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Web Letter

Kate Michelman's letter is troubling, but even more troubling is the fact that her situation is only one of millions of nearly identical ones. Most of the other stories are happening to people who are not as articulate as Michelman and whose inherent pride forces them to face the health insurance catastrophe alone. If all these stories could be told as cogently as hers, at a Congressional hearing, we might approach the point where, to quote Bob Dylan, "Now's the time for your tears."

Our medical system has made incredible advances against disease. In parallel with it, the anarchy of our healthcare financing system is creating an unacknowledged crisis of anxiety around how to pay for those miracle cures. This mass anxiety in itself might constitute the new medical challenge of the next decade.

I am a self-employed resident of Massachusetts, and I was one of the responsible folks who bought their own health insurance before "reform" was adopted. Before reform, my health insurance cost was rising by 30 percent a year. Under reform, with the expanded risk pool, premiums are still rising, although at a slower rate. This cannot go on forever; at some point the cost of health insurance will outstrip my ability to earn enough to pay for it. Meanwhile, because my daughter is out of college, she cannot be put onto my policy, and because she is unemployed, she has to pay for her insurance out of pocket, despite having virtually no income.

The new health insurance policies developed to make healthcare "affordable" in Massachusetts generally have extremely high deductibles and copayments, which is simply a disguised way of making the expensive seem cheap. These policies are useful only to those who will never use the healthcare system. Those who do use it find out quite rapidly that primary care doctors are being ordered to cut their office visits to under ten minutes, and everything from prescription coverage to physical therapy needs to be fought for. People who are sick and injured are in no position to fight those myriad decisions.

It is true that no healthcare system, even single-payer, can succeed unless costs are controlled. As a society, we are paying a huge amount for healthcare. Those dollars are going into someone's pocket. Although every sector of the healthcare economy claims to be a victim, there has to be a sector that is being paid more than it needs to be paid. The overpayment may stem from greed, or it may simply arise from a multitude of tests, procedures and prescriptions that are unnecessary.

One silver lining in our present near-depression is that people are eventually going to realize they can make do with less. We need to be given the choice of a healthcare plan that is made truly affordable by providing no-frills care by decent, caring doctors who don't need yachts to feel important. We don't need the most expensive MRI machine, the potted palms in the waiting room or the six clerical assistants processing insurance reimbursements.

From my vantage point, the way to get there is to open up the VA system to everyone and clone its method of service delivery and cost control. We need to cover everyone, regardless of employment or anything else. We need to wind up with a system where no one going into a doctor's office needs to worry about anything except the diagnosis.

Web Letter

On healthcare I agree: we have a System From Hell. In previous letters I've read about the nightmare that is Medicaid--I don't want the same people who engineered the Medicaid system running my healthcare.

Why not adopt something like the Swiss have?

1. Require everyone to buy some sort of private health insurance, but subsidize those who can't afford it on their own. Benefits:
- Separates insurance status from employment status.
- Forces everyone to take responsibility for choosing their own benefits (although I think minimums should be established at federal level, see below).
- Allows everyone to see how much their healthcare really costs. Right now I don't think some people realize their place of employment may be doling out $12,000 a year in benefits. If everyone, not just the self-insured, realized how much healthcare really costs, I think there would be more political willpower to force cost saving measures like letting physician assistants/nurse practitioners/midwives/etc. handle more general care. (Another great cost-saving measure nixed by the Bush administration is allowing more centers of specialization, i.e., clinics that only do heart surgeries. These were found under independent review to be both safer and less expensive, but they competed too much with existing hospitals, which have more money and better lobbyists).

2. Set a federal minimum level of care (this could easily be modeled on the policies provided to government workers or union members). Allow these "minimum standard" policies to be sold everywhere. Benefits:
- Many states have very arduous coverage rules that drive up costs for everyone. For instance, here in Illinois maternity coverage covers three shots at invitro fertilization. This drives up costs for everyone who wants maternity. In vitro should be optional coverage; but any woman who needs maternity coverage should receive it at reasonable cost.
- This could allow economies of scale for insurance companies.

3. Require that premiums be based on amount of deductible and demographics--not on health status. Benefits: self-explanatory.

4. Make it illegal for insurance companies to deny coverage or make exclusions to coverage based on health status. Benefits: self-explanatory.

5. Possibly end the tax-free status of insurance. Benefits:
- Again, might give energy to cost-cutting reforms.
- Might actually wind up creating universal coverage that is revenue-neutral.
- It would be fair. Right now, wealthy individuals are getting an effective tax deduction at the federal level as high as 35 percent (even higher under Obama's tax code).

6. Possibly phase out the for-profit model of health insurance companies. Have health insurance companies beholden to shareholders and to patients, and you know who will lose out. Forcing a publicly traded company to go private is impossible, but perhaps if there were public interest in such a company, it could develop. And if it a minimum standard of care could apply to every state, this would make it much easier for such a company to gain ground.

I've read that Massachusetts is financially underwater because it implemented rules similar to the ones above; but listening to accounts of the Massachusetts plan in action, I'd say that it charges some of its residents too little. For instance, an artist profiled on NPR making $10,000 a year wound up paying only $4 for her cancer treatment. Call me heartless and cold, but a childless woman can afford to pay more than that, even when she makes only $10,000 a year. And quite frankly, I know too many artists who work part-time/full-time on top of painting/photography/writing etc. who aren't asking the rest of the world to subsidize their passion. Unless you're mentally or physically handicapped or caring for multiple dependents, you can do a payment plan.

I've written a lot about getting insured if you're unemployed or self-employed, like my husband and I, and have pre-existing conditions. It is possible now, but expensive, and at times unfair (I have laughable maternity and am currently trying to save $16,000 to have a baby). Still, it's better than nothing--at least we hope.

Finally, everyone interested in this topic should read Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer--it is simply one of the best books out there on "rationing" and real health--and it is wonderfully non-partisan.

Web Letter

If you want to understand the failure of the anti-choice movement, here’s exhibit A. Vincent Canter, apparently a reading-comprehension challenged troll, couldn’t forgo an opportunity to hijack a story of personal tragedy--and courage--to insert an incoherent anti-abortion screed. Try reading more carefully next time. Then you would see that Ms. Michelman was abandoned by her first husband, not the one she is heroically supporting in every way. But then again, when did people like you care for facts when they get in the way of your opinions? By the way, that streak of misogyny in your comments also undermines your argument, such as it is.

Web Letter

I can completely relate to the author's story and life because it sounds so parallel to my life and experience.

My 34-year-old husband was diagnosed with a brain tumor just over four years ago. Since then he has undergone three brain operations and now has moderate-to-severe brain damage that effects him both cognitively and physically. He currently lives in a long-term care brain injury recovery facility because I can not take care of him and our now 3- and 6-year-old daughters. He is like an Alzheimer's patient.

My 3-year-old daughter has chronic kidney disease as well as congenital vision problems. She is expected to need a kidney transplant one day.

Prior to our healthcare bomb dropping, we too were contributing members of society, living the typical suburban life. My husband and I both have engineering degrees. I was a stay-at-home mom for our two girls and we did everything right. We worked hard, paid our way, had no debt, long- and short-term savings, and of course... great health insurance--the best BCBS offered!

Now, in order to pay for my husband's care, we have lost all our savings, been forced to cash out our abundant retirement accounts, sell one of our cars and our house. Now that we are destitute, my husband can receive Medicaid to pay for his rehab since BCBS (which I still pay close to $400 a month for) will not pay for his care anymore. Oh, and I lose the BCBS insurance in two months.... I'm not sure how I'll then pay the $1,000-a-month-plus in medical bills for our daughter.

The girls and I live on his Social Security and long-term disability check--which are not enough, even with the most meager budget, and I go backwards each month. I would love to return to work to use my engineering degree to take care of my family, but if I do, Medicaid will seize my paycheck to pay for my husbands $10,000-a-month care, while refusing to consider my now necessary child care costs, for daycare. So I would actually go deeper in a hole each month if I went back to work!

This wonderful system leaves me no option but to financially emancipate myself from my husband through divorce in order to be able to preserve my paycheck and provide for my girls. Nice, huh? Yes, the Republicans are so concerned with family values!

It makes me sick, and I'm convinced there is a special place in hell for politicians and insurance company executives.

Web Letter

Many writing in this forum and ranting against private insurers seem unaware of how medical insurance works. Private for-profit, non-profit or public, insurers must make or collect enough money to pay future and existing claims.

The public option simply digs deeper into taxpayers' pockets or borrows, kicking the problem down the road. Private insurers raise premiums, co-pays or deductibles. Either way, someone pays.

The real problem with the US healthcare system is that its costs are out of control and out of line with the rest of the developed world. Healthcare in those other OECD nations is also expensive, but the out-of-control costs are only half those in the United States (see the graph, Exhibit 1, on the Kaiser Family Foundation site).

It's not clear from the story whether Ms. Michelman engaged any kind of advocate to negotiate the bills, especially those of her uninsured daughter. Uninsured patients are routinely gouged by the medical industry, being charged retail prices for services that are heavily discounted to insured patients. These "retail" prices can be double or even triple. Then activists and pundits scapegoat uninsured patients for failing to pay these inflated "uncompensated" costs.

Sadly, while lack of health insurance is one piece of the problem outlined in Ms. Michelman's story (I agree with the writer who observed that if you're gonna ride horses, it is wise to carry protection), the issue is a lot bigger than the much-parroted "47 million uninsured Americans" popular definition of America's healthcare crisis.

Massachusetts "solved" its problem by using the tax system to force the uninsured to buy private insurance or giving it to poor people. Of course, if your economics are underground you can continue to "go naked." Costs continue to skyrocket in every liberal's favorite blue state, but Bay State lawmakers and their owners--hospitals, insurers, healthcare workers and drug companies--continue to taut the success of "near-universal coverage."

Web Letter

Ms Michelman's tragedy struck a chord to me, as she was always one of my personal heros. In the responses, what is missed here is that healthcare is a responsibility--not a right or a privilege or an entitlement. A personal or family health crisis is tragic and emotional. In that state, no one wants to hear responsibility, they just want relief.

But we have been "relieving" ourselves with an unhealthy diet consumed on a polluted, toxin-laced planet. If we do not, as a culture, get after the core causes of most chronic illness and bad health, and take responsibility for risky behavior (as the actuary said)... well, we will be paying all of our disposable income for healthcare taxes.

We have also been fooling ourselves that our convoluted policies on birth control and sex eduction are working. We have one of the highest teen pregnancy rates in the world--we are literaly popping out uncared-for beings into a society bursting at the seams.

But we have no meaningful cultural structures in place to promote "universal," healthy, connected, personally responsible family systems. A generation looks to goverment systems for values no government can ever provide.

And abortion... Abortion is tragic. Abortion is a conumdrum. I too, like Ms. Midelman, believe the decision should not rest with politicians but with the pregnant woman herself. But it is still killing for convenience. There is still a demand for abortion because, in so many segments of society, another being to care for signals the end of hope.

The irony is not lost on me that Ms Midelman, in 1969, had aborted a pregnancy of a being she "could not care for." And now, a generation later, she is burdened with the tragedy of living family members she cannot care for, but would certainly not consider killing.

We get easily emotional when we read stories of the the families of these chronically ill--because it is, for the caregiver, a signal of the end of hope.

Still, overtaxing all of society to pay these massive growing expenses is not the answer. It's a knee-jerk emotional response, well-meaning but wrong. We are rapidly loosing our incentive to be productive under a confiscatory tax system that is unfair, indecipherable and, as we see every day, misused and hopelessly corrupt.

Government is not the answer to all problems. I began life as prochoice not because I am proabortion but because I want government out of my business. Government is not good at business! Look what it did with the education, banking, insurance & auto businesses. Putting the US government into yet another business, the healthcare business, signals another end of hope.

My hope is that we are capable of making our own decisions, solving our own problems, cleaning up our own planet, with the ability to keep what we earn. We need to rethink the risks we take and rethink what we allow to be put into our water, our soil, our food supply and our bodies.

For that we all need to change cultural conciousness, and stop expecting the government to provide hope, or bailouts of any kind, on any level.

Web Letter

Frankly, lady, I can't make heads or tails out of this story of yours. You say your husband "abandoned" you, yet you say he was also physically incapacitated by Parkison's at the time. I'm guessing he didn't leave you for a hot young nurse, but rather you left him because you got sick of taking care of him.

Fair enough. Life's tough, you do what you have to. But as a loving dad, I can tell you that most fathers out there take immense pride in providing for their kids. As a loving and responsible parent, I would really appreciate it if some doctor didn't kill my kid without at least asking if I'd be willing to raise it myself. I think the requirement to at least ask the real dad before they kill his kid is pretty reasonable. I realize their are rare circumstances such as rape that would make the requirement unreasonable. But I think you would also admit that those circumstances account for a small minority of abortions.

Maybe you married a bum who abandoned his kids. Or maybe you married a good man who suffered from Parkison's like thousands of other men, and he simply couldn't provide for you anymore. Sorry about your situation. But not every man is a deadbeat. Contrary to the steroetypes of single fathers and their kids out there, most of these aborted kids actually have a loving parent who'd be perfectly willing to raise them. It's just that it isn't always their mother.

What right-to-life organizations find when they actually talk to scared young mothers is that when these women get information about the family and community resources that are out there (that is, resources including the dads), many of these women actually take great pride in raising these kids successfully, in cooperation with the dads, even when they don't stay together with the dad. The reason abortion rates have declined so quickly in the last decade, even while unwed pregnancy has skyrocketed, is that women are discovering that in fact they have not been "abandoned" by a man but, rather, they have made a choice to create a child out of wedlock, just as much as the father made that choice. Once they realize that, they may understand that the kid still deserves a father and a crack at life, even after the mother has decided to end the sexual relationship with the dad.

Web Letter

I think Kate Michelman touched the one element of our current crisis that is going to force change this time, and that is that now it is affecting those that have previously been untouched. It is touching those that in the past probably fought a universal policy, thinking the care would be sub-par to what they then had.

I am probably about the same age as Kate; I too feel like I have done everything right and proper. First, I was the first member of my family to ever attain the level of college graduate. I did this in part by serving in the US Air Force for six years to obtain financial assistance. I have had great jobs, though never at the financial level I had once thought I would achieve with a degree.

During my entire adulthood I have been employed and insured. But, over the last twenty years we have watched coverage deteriorate to the point that it is almost immoral to call it "insurance," as this word insinuates some form of protection, which it no longer offers. First, optical and dental were removed as part of the packages of most companies. Then the great coverage usually fully covered by employers started to deteriorate, and company contributions either were reduced or simply couldn't pay for coverage anymore. We have been asked year after year to pay more and more for an ever-declining level of coverage. Many are given no choice to go elsewhere, as small companies would lose all coverage if employees were allowed to flee the system. So we are forced to pay more and more for what amounts to useless coverage.

For me, it has induced more than anger as I detect from Michelman, and more than hard decisions, which I too have been forced to make. I have luckily been healthy throughout this time and never really needed nor used my insurance. Part of my anger is that I have paid for my coworkers and their families for thirty years, but the only two times in my life I have needed it, I have now been let down.

My story started in 2001 when my child was diagnosed with autism. I would soon discover that in my state or Oregon, insurance coverage is denied for any autism treatments. Despite them telling me that there is no treatment and that her fate lay in an institution, I found out otherwise. So, like Kate, I drained my IRA and sold my home to pay for my child's treatments to our great success. I now have a child mainstreamed in school. While not 100 percent recovered, most laypeople would never know she had such a devastating diagnosis nor prognosis. I still pay tremendous amounts for tutoring and care to keep her progressing and at grade level, along with the social issues that are now our only real true obstacle left.

So in October of 2008, I received the devastating news that I have cancer. Six months before, my company had switched to an HSA and I was given no choice in the matter. No one told me this was George Bush's attempt to give the wealthy a tax-free cash haven and was not really a viable insurance format for everyday people. With only six months to contribute to the IRA, it was woefully inadequate, and this horrible coverage was costing me $300 out of pocket a month just to have it, while it used to be free, This was the money I could have put into the HSA but could not only afford an additional $50 a month. The deductibles were $3,000 for me and $3,000 for my child, and then a $10,000 out-of-pocket before it kicked into 100 percent. My total out-of-pocket for 2008 was nearly $20,000. And this they call insurance.

But this is not the end, of course, for me, I can now look forward to this $16,000 to $20,000 a year if I want to try to survive for my child's sake. It is simply not viable, not possible, it is a pure catastrophe. Michelman is right in that she is not alone. I was even refused treatment by the first hospital I went to because my insurance was so bad. They wanted $15,000 up front or they would not treat me. I am quite sure that I am being counted as "insured" by the new administration, possibly unaware the millions of us are not even close to being insured.

My decision is a medical "Sophie's choice." If the cancer re-occurs I have three options: (1) continue racking up tens of thousands in debt, and if I die anyway, I leave my child with nothing to contribute to her care; (2) quit my job and hope I can get on public medical assistance before we become homeless; (3) stop all tests and treatment, hope for the best and let the dominoes fall where they may, meanwhile putting every penny I make into a fund so my family can care for my child and be able to offer options for her future.

This is what our country has come to. Some still believe compromises and simply modifying the current paradigms will fix things. If my case and Michelman's show anything, it is why this is impossible. Nothing will fix this except remaking the entire medical system, turning it on its head and rebuilding it from scratch. An American system of single-payer, where no one is left out, no one has to decide to commit "suicide by cancer," no one has to come up with thousands or die, where mayonnaise jars collecting coins at rural stores is not our backup system for catastrophic medical crisis in our nation. I am tired of hearing how Canada or France or the UK is not what we think, as if we can't do it better. The system we have cannot be fixed, we need a new system and that means throwing out all of the babies and the bathwater and starting from scratch.

Kate, I will gladly join you in your new fight. Just call me. Trust me, I have nothing left to lose.

Web Letter

This article was upsetting to read. How did the United States ever get itself in this position? Why have our citizens put up with it for so long? Why are the insurance companies allowed to get away with "legalized fraud"? It is so difficult to comprehend.

One part that really struck home for me was the fact that Mr. Michelman's long-term insurance plan only paid for a "fraction" of the cost of his long-term care. Was he warned of this when he purchased the policy? Something similar is happening to my own husband (also a former college professor). Seriously ill for three years, he is battling his "excess major medical plan" (AIG!) that promised to pay "all" out-of-pocket expenses. I can't even begin to describe what this company has put us through, but I'm seeing an insurance attorney. I hope Ms. Michelman does too.

As a fellow American, I have this to say to Ms. Michelman: I am so sorry you and your family are being treated this way after a lifetime of good citizenship and service to your country. I apologize for not doing my part to fight the inequities of our healthcare system. I promise that from now on I will do all I can to work towards the goal of universal healthcare.

This is probably unconstitutional, but I wish the federal government would nationalize all the health insurance companies and make them non-profit.

It has taken many years, but I believe our citizens are on the brink of an old-fashioned revolt! It can't come soon enough for me!

Web Letter

Ms. Michelman's heart-rending tale shows many of the failures of our current health care system, including the fallacy that is private insurance. If I have learned one thing in my years as an Emergency Physician it is this: if you get really sick in this country, you ultimately end up on Medicaid/Medicare. Private insurances generally have a lifetime maximum of $2 million. A patient with a serious trauma will go through this in a month, generously. Unfortunately, for the disabled it takes two years to qualify for Medicare even after getting Social Security, I don't know why. Obama, whatever his other failings on healthcare, is trying to rectify this.

However, I do have a couple of suggestions to avoid falling into the same situation. First of all, private insurance is helpful for most medical costs, and one should obviously not undertake activities such as riding horses without it. If an uninsured non-dependent family member with minimal assets--the situation I assume for Ms. Michelman's daughter--falls seriously ill, it is much more advisable for her to file for bankruptcy and get on Medicaid/Medicare than for a family member to pay exorbitant bills.

In terms of chronic disease, if a family has assets, long-term care insurance is no substitute for estate planning and consultation with a good trusts and estates attorney. A sad state of affairs.

The irony, of course, is that had Ms. Michelman's family had no assets and no insurance, Medicaid would have stepped right in and paid for all this care pronto, often even if the patient was undocumented.

Private insurance is a scam... pure profit for the insurers. Once anyone gets ill, seriously ill, the government ends up being the insurer of last resort. I see it every day and any hospital social worker will tell you the same.

Our medical system is not without its pluses and mercies. In Canada, a non-resident cannot necessarily go to the ER without paying; here anyone can and does receive treatment. My guess is that Ms. Michelman's daughter received a much higher level of trauma care than would be available in any other country; trauma is a high-resource field not generally deemed cost-effective in most other countries. The American health care consumer would not find rules limiting mammograms to those 50 and older, excluding those over 65 from dialysis, limiting high-cost cancer drugs or excluding those under 25 from cervical cancer screening acceptable, as is common throughout other healthcare systems.

Unfortunately, the financing and provision of that care worsens by the day, and the system is untenable, unfair and cruel. We need something better, if still imperfect. Until then, hide your assets and talk to a lawyer.