforts. That means fewer big bills for E.R. services, but it also means fewer unpaid claims since people who couldn’t afford to see a doctor and waited until they had to go to the E.R. are unlikely to be able to pay off E.R. bills.
Insurance companies will most likely be paying for more health care now that their members can see a doctor with no out-of-pocket costs. If providers end the vicious cycle of raising rates to cover a growing number of unpaid bills, insurance companies, like the rest of us, will end up paying less for health care services. While it does seem to make economic sense, that’s not the only reason to ensure that people can get needed health care. Some still believe that human life has value. Maybe protecting that life and protecting the very idea that human life is worth it makes sense in a way that goes beyond economics.
My name is John Ross and I have spent my entire 40 + year career in health care. Specifically, my background and experience is in developing and managing evidence planning, reimbursement applications, and health economics strategies for a number of fortune 500 health care technology businesses. In short, my job was to help the companies that I worked for to understand the health care market place from three important perspectives. The first was to answer the question; “What can we expect to be paid for the medical technologies we are developing and planning to market? The second question; “will the results and/or lower costs associated with the use of these medical technologies justify the payment level we think they deserve? Finally, what product development, marketing and sales strategies do we need to employ to insure that our future medical technologies are quickly accepted by hospitals, physicians, payers and patients? Obviously with such a focus I had to deal with Medicare (health insurance for folks over age 65 and the disabled), Medicaid (state-run insurance programs for the less fortunate) and commercial health insurance companies (the companies that insure and administer employer-based health insurance plans). I also spent a lot of time assessing the needs of physicians, hospitals and large integrated health care delivery networks that purchase and use a wide array of medical technologies.
From a funding standpoint I have seen America’s health care system go from almost “anything goes” to today’s increasing focus on cost and outcomes. Outcomes, is just another way of asking the question; “for the dollars we are spending nationally or on a particular patient’s disease or injury are we getting a good value in return? In other words, is the price of the drug, medical device, procedure, diagnostic or surgical intervention worth the cost in terms of better results and lower costs compared to how we would traditionally manage this patient’s condition?
This blog is a forum for talking “honestly” about:
1. Where health care in America is going?
2. Why it is going there?
3. What can we expect from tomorrow’s health care system compared to what we have become used to?
4. What we can do to the best of our ability to use less of it (think preventive health strategies)?
5. How we should think about and help those unfortunate individuals, young and old, who need more of it than we do?
6. How can we help to make sure those who need health care get access to good health care when they need it?
7. What can we do to increase the chances that state of the art health care will be there when we need it and at a price we can afford?
I will also provide education as to how the health care system works from the various perspectives of the stakeholders. It is vital that we understand these perspectives, what drives them and the many conflicts that exist. Areas to cover will be:
1. What is happening to hospitals and physicians in this changing health care landscape?
2. What is happening to the development of innovative future medical technologies and pharmaceuticals?
3. Where is Medicare policy going with regard to payments to physicians and hospitals and other care settings?
4. What is the future of employer-sponsored health insurance plans?
5. Where is changing with regard to private health care insurance companies?
6. What will happen to patient costs?
7. What can I do to avoid premature, unnecessary or unproven health care interventions?
8. What role will “evidence and data” play in the future in giving us more information from which to make personal or family member health care decisions?
I would like this to be the place that you can visit when you hear politicians or anyone else for that matter promising something from health care that just doesn’t make sense. We all know the feeling we get when we hear an “it’s too good to be true” story. When we hear such fantastic promises, we better check it out and this will be a place where you can do that. So, bring your concerns and questions and I will do my best to help you to checkthemout!
Have you heard this one; “under my health plan, you need not to worry. Your costs will remain reasonable, you can keep your doctor and you will have access to state of the art health care”. Or, “it is every ones right to access the very best in health care, young and old, rich and poor no matter your ability to pay.” This would be nice but it is simply not reality and it is time that we talk about these things and deal with them with our rose-colored glasses removed. So, no matter what your point of view on this subject I encourage you to visit ask and comment. We need a grass-roots effort aimed at understanding health care and in particular we need to talk about its funding limits and what we can do to assure that those who need it – get it, and at a level of quality and at a manageable cost such that we can afford it as a nation. If we don’t do this it is highly likely that health care as we have known it America will not be available when we face our own or a family members serious and costly illness.
The fundamental flaw in our individual approach to health care is the notion that we have no responsibility for it except to expect it to be there, with no delay, and at state of the art levels of care. And that for the most part it should be paid for by someone else. Most politicians right now are not leveling with us. They don’t want to address the areas that I have addressed even in this my first edition health care blog. Well, I think that we are better than that! I think with the right information we can manage through the changes that are coming. We want to do the right thing but to do so we have to be informed as to how stretched the health care system is and what we can do to unburden this precious resource.
First, we can stretch health care dollars and resources by taking better care of ourselves. The goal is to do what “we” can do in terms of learning about and practicing preventive disease strategies, thereby reducing the amount and cost of health care interventions we need. By behaving this way we free up our local health care systems funding and limited physical capacity to treat those who are truly in need. Every one of us that invests in preventive disease strategies will find that the beneficiary is you, your family, and your finances. Pretty tangible benefits wouldn’t you say? Perhaps bigger than that is what this behavior and better health for yourself and the avoidance of chronic diseases such as high blood pressure, heart disease, pulmonary (breathing) conditions, diabetes and a host of other conditions can do to unburden the nation’s health care system. We need to preserve it, both in terms of resources and dollars, for those who are less fortunate and have to access the system for serious health problems. How good would that feel?
Some would say that America is a scary place to be these days. The events of 9/11, the Iraq and Afghanistan wars, continued threats from terrorism, the housing and subsequent financial meltdowns, the political infighting that gets us nowhere, and yes the health care crisis. These all create the tendency to make us want to “wring our hands” instead of “wringing the necks of politicians” that refuse to provide the leadership that we need.
I have come to a conclusion. I have seen enough to know that the leadership we need has to come from us, the individuals who make up the electorate. Waiting around for politicians to act means we don’t understand the world of politics. Politicians only move in one direction or another when an exercised and voting electorate (that’s us) frames the issues and leads the way to a solution. It is almost never the other way around.
Bringing it back to health care and the question of what one individual can do to improve things, it starts with one individual and another until we have millions pulling in the same direction. If we manage our health to the best of our ability (and I want to emphasize, truly to the best of our ability) and access the health care system only when we need it, paying a little more out-of-pocket for the incidental and non-life threatening ills and spills we all experience, the system could accommodate us all when we really need it.
So there it is in a nut shell – I have spelled out what I believe is our responsibility; that if we all pulled in the same direction as described above (think of disease prevention and what this can do for you and those who do need to access the health care system) we would dramatically and permanently free up this precious and finite resource and it would be there for others in need and, when we need it and in most cases at far less cost. We are all in this together folks, rich and poor, the older among us and the younger and if we just act responsibly and for the good of others in this matter, we would solve the problem. And then, we could work on the next challenge and the next one after that until we see clearly the power of teamwork – “all for one and one for all”. That kind of thinking and behavior can work wonders. We all know it deep down – so let’s just do it!
First, let’s get a little historical perspective on American health care. To do that, let’s turn to the American civil war era. In that war, dated tactics and the carnage inflicted by modern weapons of the era combined to cause terrible results. Most of the deaths on both sides of that war were not the result of actual combat but to what happened after a battlefield wound was inflicted. To begin with, evacuation of the wounded moved at a snail’s pace in most instances causing severe delays in treatment of the wounded. Secondly, most wounds were subjected to wound related surgeries and amputations and this often resulted in massive infection. So you might survive a battle wound only to die at the hands of medical care providers whose good intentioned interventions were often quite lethal. High death tolls can also be ascribed to everyday sicknesses and diseases in a time when no antibiotics existed. In total something like 600,000 deaths occurred from all causes, over 2% of the U.S. population at the time!
Let’s skip to the first half of the 20th century for some additional perspective and to bring us up to more modern times. After the civil war there were steady improvements in American medicine in both the understanding and treatment of certain diseases, new surgical techniques and in physician education and training. But for the most part the best that doctors could offer their patients was a “wait and see” approach. Medicine could handle bone fractures and perform risky surgeries and the like (now increasingly practiced in sterile surgical environments) but medicines were not yet available to handle serious illnesses. The majority of deaths remained the result of untreatable conditions such as tuberculosis, pneumonia, scarlet fever and measles and/or related complications. Doctors were increasingly aware of heart and vascular conditions, and cancer but they had almost nothing with which to treat these conditions.
This very basic understanding of American medical history helps us to understand that until quite recently (around the 1950’s) we had virtually no technologies with which to treat serious or even minor ailments. Nothing to treat you with means that visits to the doctor if at all were relegated to emergencies so in that scenario costs were obviously minuscule. A second factor that has become a key driver of today’s health care costs is that medical treatments that were provided were paid for out-of-pocket. There was no health insurance and certainly not health insurance paid by someone else like an employer. Costs were the responsibility of the individual and perhaps a few charities that among other things supported charity hospitals for the poor and destitute.
What does health care insurance have to do with health care costs? Its impact on health care costs is enormous. When health insurance for individuals and families emerged as a means for corporations to escape wage freezes and to attract and retain employees after World War II, almost overnight there was a great pool of money available for health care. Money, as a result of the availability of billions of dollars from health insurance pools, encouraged an innovative America to increase medical research efforts. As more and more Americans became insured not only through private, employer sponsored health insurance but through increased government funding that created Medicare, Medicaid and expanded veteran health care benefits, finding a cure for almost anything has become very lucrative. This is also the primary reason for the vast array of treatments we have available today. I do not wish to convey that this is a bad thing. Think of the tens of millions of lives that have been saved, extended and made more productive as a result. But with a funding source grown to its current magnitude (hundreds of billions of dollars annually) upward pressure on health care costs are inevitable. Doctor’s offer and most of us demand and get access to the latest available health care technology, pharmaceuticals and surgical interventions. So there is more health care to spend our money on and until very recently most of us were insured and the costs were largely covered by a third-party (government, employers). This is the “perfect storm” for higher and higher health care costs and by and large, the storm is intensifying.
At this point, let’s turn to a key question. Is the current trajectory of U.S. health care spending sustainable? Can America maintain its world competitiveness when 16%, heading for 20% of our gross national product is being spent on health care? What are the other industrialized countries spending on health care and is it even close to these numbers? Add politics and an election year and the whole issue gets badly muddled and misrepresented.
I believe that we need a revolutionary change in the way we think about health care, its availability, its costs and who pays for it. And if you think I am about to say we should arbitrarily and drastically reduce spending on health care you would be wrong. Here it is fellow citizens – health care spending needs to be preserved and protected for those who need it. And to free up these dollars those of us who don’t need it or can delay it or avoid it need to act. First, we need to convince our politicians that this country needs sustained public education with regard to the value of preventive health strategies. This should be a top priority and it has worked to reduce the number of U.S. smokers for example. If prevention were to take hold, it is reasonable to assume that those needing health care for the myriad of life style engendered chronic diseases would decrease dramatically. Millions of Americans are experiencing these diseases far earlier than in decades past and much of this is due to poor life style choices. This change alone would free up plenty of money to handle the health care costs of those in dire need of treatment, whether due to an acute emergency or chronic condition.
Let’s go deeper on the first issue. Most of us refuse do something about implementing basic wellness strategies into our daily lives. We don’t exercise but we offer a lot of excuses. We don’t eat right but we offer a lot of excuses. We smoke and/or drink alcohol to excess and we offer a lot of excuses as to why we can’t do anything about it. We don’t take advantage of preventive health check-ups that look at blood pressure, cholesterol readings and body weight but we offer a lot of excuses. In short we neglect these things and the result is that we succumb much earlier than necessary to chronic diseases like heart problems, diabetes and high blood pressure. We wind up accessing doctors for these and more routine matters because “health care is there” and somehow we think we have no responsibility for reducing our demand on it.
It is difficult for us to listen to these truths but easy to blame the sick. Maybe they should take better care of themselves! Well, that might be true or maybe they have a genetic condition and they have become among the unfortunate through absolutely no fault of their own. But the point is that you and I can implement personalized preventive disease measures as a way of dramatically improving health care access for others while reducing its costs. It is far better to be productive by doing something we can control then shifting the blame.
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