Trump Care BS Overdrive

So, after almost four years as president (and decades of hard work by Republicans before Trump), Trump finally announced the big GOP healthcare overhaul to replace Obamacare. It seems basically to consist of:

1) a promise to cover pre-existing conditions (after first ensuring the SCOTUS takes that coverage away). No details of how that promise would be fulfilled, what laws would be enacted to force insurance companies to take all comers. But no worries. As we all know, you can take a "promise" from Donald Trump to the bank!

2) a one-time redistribution of $200 to everyone on Medicare to help pay for prescription drugs (because Trump couldn't manage to force drug companies to reduce their bottom line and lower the price they charge for drugs). The fact that this payout will happen just before election day is only a coincidence, surely. I mean he could have done it Jan. 21, 2017, but I guess it wasn't a priority then.

3) a promise to stop doctors from charging for services not covered by a patient's insurance policy, in other words "surprise billing". It's about time the government stepped in and controlled what doctors bill for services or insurance will cover. Can we hope to have complete price controls on all medical services eventually? Anyway, it’s a good first step, though it does seem that all Trump is doing now is “investigating” how this might work. I guess we need to give him for time to figure it out.

Maybe that's why he needs another four years. It took four years to come up with an outline of plan. With another four years he and the GOP can come up with the actual plan. Maybe just before election day 2024.

Trumpcare Obscenity

Last week occurred one of the most shameful episodes in US politics. Even more troubling than the precipitous firing of an FBI director in the midst of an investigation of people close to the president.

For seven years, Republicans have fumed and ranted over Obamacare, campaigning endlessly with the promise of repealing the groundbreaking health care law. The House of Representatives held some 60 meaningless votes to do just that (meaningless, since they knew that none of those attempts at repeal could survive a veto by President Obama).

Then, with a Republican president (so-called*) finally installed in the White House, GOP lawmakers had their chance. And they blew it. 

First of all, the GOP didn’t have a coherent plan of its own ready to go, even after seven years. At least not one they all agreed on. It’s understandable, of course. They were taken by surprise in November. No one expected Trump to win, and consequently no one expected the Republicans to be forced out of their comfortable role of the opposition party. They didn’t expect to have to step up and actually govern.

Secondly, the plan Paul Ryan, the GOP leader in the House, did slap together after Trump’s surprise win was rushed toward a vote only a month after Trump took office (and just over two weeks after the plan was unveiled). The aim was to pass the bill on the seventh anniversary of Obamacare’s launch. It was a schedule dictated by optics and symbolism, but it meant the plan was only half-baked.

(And compare this to the torturous process of passing Obamacare, which took a full year, dozens of public hearings and much political wrangling. It was a process that conservatives never tire of characterizing as “ramming” a rushed law down the throats of the American people. A year, compared to two weeks.)

Thirdly, the Trumpcare plan was instantly unpopular. A poll showed only 17% of Americans supported it. And for good reason. According the analysis by the Congressional Budget Office, the GOP’s “reform” would force some 24 million Americans off insurance. The White House’s own estimates pointed to even higher numbers of people losing their coverage.

No wonder not even House Republicans could agree on the Trumpcare plan, leaving severe doubts that it would pass, even in a House made up of a 44-seat majority of Republicans. Trump tried to force the issue by instructing a now-doubtful Paul Ryan to proceed with the vote regardless. In the end, Trump had to back down and seemingly stopped caring about the bill.

Win one for the Democrats! No vote was taken. The bill died. Except, Trump and the GOP couldn’t bear the publicity that came with the lost. And, needless to say, the bill hadn’t really died. It was only in a coma, an induced coma.

I suspect that Trumpcare was brought out of this coma because Trump started to chafe under the perception, happily foisted by the media, that things weren’t going well for him. The operation of his White House continued to be a farce, and his first 100 days had passed without any significant legislative accomplishments.

Sure, he has signed lots of documents, executive orders, some of which have real effects (for example, allowing the completion of the Dakota Access oil pipeline to proceed), while many of which just stated Trump’s intention of doing something (like repealing Obamacare or building a border wall) but didn't result in any real-world actions by themselves. And sure, he got a conservative added to the Supreme Court after the Republicans had kept the seat open for a full year.

But in terms of actual laws that move forward on some key campaign promises, such as actually building a border wall, the symbolic first 100 days surely had to be a big disappointment for Trump supporters -- if they were honest about it.

To make matters worse, the recent budget passed by the GOP-dominated house lacked many clear-cut victories for Trump, and yet was filled with concessions to Democrats, over which the Dems couldn’t help publicly gloating.

The Democratic gloating was so bad that Trump and the Republicans -- snowflakes that they are -- complained bitterly that the Democrats were “spiking the ball”. And this from the man who celebrated his narrow win in November with an endless series of victory rallies where he did nothing but gloat. What is good for the GOP goose is, apparently, not good for the Democratic gander.

So, perhaps to soothe Trump’s feelings over his lackluster first 100 days and the humiliation of his failed budget, the GOP took another stab at killing Obamacare.

By injecting some amendments to the comatose Trumpcare bill, Paul Ryan and company were able to win over the ultra-conservative “Freedom Caucus” of Republicans who had formed the biggest obstacle to the bill’s first incarnation.

It seems the Freedom Caucus’ biggest objection had been the fact that Trumpcare didn’t remove Obamacare’s requirement to cover certain “essential health benefits”. This has often been a talking point in conservative media, which argues, for example, that middle-age men, in no danger of getting pregnant themselves, shouldn’t have to pay the additional cost for maternity-care coverage. 

The new amendments essentially allow individual states to opt out of this and other provisions of Obamacare, thereby placating the Freedom Caucus, which apparently won’t rest until every person dying without health insurance can die happy in the sweet knowledge that at least they died free. And not a burden to their fellow, freedom-loving, more prosperous Americans. Amen.

With this sweetener added for the Freedom Caucus, the bill passed, but by only four votes. No Democrats voted for it, which makes me wonder about those fashionably cynical folks who love to claim that there are absolutely no differences between the two parties.

This second try at passage was also rushed, this time apparently in order to hold the vote before the House left town for a “spring break” vacation. It’s often claimed these “recesses” are an important chance for the hard-working legislators to spend time in their home districts getting in touch with “the people” and hearing their concerns. Oh boy, do I ever hope they are actually doing that this time. I’m sure those brave enough to hold town hall meetings are getting an earful. We already know that Congressman Raúl Labrador,  a Freedom Caucus member from Idaho, got lambasted by the people in one such town hall after he foolishly claimed "Nobody dies because they don't have access to health care". Obviously, he inhabits a different world than the rest of us. 

So, the House Republicans wasted no time. Pushing the vote through so quickly had the added benefit of not having to hold hearings or giving the CBO time to score the new version. It's much easier to ignore how much worse the bill will be for poor people if you conveniently vote before you find out something unpleasant like that.

And in some sense, it doesn’t matter. Every House Republican can take solace in the fact that the Senate will radically change the law. In fact, some key senators have already said they will write their own bill from scratch, potentially making the horrible House plan marginally less horrible. Even then, it’s far from certain that a kinder, gentler Trumpcare will be able to pass the Senate.

I doubt the House Republicans even care. It seems the important thing was to pass something, anything, giving voters the impression the House had finally done something, not to mention giving so-called* President Trump the appearance of a win. And he grabbed onto that appearance of a win with all the desperation and gusto that he might normally reserve for some random woman’s genitals.

After the vote, the entire GOP caucus was bused over to the White House to celebrate in the Rose Garden like a jubilant fraternity at a keg party. In light of the travesty they had just committed, putting the future of millions of sick Americans in doubt, that display of heartless self-congratulation was simply obscene. There is no other word for it. 

* A "so-called" president in my mind, since Trump applied that label to a sitting federal judge who should be granted at least as much legitimacy for the office he holds as any president who loses the popular vote by some three million.

A Sick Business

The other day I ran across an article in the Atlantic Monthly that perfectly illustrates something that seems could happen only in America. I literally had to shake my head.

The writer, Olga Khazan, explains how the convoluted American insurance-based health care system is rife with pitfalls even for folks who have what is normally considered adequate insurance. For someone like me, who doesn’t have to deal with this sort of thing, it was an eye-opening read.

The main thrust of Khazan’s story was that fully covered Americans can still face unexpected medical bills, hassles with hospitals, and legal tussles with their insurers, all due to the byzantine nature of the American system.

One of the cases Khazan cites involves a Texas woman with a history of heart disease who began to have chest pains one day. When she and her husband became alarmed enough to seek medical help, they first shopped around. Finns reading this might be puzzled, but that is exactly what the couple did. They used a smart-phone app provided by their health insurance company to find a local health-care provider that would accept the woman’s insurance.

This is the approach reportedly advocated by some health-care experts and high-profile conservatives. Jeb Bush, the stealth GOP candidate for president, recently touted the “there’s an app for that” approach as the optimal alternative to Obamacare. The thinking is that what works best is a completely market-based system, where choosing medical treatment, even emergency treatment, is just like any other consumer choice – just like finding the shampoo or deodorant that suits you best. 

With the help of her phone app, the woman in Texas settled on a particular “stand-alone” emergency room, not a hospital, to treat her chest pain. Stand-alone ERs didn’t exist when I still lived in the US, and I’m sure we don’t have them here in Finland. I recall seeing one in a shopping center in my hometown on one of my more recent visits to Georgia. It’s like a branch of a bank, a smaller facility conveniently located for suburbanites. As such, I guess it’s not a bad idea, but they seem to share some of the unfortunate business practices of much larger facilities.

Luckily for the woman in Texas, there was nothing wrong with her heart, as was borne out by an EKG and some blood tests. Her visit to the stand-alone ER was short, but it came with a hefty price tag. When totaled, the bill came to $4600 (€4100), which seems staggering enough to me. Only half of that was for any kind of medical procedure (for example, the EKG was $300). The other half ($2258, or €2030) was just for the use of the ER itself, “facility fees” similar to those charged by full-fledged hospitals.

While her insurance covered most of the invoice, she was still on the hook for $500, which she was evidently able to reduce by negotiating a lower sum with the bill collection agency (hired by the ER to get its money). 

Apparently, when you’re sick in America, it helps to be a persistent haggler, as well as a smart shopper.

Another story Khazan shared in her article involves a Dallas man who suffered two strokes within a period of six months. The hospitals he was taken to in both cases were “in-network” for his insurance plan, meaning they had existing agreements to accept the man’s insurance. There was no worries about whether his treatment would be covered. Or, so he thought.

Apparently, individual doctors working in American hospitals often can charge separately for the care they provide to the hospital’s patients. And, they don’t have to necessarily accept the same insurance plans accepted by the hospital itself. This appears to be why the Dallas stroke victim received completely unexpected bills for “out-of-network” care not covered by his insurance. Three years later, the man is still in the midst of taking legal action over the extra charges.

I’ve heard of many stories similar to these. For many people, coming home from the hospital is often just the beginning of the next hardship to overcome, a protracted fight with insurance companies and bill collectors.

The very idea of this way of doing things seems alien to me after living so long in a country with a completely different approach to health care. Perhaps the best way to show what I mean by this is through a little example of my own.

Three years ago, I experienced a very minor health scare. Normally, I don’t like to share such personal (and let’s face it, trivial) details, but I’m trying to make a point here.

It was a Monday in July. I had just had an ocular migraine, in which your vision is temporarily obscured by shimmering “lights”. This in itself was no big deal. I have these ever so often. It’s not painful, but you essentially lose much of your vision for a few minutes due to something happening inside your brain.

This time, however, immediately after the migraine subsided, my left arm went completely numb and I had some pain in my chest. I was not even able to lift my arm above my head. That had never happened before, though in the past I have had occasional numbness in my arms due to pinched nerves.

I was sufficiently freaked out by this combination of events that I decided to see a doctor right away.

I didn’t shop around first, but I did need to make a call to decide where to go. The default choice would be the Paloheinä Tervyskeskus, the city-run health-care center closest to my home (about a mile away). Paloheinä is closed in July, however, when many services are scaled down in mid-summer when Helsinki almost turns into a ghost town, so I called a central health-service number to find out which other nearby clinics were operating. I was directed to go to Maunula, less than three miles away. I know the place well, since that's where I usually see the dentist. 

When I got there, a nurse checked me out and did an EKG, which showed nothing alarming. As it was near closing time, she asked me to come back the next day, a Tuesday, for blood work. On that second visit, she performed a second EKG (which seemed a bit unnecessary, to be honest). No change from the day before.

On Wednesday, I got a phone call from a doctor at Maunula with the results of my blood test. Nothing to worry about there, either. Still, he wanted to see me and booked a time for me the next afternoon. When we met, he explained that whatever had caused my symptoms, it wasn’t heart-related (a relief) and was most likely due to the kind of neck problems I had needed surgery to correct back in 2005. Thinking that this previous condition might have again deteriorated, he made an appointment for me with a neurosurgeon at Meilahti Hospital.

About six weeks later, I had an MRI done at the hospital. People who have undergone this procedure know that patients often have choice of music to listen to while encased in the incredibly noisy MRI machine. As it was a Sunday afternoon, I asked the technician to tune the sound system’s radio to Yle Mondo, which I knew at that time of day would be broadcasting National Public Radio from the US. Lying inside that huge machine, in a space the size of a coffin surrounded by powerful magnetic fields, I listened to the familiar soothing voice of Garrison Keillor on “Prairie Home Companion”. That is how I like to spend my Sunday afternoons.

The consultation with the neurosurgeon a few days later was short and sweet – no drastic changes showed up in the MRI. Nothing to worry about, and in fact, a similar episode of sudden numbness has not occurred since. Knock on wood.

A few weeks after all this happened, the bills started rolling in. The first was for the visits to the Maunula clinic. It was €13.80. The next, from the hospital where I’d had the MRI and neurosurgeon consultation, was almost double that, €27.50. The total came to €31.30 (about $40 at the time).

These two bills were basically office fees, comparable in some sense to the 2000-dollar-charge levied on the Texas woman for her brief visit to the stand-alone ER. For the EKGs, blood tests, doctor consultations, even the MRI, I was charged nothing. Zilch. This is what we pay taxes for.

Thinking back to my own experience on that July day, the differences to the American system could not be more glaring.

I didn’t have to shop around for the health center that would take my insurance. It’s a moot point. I don’t have insurance. I don’t need insurance.

I didn’t have to worry about sticker shock from unexpected bills because some of the professionals providing me care don’t accept my particular insurance plan. As said, I don’t have insurance. Don’t need it.

I didn’t have to haggle with an insurance company or collection agency to get my unexpected out-of-pocket fees reduced. There would be no insurance company to haggle with anyway, and besides 30 euros was something I could manage to pay without undue hardship (duh!).

To be sure, it is possible to buy health insurance in Finland, and there are private health-care providers here for folks who prefer that and are willing to pay the higher costs. Most people I know don’t use them, unless paid for by their employers. Most Finns I know usually use the public, single-payer system.

As it happens, the US Supreme Court is set to make a ruling any day now that could be a major blow to many Americans who finally have health insurance thanks to what Republicans, out of ignorance or naked ideology, love to call "socialized" medicine (a.k.a. Obamacare). It's not, not by a long shot.

Even though Obamacare is an improvement over what came before it -- and I do hope that the nine justices leave it untouched -- it’s good to remember that many liberals consider it, in reality, to be a half-assed compromise that relies on keeping the private insurance industry intact. 

I’m sure many of us would have wished that in 2010 Congress had instead enacted a single-payer system like Finland has. I'd like to think most Americans, if they actually thought it through, would prefer the same.

Or maybe they just prefer making things really, really difficult.