In August 1989, Chicago Congressman Daniel Rostenkowski, then Chairman of the “powerful” House Ways and Means Committee, narrowly escaped an angry mob of seniors in his own district who attacked his car with umbrellas. His crime: eliminating the gaping patient financial exposure built into the Medicare program in 1965 by raising taxes on the “high income” elderly. In November, 1989 Congress rescinded the so-called Catastrophic Coverage Act, a bipartisan reform signed into law by Ronald Reagan just sixteen months earlier.
In the spring of 1994, Bill and Hillary Clinton abandoned their famously arcane health reform plan and months later, forfeited control over Congress in the 1994 mid-term elections. Health reform was a major factor giving Newt Gingrich’s House Republicans control for the first time in forty years. Twenty five years later, Barack Obama succeeded, with huge Democratic majorities, in passing the Affordable Care Act and . . . lost control of the House less than eight months later in the largest Republican landslide since 1938, due in major part to voter backlash against “ObamaCare”.
What was the common denominator of all these political events? The answer: powerful voter retribution for tinkering with the healthcare system, successfully or not. Why is health reform such risky business for politicians?
First, US. healthcare is a vast enterprise, the size and complexity of a large industrial nation. In 2017, we will spend more than $3.5 trillion on healthcare, roughly equal to the GDP of Germany. It employs sixteen million people. Its physicians, scientists and engineers, hospitals, pharmaceutical and technology firms, information technology vendors, not to mention patients themselves, are, collectively, the most powerful private interest group in the country. Invading a third world country like Iraq or Afghanistan is child’s play compared to reforming the US health system.
Second, and more important, the health system touches every American at vulnerable times. Virtually every mother in America became a mother in one of its hospitals. One third of us will die in those same hospitals, and perhaps half of us will spend some time in the hospital in the last month of our lives. There are nearly 5000 US hospitals, more than 800 thousand practicing physicians and millions of nurses and other health professionals devoted to shepherding us through critical life passages. They see us, and try to help us, when we are not at our best.
But third and most important, American voters view health reform schemes emanating from Washington through a prism of fear borne of intimate personal experience. For example, nearly 1.6 million people will be diagnosed with cancer this year, and six hundred thousand people will die of the disease. There are over 14 million cancer survivors in the US, most of whom have families most of whom have families who have to deal with the fear and risk along with them. That adds up to many tens of millions of people directly affected by just one illness. Every one of those 14 million cancer survivors, including the author of this post, is the proud owner of a “pre-existing condition”.
The primal fear of becoming ill is now accompanied by the fear of being bankrupted by the medical bills that result. More than 43 million Americans have unpaid medical bills. Nearly 40% of adults have been contacted by bill collectors for those bills.
And there isn’t much of a margin in most household budgets for that surprise medical bill. Almost half of American households cannot cope with a surprise $400 bill without borrowing the money or selling something they own. Medical expenses are the major contributor of personal bankruptcy . It is worth noting here that personal bankruptcies have fallen by HALF since the Affordable Care Act was passed.
And finally, as the 2016 election of consummate outsider Donald Trump, with nary five minutes of prior experience in government, conclusively demonstrated, tens of millions of voters do not trust the competence of the federal government or believe that it is working for them.
So- health care- nearly 20% of the economy, hellishly complex, intimate attached to voters’ darkest fears and their pocketbooks, encased in a huge mesh of powerful interest groups and vast public skepticism over whether government can do anything right. What is there for a politician not to love here? Political leaders intent on “reforming” healthcare are messing with something with a lot of nerve endings attached to primal voter fears, both for their own health and their finances. And there isn’t a great deal of trust to go around.
Republican health reformers, as you take your turn, take note: health policy isn’t brain surgery. It’s actually a lot harder. Voters remember what you promised. Recall Obama’s most costly promise: “If You Like Your Health Plan, You Can Keep It”. It also pays to be humble about what you can accomplish. Trump promised a “terrific” health plan that “covered everybody”. And the Hippocratic Oath doesn’t just apply to medicine. It applies in force to health policy, particularly the “First, Do No Harm” part.
Jeff Goldsmith is President of Health Futures and National Advisor Navigant Healthcare.
Categories: Uncategorized
Thank you Jeff for coming right out and saying the medical bankruptcy issue has become politicized. Himmelstein did that when he wrote this crock of an article that ~50% of bankruptcies were due to medical issues. It was a terrible questionaire that IMO was meant to demonstrate that result. I remember the arguments at the time and his criteria were ludicrous. [Theoretically a billionaire declaring bankruptcy due to overleveraging would be blamed on medical bills if he had $1.000 worth of oop costs.] If I remember correctly other studies used actual bankruptcy claims available at the court house (instead of a questionnaire) and found in only only a small number of cases was medical bills the primary cause for bankruptcy.
This is not to say that high oop costs aren’t a problem, as you say, they are. Thanks for your treatise and if I can comment on unpaid hospital bills, they exist even from those with insurance. It’s hard to figure out how much hospitals are really losing from the uninsured since their charge master can charge many multiples of their average receipts for the same procedures obtained through insurance. Many uninsured pay more than average. Some state supported hospitals lose more money than they should because they are not aggressive in collecting payments from those with adequate financing that refused to buy insurance. Still other unpaid bills arose from those that couldn’t afford the premium so that they had to be subsidized in the first place.
The last category (poor patients) have their bills in part or in full passed onto everyone else whether or not they are insured for they require some type of subsidization. The actual amounts passed on I don’t believe are that great and perhaps (I don’t know for sure) they are dwarfed by charges to the private sector to make up for lower prices mandated by Medicare and Medicaid.
Just because the medical bankruptcy issue has become politicized doesn’t mean it isn’t a problem. A lot of the decline in overall bankruptcies happened before the ACA was enacted due to the economic crisis. But it did significantly reduce financial pressures on patients, and you can see that by the changing composition of the self-pay debt in hospitals. I wrote a treatise on this a few months ago: https://www.hfma.org/Content.aspx?id=52408
and you can see a big drop in uninsured self pay debt to hospitals after the first year of ACA coverage. Hospitals don’t collect much of their self-pay debt. Those costs are simply passed on to everyone else in the form of higher charges.
Jeff, Yes, that is what is on the minds of everyone for the public is split into two groups. One group has a vision of what the world should look like and the other has the data.
Thanks for your non-partisan post for it had its effect (at least on me) even if the conversation veered to a politicized disussion.
I do take issue at some of the statements you hypertexted to “Earlier this year, the financial-advice company NerdWallet found that medical bankruptcy is the number-one cause of personal bankruptcy in the U.S. ” That type of correllation is created solely for partisan reasons. It’s BS the way it is written as are many of the bills sent to patients. We have to actually look at what was paid. Additionally, the hospital’s existence is as a manager and as a manager has the duty to honestly disclose fees. IMO lack of disclosure should lead to the hospital eating the bills of any non paid services or managing the services appropriately so that patients are fully informed.
Note well how my strenuously non-partisan post on how hard it is to get health reform right devolved into a spirited discussion of the current President. Praise the combatants for their civility, but . . . it really is all about him!
He is the President. Hillary would have been much worse. Obama was a disaster.
Everyone makes mistakes and is wrong sometimes. That’s just the nature of being human. Trump never seems to admit to any mistakes and tries to shift blame to others when things go wrong. Even I who wish him well and hope he is ultimately a successful president even though I didn’t vote for him am just turned off by his personal style and find myself tuning out almost everything he says. The exaggerations are a turnoff too even though he got away with them in the real estate business.
His staff seems afraid to tell him anything he doesn’t want to hear except for, perhaps, Ivanka and maybe Jared. This is not a formula for success. He needs to make some adjustments in style at the at the very least and, as Melania said, stop the tweets.
“Trump’s comment about how unfairly he thinks he’s been treated compared to other presidents in history is inaccurate.”
Yes, we agree he puffs alot, but I don’t think even GWB was treated so badly. We have to remember GWB had more supports from his own party and the Democrats weren’t as radicalized. He is at ~ 100 days and they have been calling for his impeachment on phony grounds.
No I am just trying to say that Trump’s comment about how unfairly he thinks he’s been treated compared to other presidents in history is inaccurate. As you said earlier, he puffs a lot. This is just another example of puffing or exaggerating. Accuracy is not his thing evidently.
“You assume my total dislike for lying Trump equals a dislike for the process as designed by the founders.”
I don’t have to link the two. You have demonstrated your dislike for Americanism and the Constitution along with what our Republic stands for, There is not need for me to point these things out in this space because you demonstrate that most of the times in your own replies.
“Trump won on a technicality”
Listen to you. Trump won based upon the rules. For all we know an election 24 hours later could have led to different results. You can’t get over his victory. Neither can Clinton nor the Democratic Party. You can see that every time they try to bring down the President while other countries are saying they will nuke us into oblivion.
” You hate Hillary”
I don’t really hate her. I find her dishonest and that dishonesty extends over more than one decade. If she had won I would have accepted her as President just as I accepted Obama. Objection to specific policies and acceptance are not mutually exclusive.
“From you’re comments you seem to be a Libertarian – one step above anarchy.”
You are probably correct that I lean towards the libertarian spectrum, but I believe in the rule of law and our Constitution. That belief means I don’t believe in anarchy. Along with a book on remedial statistics you should probably get a book to provide a remedial understanding of libertarianism and its very wide spectrum of ideas. I don’t know if such a wide spectrum can even fit into your head.
“Obama was a failure to me.”
Yes, I know. He could have been King.
“You hated Democrats for the process which created the ACA, but Republicans were no better when they attempted to repeal/replace.”
I’ll accept that to its limited extent, but you already recognize that I am not a classical Republican or Democrat with my libertarian leanings.
“When will even you start to get embarrassed by Trump-isms?”
Why would I be embarrassed by Trump-isms? Trumpisms eminate from Trump just like Peterisms eminate from you.
“The violence against Ann Coulter as just stupid mindlessness”
No it isn’t. This violence from the left has been persistently promoted for decades. Your historical lack of knowledge is appalling.
Great demonstration, Barry, of what the left really wants, a fractured nation with a war (violence and tribalism, but not necessarily outright rebellion). Are you trying to say that Trump is lucky because he doesn’t have to be a war time leader in a second Civil War?
“Voting properly is a learned function”
I guess voting properly is done only by those that agree with you. That is how dictatorships function.
“But we can’t have tax funded universal coverage without price controls.”
Not so.
Lincoln got secession, the Civil War, and was ultimately shot in the head. I don’t think Trump has much to complain about by comparison.
No president in history has been treated more unfairly!
Does anybody know where he gets those chairs?
How much do they cost?
Are taxpayers subsidizing gaudy furniture?
Is his ugly furniture American made?
The American people want to know.
As usual Allan you are wrong.
You assume my total dislike for lying Trump equals a dislike for the process as designed by the founders. Trump won on a technicality, doesn’t mean I have to like him. But the process has been perverted with big money from special interest and a system of political bribery. I’m not sure the founders really wanted it to turn out that way. You hate Hillary, does that mean you hate the process, guess not since Trump won? Would you have supported the process (and her) if she’d won?
From you’re comments you seem to be a Libertarian – one step above anarchy. Is that what you think the founders wanted? But it’s easy to hate government protected by a government program called Medicare. Why don’t you put your money where your mouth is and get that really good cheap private policy.
Obama was a failure to me. He had no fire in his belly after his election, amplified by Republicans who decided not to work with him at all – against what would have been best for the country. You hated Democrats for the process which created the ACA, but Republicans were no better when they attempted to repeal/replace. I supported Hillary because in the face of what we had as the other choice there was no choice – and it’s proving itself out. The election came down to the 1991 David Duke/Edwin Edwards choice where bumper stickers said – “Vote For the Crook. It’s Important.”
When will even you start to get embarrassed by Trump-isms?
The violence against Ann Coulter as just stupid mindlessness that played into the goofy right’s hand.
My guy makes mistakes. Yours lies. Sigh.
The **intentional** lies of Obama and Clinton were legion. Trump puffs a lot and makes some mistakes, but when it comes to lying compared to those two Trump at best/worst is a novice.
Bobby, the discussion of our founders before the revolution was that a democracy was worse than a monarchy. That is why we are not a democracy rather a constitutiona republic that has democratic elections. I hope you recognized why our founders were so against a democracy.
It’s strange how some like Peter only believe in our Democratic Republic when they get their way. Perhaps he supports all the violence being seen by groups on the left that believe in free speech only as long as they agree with what is being said.
Peter must have been a strong supporter of Hillary who broke all sorts of laws where other people have gone to jail for doing the same. I wonder who killed Mark Rich? I wonder if he is dead because of his likely involvement in the Wiki Leaks disclosures about Hillary. I was sort of surprised that Bernie Sanders yielded to Hillary after her rigging the Democratic ballor for he might have prevailed in the election. Maybe he was smart and figured life was something one didn’t want to make shorter.
Voting properly is a learned function, which is hard for the populace that follows the party of hate and ignorance for the promise of a few shekels more at the expense of their fellow citizens . You’ll see a shift to Medicare for all when self funding employment plans and other employment plans (tax supported now) start to take their toll on affordability. How high can those deductibles and co-pays go.
But we can’t have tax funded universal coverage without price controls. It’ll take a crisis, maybe another bankers fraud scheme when the financial rules are taken away – again. We do see how those with Obamacare really do want what other universal plans have – tax funded subsidies, no pre-exist, no caps. Now tell them there’ll be no networks where you can really choose your own doctor.
Back when I lived in Vegas there was this poignant “libertarian-anarchist” prof, Hans-Hermann Hoppe (who got sanctioned for some gay-bashing), who once wrote that Monarchy was preferable to Democracy — his analogy was rented cars vs owned cars. Monarchs, given that they “own” their countries, take better care of them than do the “renters” that are Democratic officials.
Hey, it was UNLV, what can I say?
Always surmised that Matthew was a closet monarchist!
and those voters just gave us Donald Trump? They could have given us Bernie Sanders. Who cuts the deals and sets up the economic accountability to make “single payer” anything more than a slogan?
Matthew, the constitution was set up to prevent kings. How is your wish for such a king any more attainable than Medicare for all in a money driven political system?
Jeff, the political system is accountable to the voters. Who are the hospitals accountable to, who are the drug companies accountable to, who are the insurance companies accountable to?
Jeff describes exactly why we need a King–albeit a well meaning one, not the idiot who just got elected to the position of President who actually thinks he’s Louis XIV & has the chairs to match
“You get to keep your doctor, you get to keep your plan if you like it. And we’re going to decrease premiums by $2500 for families.”
It’s very easy to make promises. Keeping them, not so much.
do you trust our political system to get it right?
“Every one of those 14 million cancer survivors, including the author of this post, is the proud owner of a “pre-existing condition”.”
“The primal fear of becoming ill is now accompanied by the fear of being bankrupted by the medical bills that result.”
“And there isn’t much of a margin in most household budgets for that surprise medical bill.”
Not in Canada. Medicare for all – it’s time.
“You’re going to have such great health care, at a tiny fraction of the cost—and it’s going to be so easy.” – Donald Trump, Oct 2016 rally in Florida
Trump over-promised. So did the Democrats. Of course people are going to get angry.
Steve