Healthcare After Quarantine
As ideological spin is momentarily pierced: questions to ponder
The economic stresses of the travel ban, quarantine & social distancing policies force the U.S. to confront realities previously obscured in ideological political spin. For example, intense debate of “lives vs. livelihood” consider whether there is an acceptable human sacrifice to hasten return of the financial status quo. We can self-isolate in our preferred news bubbles and take their messages at their word — until our direct life experiences begin to contradict. At that point, anyone rational should ask questions.
- Should Healthcare be delivered as a business?
- Why is healthcare so tightly tied to (and limited by) your employer?
- How much does political competition and outrage cloud our clear thinking?
Example Moment of Pause: Nurse layoffs during the pandemic
Last Friday, The New York Times reported:
“As hospitals across the country brace for an onslaught of coronavirus patients, doctors, nurses and other health care workers — even in emerging hot spots — are being furloughed, reassigned or told they must take pay cuts.”
Right now in Upstate NY private practices, urgent care and hospitals are running far below the patient throughput rates they need to break even. Yet it feels like the quiet before the imminent storm — particularly as NYC signals intent to send patients upstate for overflow care.
The Times article “During a Pandemic, an Unanticipated Problem: Out-of-Work Health Workers” (or alternately USA Today’s “Thousands of US medical workers furloughed, laid off as routine patient visits drop during coronavirus pandemic”) brings into focus one of the foundational issues the U.S. will need to assess once the crisis subsides.
Should Healthcare be delivered as a Business?
Medical practice income has reduced to a trickle as non-emergency visits are canceled during quarantine and social distancing reduces activities that typically drive urgent care (and give pause to people considering potential exposure). Additionally, financial uncertainty regarding reimbursement as unemployment soars /<USA Today> when we rely upon employer-based health coverage. Even if the stimulus covers Covid-19 treatment for the uninsured, it does not cover the other types of visits to the practices, compounding the perceived risk and undermining confidence.
These articles detail how these conditions lead the health system (hospitals, HMOs, urgent care centers — now run as corporations with shareholders) to cut costs by furloughing nurses and support staff, while contracts with providers (MD, DO, PA, NP) based on patient volume severely cut pay. Providers once owned their own practices, as partners and exercised more independence and discretion in how they delivered their professional service. But acquisitions by hospital networks have usurped that autonomy and force those physicians into practices prioritizing profit — for example, connecting income with throughput.
Meanwhile, despite the commensurate reduction in claims, those of us fortunate to be employed continue to pay insurance premiums. Presumably HMOs are supporting their medical staff, while keeping their practice afloat. It would seem the insurance companies now accumulate those funds missing to pay the furloughed healthcare workers.
Even assuming market-based healthcare is ideal, this is a counter-productive use of valued resources.
Why is healthcare so tightly tied to (and limited by) your employer?
Why should employers be the center of responsibility for healthcare delivery for the families of employees? Employers should be focused on their business; dealing with health benefits is a distraction. Similarly for the workforce, a desirable job may not offer sufficient health care options by way of that employer’s (potentially arbitrary) selection of plans. Yet because of the mere fact the employer offers a plan at all, the worker is restricted from or penalized in using alternatives.
Additionally, desirable job mobility is stifled by the complexity of switching from plan to plan with different provider networks and rules. The discontinuity is another hit to national productivity, as workers invest time making sure their family is supported: finding in-network doctors, re-justifying treatments, etc.
The form the market takes impacts even minute decisions and behaviors. When my employer switched from $20 HMO co-pays to high deductibles, I had an employee hold off taking his son to the ER for an ankle injury during soccer, concerned with it being a spurious and the cost being substantial ($500). His 12 year old walked on a broken ankle for 2 days before finally going. And this is with the employer-based support.
The origins of tightly-linking employment to healthcare are not really relevant at this point. When the economic stress from the pandemic-quarantine lead to massive layoffs, the soundness of employer-linked-healthcare was severed. Upon lifting the quarantines, a massive backlog of medical demand (physicals, non-emergency treatments, postponed procedures) will now additionally be complicated by changes in insurance status, if insured at all.
Healthcare is something everyone needs, and already when someone cannot pay — after the collectors have taken all they can — we collectively pay for that in the form of risk-scaled costs and bloated bureaucratic layers of bullshit jobs coding and processing claims, navigating a zillion reimbursement contracts for pricing, etc. The trends toward the gig economy further complicate, as more and more workers shift from major employers to freelancing.
Are we replacing American pragmatism with ideology?
But if we’re honest, if we truly can put aside our “red team vs. blue team” ideological standoff for a moment — can we see some significant flaws in thinking about health as a product or service? Physical health and well-being is not a normal economic commodity — for what else would you literally trade all that you own — including mortgaging your home or bankruptcy (if not for yourself, your child or spouse?)
The present system cannot be the capitalist ideal for a market by any stretch of imagination. So is anything not capitalist a bad un-American thing? Once more — step out of the spin, be smarter than the media talkers — what we label things gets weaponized by those partisans, and substitutes ideology for rational problem-solving; ideas fueled by special interests employing lobbyists to protect their status quo.
Never accept naive interpretations of labels, make an effort to understand words like socialism or progressive — and the difference between liberty vs. freedom.
Truly (“Adam Smith grade”) free markets would not tolerate such protections, by the way. Licensing requirements limiting supply, bail-outs / subsidies and lack of antitrust regulation all contradict free market principles. A symptom of free market failure is concentration of wealth and influence. It is not a market where anyone is free to amass personal wealth, a free market is where free competition gives a fair shot for ever-new ideas, products and services.
Doing what is needed — even if hard — is a core American ideal
A crisis lets us see more clearly — and motivates us to do the right thing, even if it will be very very hard and disruptive. To squander this moment in time will only amplify political spin later, exhaust time and money in debate, and delay the benefits we can begin to gain.
Special interests have been apt at spinning anecdotal stories from single provider systems like the UK’s NHS — or similar in Canada or Australia to muddy consideration by the public.
These incumbent, privileged special interests, however, are the very-same who create the layers of bureaucracy and a complex maze for reimbursement. They are the same who acquired your local private physician partnership, then prioritized financial metrics which undermine how those physicians may choose to deliver quality of care. Their obligation to meet quarterly shareholder demands have driven short-sighted actions such as layoffs and furloughs of medical staff.
In prioritizing profit-for-shareholders, healthcare providers implicitly undermine the foundational purpose of the profession to provide a critical public service.
Yes, it would be highly-disruptive to deconstruct the existing major insurance providers and eliminate bureaucratic jobs in coding and processing claims.
Yes, single payer systems are imperfect and there will be anecdotal examples of deficient care in their radical simplification and volume-driven efficiencies.
Yes, this would mean change and change means uncertainty and risk.
A possible future?
If nothing else, America is abundant with innovation. Surely we have not yet considered all the alternatives to forms of providing healthcare, paying for healthcare, improving public wellness, mental health, diet, fitness, etc.
Some changes are already in motion: telemedicine such as Maple, digital platforms to give small practices large network efficiencies, and low-cost 24x7 AI chatbot (or “docbot”) services. Engineers and scientists have inherently low tolerance for obvious inefficiencies and limitations lingering when there are technological solutions at the ready — this is an unstoppable force of change.
Perhaps providers and nurses presently furloughed by the large consolidated health networks could reform their previous partnerships, leveraging new digital technology platforms to run efficient and competitive-scale practices.
As autonomous partnerships once more, care delivery can be decoupled from the assembly-line methods compelled by the shareholder-focused networks. Physicians can then provide locally-focused services under their own professional discretion while joining through digital platforms to coordinate and compete with the large legacy care providers.
Perhaps the same information technologies and artificial intelligence can revolutionize efficiencies, eliminate fraud, and massively consolidate the processing of claims and reimbursement to the point of implementing what is effectively a single-payer system anyway, ruthlessly commoditizing the competitive differentiation and inefficiencies supporting the large legacy policy providers.
Perhaps the relative effort, cost and complexity of employer-dependencies in such systems will clarify the degree to which these add no practical value beyond window-dressing for satiating punish-the-lazy ideologies.
At which point — the transition to something like the NHS would be tremendously simplified anyway.
