medical bankruptcy

How to Become Homeless

R. Horton2 Comments

People use the phrase “homeless people” as if it refers to a type of person instead of a type of circumstance. People without access to shelter are sometimes born into a homeless situation, but they are not “born that way” in the same way that tall people are born with genes for height.

If you spend any time at all talking to people without homes, you will quickly realize you are much closer to being homeless than you are likely to want to admit. I honestly believe this is why so many people avoid those conversations at all costs.

I suppose we are most affected by stories that relate closely to our own lives. At least, I know that is true for me, so I will never forget meeting a homeless man who taught at the same college as I. He was highly educated and had been living quite comfortably until a medical emergency left him in a coma for some time. He wasn’t expected to live, much less come out of the coma and leave the hospital, but sometimes medical miracles do happen.

When this man got out of the hospital, he found that his sister and nephews, thinking he was dying, had emptied all the money from all his accounts and gone on a cross-country spending spree. The money could not be retrieved, and prosecuting the thieves would mean sending his own family to jail. As he told me he couldn’t bring himself to file charges, tears rolled down his cheeks. He was still teaching classes while trying to hide the fact that he was homeless from his students and employer.

I spoke to hundreds of people who were in crisis, and I would say that the most common causes of their homelessness were medical emergencies that resulted in job and/or income loss, failed businesses or theft of businesses funds by unscrupulous business partners, failed romantic relationships, mental illness, grief, domestic abuse, and, yes, addiction. This last one (addiction) should simply fall under illness, but I recognize that many people believe that addiction is a personal choice, and this belief enables them to blame homelessness on the victims of depression, grief, or other factors that lead to addiction. No one chooses to become an addict and lose everything.

Another category deserves a separate post, really, and that is young people who are thrown out of their family homes for being different, usually for being LGBT+. These young people are extremely vulnerable to exploitation and abuse, including murder.

I suppose some people are wealthy enough to be insulated from the risk of homelessness, but many people I spoke to had lost all the things you have and take for granted. They had homes, cars, businesses, and all that goes with those things, including pride, self-worth, dignity and comfort. Many of the people I met were able to maintain their feelings of pride, dignity, and self-worth despite seemingly every part of their families, their society, and their government trying to take those away from them. I was and remain in awe of the people who have managed to fight their way back from the brink without being destroyed by their situation.

Many aren’t able to overcome the odds, and each death is a failure of society to look out for every member. Immanuel Kant famously said that if we will heartlessness to those who are victims of misfortune, we are willing indifference to our own suffering when our time comes. No one gets out of this world alive, so your time is coming. Have you acted in ways that make you worthy of compassion and respect?

Photo by Chris John on Pexels.com

In US, Illness is Financial Anxiety

R. Horton

In August 2016, I moved from Texas to the northwest of England. Last summer, I while walking in the local park I slipped on a stepping stone and sprained my ankle. As the pain pulsed through my body and my ankle began to swell, I began to wonder whether I needed an ambulance, an x-ray, or possibly even surgery.

I did not think about the cost of an ambulance or whether my insurance might refuse to pay for it, the cost of an x-ray if needed, the price of surgery, or even co-pays for medication or any possible treatments. I was worried only about my condition and getting better.

I enjoy hiking, cycling, dirt bike riding and other sports with risk of injury, so I’m not unaccustomed to dealing with the occasional injury. With similar injuries in the United States, though, I always thought immediately of the cost. Mind you, I was never uninsured, but even with insurance proved by the college where I taught, a shattered tibial plateau in 2001 that required two surgeries and months of physical therapy left me with surmountable but daunting bills long after I had recovered. Since 2001, prices have risen dramatically along with higher deductibles, narrower networks, and higher copays for treatment.

In the United States, illness or injury means an immediate calculation of costs and threats to financial security even for working people securely in the middle class. For others, the situation is much worse. Of course, long-term illness or injury can throw middle-class workers out of work, which means they will lose their insurance, unless they can afford COBRA payments to maintain their insurance for a limited time after employment. In my experience, COBRA payments are much higher than people expect or are able to pay.

As a student in medical humanities, I read many narratives of illness. They all focused on suffering from the condition, facing mortality, finding or making meaning in the face of prolonged pain, but not so much about what truly horrifies Americans when they fall ill. Illness or injury should be a time to focus on healing, if possible, or confronting or preparing for prolonged pain in the case of a chronic condition, or to prepare for death in the case of terminal illnesses. It should not be a time to worry about financial ruin for oneself and one’s family.

The study of medical ethics offers many opportunities to contemplate challenging philosophical problems with rich and varied intellectual interest. However, access to healthcare is by far the most pressing problem in the United States. Anyone concerned about illness, suffering, and medicine must assume the obligation to relieve the suffering created by unaffordable healthcare.

 

 

Illness as Financial Ruin (US only)

R. Horton

Every human who has drawn a breath has faced illness, injury, and death. The universal experience of illness creates vulnerability, loss of identity, anxiety, diminished autonomy, and fear. The inescapable battle between health and illness defines human experience and shapes our personalities, our worldviews, and spiritual depth.

For most of the developed world, though, it does not mean financial ruin. In the United States, alone among developed nations, even a relatively minor injury such as broken bones or illness requiring a brief hospital stay can lead to economic disaster. As a result, when we in the US get sick, we don’t think about how we can recover, how we can endure the pain, or the spiritual significance of our pain; rather, we think of how we will pay for our bills.

poorunclesam-800pxAs we face our anxiety over possible diagnoses, we must constantly be prepared to battle with insurance companies, aggressive hospital billing agents, and doctors exhausted from dealing with insurance paperwork. Few things in life create as much anxiety as financial insecurity, and illness always brings the threat of insecurity to US residents. When people have serious accidents, they balk at calling an ambulance because they fear the bills—they worry over whether the ride will be covered and whether the ambulance will take them to a hospital that is in-network. As a result, many people suffering medical emergencies drive themselves to the hospital.

When it isn’t an emergency, Americans often forgo treatment altogether. A Gallup poll in 2014 found that one-third of Americans skip needed medical treatment because of cost concerns, even when they have insurance.  According to the report, “Some 34% of Americans with private health insurance say they’ve skipped out on care because it was too expensive, up from 25% last year. Additionally, 28% of households that earn $75,000 or more report that family members have delayed care, up from just 17% last year.” The Affordable Care Act succeeded in insuring more people, but it also created greater financial burdens for middle-income families through higher deductibles and co-pays. Many people who have been accustomed to being able to afford healthcare now find that it is out of reach.

While healthcare inflation has slowed a bit in recent years,  catastrophic medical events put the costs incurred out of the reach of most of us. The United States alone finds medical fundraisers to be normal and routine. According to an article in Journal News, the number of GoFundMe contributions for medical expenses “was up more than 293 percent in 2014, when more than 600,000 medical campaigns were launched, compared to just over 158,000 in 2013.”  Families with or without insurance cannot afford their medical bills. A serious accident or illness such as cancer creates an existential crisis while forcing people suffering from illness and their families to scramble to avoid destitution.

I don’t write this impersonally, my wife and I buy our insurance through the healthcare exchanges. We pay $682 per month ($8,184 per year) with a $4,000 deductible per person. The out-of-pocket limit on expenses is $13,700 per year. Balance-billed charges do not apply to the out-of-pocket limits, so there really is no upper limit to possible charges. Ignoring balance billing, my costs could easily exceed $20,000 per year.

I often hear the argument that universal healthcare coverage is too expensive and will require raising taxes on the middle class. As I see it, I would still benefit from a tax rise of $15,000 or even $20,000 each year. It is true that others are not in my position, but all Americans should realize they are at risk. No one stays young and healthy. Eventually, everyone will be at greater risk for catastrophic illness, but even those who are currently young and healthy can face illness and injury, though we may not like to think about it. Further, everyone’s income is subject to great variability. Those who have employer-provided health insurance may not want to pay in to a national system, but employer-provided insurance is never guaranteed. Employers may cut benefits, employees lose jobs through layoffs and termination, or illness can end employees’ ability to work.

The same is true for business owners. The tides of fortune shift. When the Affordable Care Act was passed, Mary Brown brought a lawsuit against it, saying she did not want to be compelled to purchase health insurance. Mary Brown owned an auto repair shop that went under due to the pressure of economic recession and the Gulf oil spill in 2010. Of note, her bankruptcy filing listed “among the couple’s unsecured creditors several providers of medical care – a hospital and a physician group in Florida; an anesthesiology group based in Mississippi; and an eye care center in Alabama.” https://newrepublic.com/article/98145/affordable-care-act-mandate-lawsuit-nfib-mary-brown-bankruptcy-court-standing

Like many people, when she was doing well, Mary Brown thought that guaranteed universal access to healthcare was something the government was providing to other people. It didn’t occur to her that she might ever be in a position where she could not pay for her own medical care, but that is exactly what happened. I recently had the opportunity to speak to a Swedish citizen about Sweden’s healthcare system. He was a middle-aged man who explained that healthcare was paid through higher taxes. He said he didn’t mind the taxes, though, because you never know when you will be the one needing care.

It seems many Americans are not able to make this basic calculation of risk. Most people, even those who consider themselves well off, are not immune from the financial ruin that illness and injury can bring. Once people realize their own vulnerability, they support universal coverage for healthcare. The time for a more sober and accurate assessment of risk is well past due. We must wake up to the fact that the US healthcare system is not sustainable, that it leaves us at risk of financial failure, that it makes the experience of illness exponentially more stressful, and that we can do better.

It will not be easy. The US spends far more than other developed nations on healthcare. Each excess dollar we spend is profit for an insurance company, hospital, testing facility, pharmaceutical company, biotechnology company, or other player in the healthcare industry. Many people profit from the dangerous, expensive, and inefficient system we have in the United States. Every reduction in healthcare spending will be a reduction in profit for someone, and each person (or business) facing a loss of income will argue vehemently and vociferously that such a loss of income is a horrible tragedy and an impossible feat.

We will be told that reducing healthcare spending will reduce the quality of care. We will be told it will reduce our choices and control. We will be told it is impossible. We already have little choice or control, and we already have higher mortality rates than the rest of the industrialized world, so we have nothing to lose and everything to gain. We have plenty of ideas on how to improve the system. What we lack is political will, but I think the will is growing. If we want universal coverage, we must demand it, and the time to demand it is now.

 

On the 49th anniversary of Medicare, let’s work to expand it

R. Horton4 Comments

Medicare was born on July 30, 1965 primarily to help provide medical insurance for Americans over 65. As of 2012, Medicare covered more than 50 million people and it has succeeded in preventing many people from falling into extreme poverty in their old age. And of the 50 million covered, about 8.5 million are people with disabilities, who would not be insurable through private insurance plans.

Despite a few arguments, from the for-profit insurance industry, Medicare is financially more efficient that public plans (see a discussion here ). Even pro-industry arguments tend to highlight some of the advantages of Medicare. In this defense by Merrill Matthews for The Council for Affordable Health Insurance  of private sector insurance, for example, the author says, “Executives and boards of directors consider, debate and decide company policy; in Medicare that function is often handled by Congress and itmedicare for alls legislative staff. “ The authors point out that the time of Congress is also of some value, but the cost is borne by taxpayers. Of course, the time spent by private-sector administrator is also borne by those who enroll in their plans, but private-sector administrators are not accountable to taxpayers in the same way members of Congress are expected to be. The CAHI defense also points out that private insurance companies must raise money and include the cost of raising capital in their administrative costs estimates while Medicare does not include the cost of raising capital as that is done through Congress.

The real difference, according to Matthews’ argument, though, is in the amount of money spent on patients. Matthews points out that private insurance companies spend more money on administration because “they scrutinize individual provider claims much more closely, challenge questionable procedures and determine whether, in the company’s opinion, a claim is valid or needs to be reconsidered.” In other words, private insurers spend a lot more money denying claims. If you’ve ever experienced a major illness or injury, you have been bombarded with paperwork explaining why you will have to pay your own way with no reimbursement from your insurance company.

Matthews said that in 2003, Medicare spent $6,600 per patient paying claims, while private insurance paid only $2,700 per patient. This hits consumers in two ways. First, if you’ve already received treatment and the bill is denied, you are on the hook for payment. Second, the price of your premium includes the salaries of the administrators who are committed to denying your claims, so you are paying them to refuse payment for your treatment. If you think it is good that your claim was denied, leaving you with enormous medical bills after a serious illness, private insurance is the way to go. If you want to have some peace of mind that your bills will be covered, expansion of Medicare is certainly the best choice.

Nonetheless, it is true that Medicare payments need to be lowered. The costs of Medicare payments reflect the costs of for-profit healthcare. The costs can be lowered by enabling Medicare to negotiate the costs of medicine (drugs, hospital equipment, and other medical technology). The costs of common medical procedures vary wildly from city to city in the United States (to see a comparison of four services, look here). By bringing more transparency to healthcare costs, Medicare can pay providers what is reasonable, rather than what is currently possible. While many say that markets create competition that will lower prices, this is simply not the case. The reason it isn’t the case should be obvious to anyone: patients who need healthcare are in no position to shop around. After I had knee surgery in 2001, I had complications that some blamed on my choice of doctor. When asked why I chose this particular surgeon, I said, honestly, that I lay in bed with a shattered tibia, calling doctors for appointments. The doctor I “chose” was the seventeenth doctor I called. No, I did not carefully research his credentials, prices, or hospital admitting privileges. Even at that, I had to wait two days with a shattered tibia to get an appointment. This is the reality of for-profit healthcare and for-profit insurance. It is a nightmare. While Medicare may not be a blissful dream, it leaves fewer patients with healthcare induced night terrors.

Many people seem to have a false sense of security with their employer-sponsored health insurance. In the first place, they overestimate how much of their care will be paid for by the insurance. Then they seem to forget that any serious illness or accident that makes them unable to work will also make them unable to maintain their insurance coverage. The fact that your employer provides insurance today is no guarantee that it will be there when you need it. Further, under the Affordable Care Act (ACA), employers may reduce employees or hours to avoid providing healthcare, as discussed in this article in the Wall Street Journal. And finally, under the ACA may further restrict patient choices of providers, as noted in this piece in the New York Times.

Should anyone be at the mercy of employers for healthcare? Should small-business owners and the self-employed have to shoulder a disproportionate burden for healthcare? Medicare for All is an equitable solution that is fair to everyone and enables us all to pursue our vocations according to our dreams and talents rather than our fear of medical bankruptcy. The time to expand Medicare was 49 years ago, but let’s do it now. Support H.R. 676.

Additional Reading: For more resources on this topic, see the Public Health and Social Justice website.