Health care system still in crisis, regardless of Supreme Court

Chris Lowe

A few weeks ago there was a flurry of media excitement over challenges to the Patient Prevention and Affordable Care Act (PPACA) reaching the Supreme Court. It is evident that PPACA may be in serious trouble. The danger to it could come directly from the Court, which could overturn its individual mandate, leading to pressure to repeal many of its better provisions offering patient protection, or could overturn the Medicaid expansion and reforms in the bill, which would be the largest way in which many currently uninsured persons would gain insurance. But even if PPACA survives the Court unscathed, it also appears vulnerable to right-wing Congressional attacks on its implementation, or worse if Mitt Romney is elected president.

But that political crisis is not what this post is about. Rather, it is about a relentless crisis of internal dynamics under which the private insurance based system gradually is failing. Last week the Lund Report covered a story, about how Regence Blue Cross/Blue Shield is cutting a large line of individual insurance plans, displacing about 30,000 insurance consumers and presumptively shifting them to plans that among other things don't carry mental health coverage.

The Lund Report story focused on criticism of the problems that loss of mental health coverage would cause and the inequities it represents, matters which certainly deserve attention and criticism.

But here I want to point out a broader aspect of the story. PPACA promises to move a substantial number of persons above the level of expanded Medicaid into insurance markets somewhat similar to those in which people get employer-based insurance. But at the same time, the insurance being offered in any of those markets is getting worse and worse. Regence cut off all its individual plans with deductibles less than $2500 per year for an individual, $5000 for a family of two, or $7500 for a family of three or more.

Such high deductibles mean effectively no insurance coverage for anything between basic doctor check-up visits and certain screening procedures required by PPACA, and very expensive treatments.

It is good that people will be able to get in to see doctors for such purposes. But if the primary care finds something that needs intervention, high deductibles and co-payments and co-insurance may still put the needed treatments out of reach for many people. People will still continue to self-ration by deferring needed care in early stages when problems could be handled more effectively and cheaply, until it reaches unavoidable, more expensive late stages. And then the combination of deductibles and high co-insurance on top of high premiums will continue to place massive financial burdens and strains on families.

The same problems apply increasingly to employer-based group insurance, the premiums for which continue to rise rapidly. And unlike individuals who may buy insurance in the Exchange, those getting it through employers will get no subsidies. To add insult to injury, PPACA attacks employer plans that do provide really comprehensive benefits. (Funny isn't it, how "the politics of envy" are bad when it comes to criticizing overcompensation of corporate executives, but not when it comes to fellow workers whose benefits are "too generous"?)

PPACA's long name has been shortened, ironically, to "The Affordable Care Act," when in fact its strongest provisions are those affording increased patient protection.

On affordability, PPACA will do little. It can't, because price competition in insurance premiums cannot control the prices or costs charged by doctors, hospitals, and specialty clinics. So the crises in American lives caused by our dysfunctional, fragmented and vastly overpriced health system continue to unfold and deepen, for the simple reason that private health insurance is a rotten way to determine access to care.

By Chris Lowe May 02, 2012