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The 99%, part 2 – with a word from Gandalf
By | October 28, 2011
In my last post, I talked about the true situations of those who call themselves “The 99%.” You may have wondered: what does all this have to do with doctoring?
I live in western Oregon. My town is very white – 82% White. Three times more people identify as multiracial than as Black. The reason I mention this is that White people often presume that economic collapse doesn’t significantly affect “people like us.” (Of course, the Depression has gone on for many decades without ceasing, due to the ongoing conditions of White supremacy, for people of color. But they don’t live in this town, much.)
The biggest employers are the hospitals and schools, but as you can imagine, there are only so many hospital-and-school jobs to go around.
The per capita income (which means “per-person,” including folks who aren’t earning, like babies) in my town is around $21,000 per year. A lot of my patients come from surrounding towns where the per-capita incomes are $13-14,000 per year. (All 2010 numbers, from Wikipedia.)
City-data dot com also reports that in 2009 (which in retrospect looks like a pretty good year), 22% of people in my town lived below the poverty line, relative to 14% statewide. Most of them were men and women aged 18-24. I mention this because I have been hearing a lot of people supposing that the young people calling themselves “the 99%” are privileged trust-fund kids who don’t feel like working for a living.
About two-thirds of folks below the poverty line in my town work part-time, rather than being totally jobless. The U-6 unemployment rate for Oregon (including everybody unemployed and under-employed) is just about 18%.
This is a town where every major intersection has multiple folks holding cardboard signs on multiple streetcorners. “Veteran – Two kids at home – Need gas money to Portland – Will work for food – Anything helps – God bless.” There are fewer when the weather is nice. (If they were lazy “trustafarians,” there’d be more.) One youngish, sad-looking guy held a sign saying, “Just shoot me.” It gave me chills.
I have a lot of patients who’ve been struggling for a long time. They’re mostly not that old – because I don’t have a contract with the government agencies that fund health care for older people. (Most older folks are sticking with the better-subsidized large group practices.) They may not be that old – but many are sick.
The sicker a person is, the more difficult it is for them to navigate the system – to obtain health care, medicine, food, equipment to help them see and hear, and housing with power and water, much less information, communications, transportation, education, and the things in life that contribute to mental health, like connection to friends and family, decent clothes, the resources to properly care for companion animals.
It seems normal, now, to not have many of these things listed above – because it is common. (I would argue we should not consider it “normal.”) Most able-bodied well folks who do have those things, view the lack, in others, as not terribly significant – they presume the problem is temporary.
Do you take these things for granted? Do you know how you’d provide them, if you lost your income? If you were too sick to work? Are these things you’ll need in the future, but don’t know when? Are you ready to go without them?
timely medical advice and treatment
over-the-counter and prescription medicines
home health supplies, e.g. blood sugar meter strips, colostomy bags
glasses
dental care and/or dentures
hearing aids
food – buying, cooking, storing
safe housing with power, water, and privacy
communications: phone and/or internet
access to news and information
transportation
decent clothes, and resources to keep them clean and mended
decent winter shoes and a winter coat
access to a supportive family/friend network
a reliable, responsible babysitter
veterinary care for sick animals
psychological and spiritual guidance
beauty
Folks who go without many or most of these – and I know many, many, many – they’re pretty worried the condition is permanent. Once you start to fall behind, these days, you fall farther and farther, and faster and faster. There aren’t any jobs for people who have been sick, or out of work for a long time, or who are older. There isn’t any readily-available social assistance. Freaked-out taxpayers think it would be a good idea to legislate away the assistance programs that used to be available.
You might wonder why “the poor” aren’t all on Medicaid. You might not know that in our state, eligibility is awarded by periodic lottery; about 52,000 people are on the list; many more would qualify, by income, but haven’t put themselves on the list. Recent lotteries awarded about 2,500 slots, but only about half of those chosen actually received Medicaid.
Lots of folks I know are moving in with relatives, doubling/tripling up; people are living in other people’s driveways, and not for free; they’re giving up making payments on loans, mortgages, “Care Credit” cards; some are resorting to moneymaking schemes that are against the law; others are resorting to schemes that victimize the desperate, the ignorant, the foolish – things they never would have imagined themselves doing.
Folks are stressed and depressed, drinking heavily, eating too many French fries, smoking, fighting. Folks are hurt and angry. These conditions are all significant health risks.
As Gandalf said, we must do what is in us to uproot the evil in the fields that we know.
The main one I know is the health and well-being of the people in my practice.
Almost half of them pay out of pocket for the care I give them, usually around $100 per hour-long visit. (They don’t have insurance, or are “under-insured.”) Those who need a lot of home or office visits (for example, weekly or monthly), which would be prohibitively expensive if paid for visit by visit, are supposed to chip in $50 per month. Many of them can’t even manage that, mostly because they are sick.
We have a lot of stuff we’re working on, together. Their care includes a lot of records review, research, consultation with specialists, and other behind-the-scenes doctor work. It’s going well! Except that I’m obliged to work an extra job or two, to keep the office open.
The other just-more-than-half of the patients in my practice have health insurance. They pay $15-30, usually, for a visit, and often also a percentage of my fee (“co-insurance” – often comes as a nasty surprise a couple months after the visit). They don’t visit as often, because, for the most part, they are healthier; after all, they’re still employed, so they must be healthier.
In 2011, the average yearly cost of employment-based insurance is about $5,429 ($921 out of pocket) – $15,073 for a family, 9% higher than last year ($4,129 out of pocket).
Those are the numbers I find online, but they don’t square with what my patients tell me – for example, a young University parent with two kids recently told me that they and the University together pay $1400 per month for their policy.
If my spouse and I were to get individual (not employer-subsidized) health insurance, a quick run through the quotes calculator shows our monthly bills would be, for example, with our local biggest insurers, $900-950/month – with $1000-2500 deductibles (out-of-pocket expenses to be paid before insurance “kicks in”).
If and when we met our deductible, and the insurance “kicked in,” we’d still have 20-30% coinsurance and the $20-30 copay – after we shelled out $1000-2500, on top of the monthly premium bill. (For example, the standard $180 office visit would cost $56-84 out of pocket.) This is quite typical.
The reason I go into this detail is that many people have no idea how much of their earnings “automatically” disappear from their paychecks for health insurance – and don’t add up the true cost of doctor visits, with insurance. When the bills arrive, they have repeated “sticker shock” (and often blame the doctor, rightfully or wrongfully).
I have written about this before, and received a flood of helpful advice about how to obtain “cheap” insurance. But that’s not my point. I am addressing this issue as a physician who is committed to social justice, not as a consumer asking for advice on how I can most efficiently line the pockets of corporations.
For a family in “The 66%” – for example, the math teacher mentioned in part one of this entry – health insurance can be 12% or more of their income, considering deductibles, copays and coinsurance.
For the $4,280 they spent this year, they could have had 40-50 visits in the office with me.
55.3% of the nation has health insurance through their employers.
Why do people go along with this stuff?
Folks really want to have health insurance, not so they can see me – as I mentioned, they could be seeing me for $50 a month, rather than $5,000 a month. They want it so they will be “covered” if Something Terrible happens. And they know people to whom Something Terrible has happened. Appendicitis! Gallstones! Bike crash! Car crash! Cancer! They hope that “coverage” will equal “care.”
However, the jury is out on whether their individual policy would really come through for them in the event of Something Terrible.
As Wendell Potter, the crusading insurance whistleblower, wrote in his blog earlier this month, “[Among the] 546 comments that had been posted on the “We are the 99 percent” Tumblr site… 262 of the comments mention such problems as getting denials for doctor-ordered care from their insurance companies and having to forego treatment because of hefty out-of-pocket costs.”
Even when insurance does pay, people are left with large bills. Later, it remains to be seen whether the person is able to continue receiving insurance. For example, the other day I was told about a very healthy young employed person (a spouse of a patient) who was denied insurance altogether because they had had a minor knee operation for a sports injury – an incompletely “covered” procedure they are still paying off. I know a person who broke their neck in a fall; they recovered, but their insurance premium doubled, and they had to give it up, and go “bareback.”
In order to afford coverage, people usually sign up for the biggest deductible they can tolerate. They know they’ll have to pay for everything out-of-pocket – but it’s the only way they can afford the monthly premium bill.
This means that they delay coming into my office, and try to get medical advice and treatment, as much as they can, over the phone with me. If they make it to the end of the year without having to pay too much out of pocket – without realizing any benefit from the insurance they and their employer pay so much for – they feel like they’re ahead.
If and when they do come in, it’s often with a long list of health worries that are out of control – often a long list of health worries that they ask me to spin, or cover up, in their records, so the insurance won’t find out they have something that might raise their rates.
(And here, once again, I’m not asking for advice! I recently received a whole bunch of advice from other doctors, about how to better spin and cover up medical issues in medical charts. This is not something at which I long to become an expert.)
A large number of my insured patients prefer to get most of their care from alternative practitioners who are outside the insurance system altogether. Their naturopath, chiropractor, homeopath, and craniosacral therapist, in addition to bringing their own specialized skills to the table, do not reek of the insurance trap, and are managing conditions under the insurance radar.
Patients often trust them more than medical doctors, because they believe doctors are universally in cahoots with an oppressive system that has much to do with cash and little with care. And, often against the available evidence, they believe alternative practitioners universally are not.
Meanwhile, back in the land of “The 1%,” insurance corporations (including those which doctors avoid the most carefully – cf. class action lawsuits for price fixing and not paying doctors) are projecting huge profits:
Humana, $9,250,000,000 (that’s billions) in the past three months alone.
(CEO made $6,100,000 in 2010. That’s millions. He is “The 0.00139%.”)
UnitedHealth, $25,450,000,000 in the past three months alone.
(CEO made $10,100,000 in 2010. He is “The 0.00037%.”)
WellPoint, $15,200,000,000 in the past three months alone.
(CEO made $13,400,000 in 2010. She is “The 0.00037%.”)
Cigna, $5,460,000,000 in the past three months alone.
(CEO made $15,200,000 in 2010. He is “The 0.00037%.”)
Aetna, $8,330,000,000 in the past three months alone.
(CEO made $20,700,000 in 2010. He is “The 0.00005%.”)
The Wall Street Journal, in reporting this, chirps, “The ongoing sluggish pace in operating rooms and doctors offices likely helped third-quarter earnings of U.S. health-insurance companies.”
In other words, when you’re afraid that medical care will drive you into the poorhouse, your insurance company realizes pure profit. You pay and pay and pay them, and you get nothing in exchange – unless you count partial, and temporary, relief from the nagging fear of Something Terrible.
So here is what I see.
A lot of folks who are clobbered, either suddenly or in slow motion, by the economic collapse. They have great difficulty staying in good health, or recapturing good health, because of no money. They may or may not be employed.
And a lot of insured folks spending huge amounts of money without even knowing it, so that corporations and their CEOs can rake it in. They’d like to stay in good health, or recapture good health, but may postpone medical care that might help with these, because “coverage” is not care. Don’t even get me started on the many folks who are staying in jobs that are making them sick, because they’re afraid to lose their insurance.
Isn’t there any way both of these groups of people can get the medical help they need, in a way they can afford? I’d argue that primary care, preventive care, is one way.
But I also really think we need to stop playing with insurance corporations. And I don’t think we can wait for Washington to provide national health. And much as I am fond of the colorful costumed, radical and knowledgeable folks camping out on Wall Street, I can’t wait for the powers-that-be to listen to them, either.
I am not primarily concerned with erecting giant policy-laden structures. I am concerned about particular people that I know. They are my neighbors. They need help today. I would like to help them to help each other.
“…so that those who live after may have clean earth to till. What weather they shall have is not ours to rule.” – Gandalf
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