Talk to Me Like I'm 4: Why Our Health Care System Failed Us and How We Can Fix It
Continued from previous page
But those tools in their kit boxes tend to leave the ones with the highest health care needs without coverage. An example of this is the pre-existing condition exclusion clause in many individual health insurance contracts.
It's a mess, isn't it? Remember that the government Medicare program already insures the elderly, the group with the highest health care expenses. One might argue that most of the proverbial "bad apples" have already been removed from the "barrels" of the private insurance industry, and that should make them able to figure out affordable policies for most everyone else.
One might also argue that we could all one day turn into "bad apples" and that the very purpose of insurance is to protect us from the financial consequences of that day. Yet denial of coverage is not uncommon in private health insurance, and neither is finding one's insurance terminated after claims start rising. All this means that having insurance might not mean being covered against large health care expenses.
The strategies the health insurers use to combat adverse selection are called cherry-picking or cream skimming. These strategies consist of trying to attract mostly low-users (the young and the healthy being the cherriest of cherries), while discouraging high-users from signing up, of excluding pre-existing conditions from coverage and of not covering certain services (such as maternity care) at all.
When the price of insurance is allowed to vary among applicants (as is the case of most individual health insurance), women are quoted higher prices than men because women, as a group, consume more health care until age 50 or so. Indeed, even the common (and in some ways laudable) practice of employer-based group health insurance helps to skim the cream or to pick the cherries, because it focuses on people well enough to go to work every day.
On Patchwork Quilts
The U.S. health care system is very much like an old patchwork quilt, one which has grown over time with new patches sewn onto the parts that wore out. But the quilt is fraying more rapidly, and more holes may appear quite suddenly.
Those who are lucky have access to good health care and employer-covered group insurance at a still-affordable price. Those who are unlucky and lose their jobs may also lose their health insurance. Those who are medically indigent or who work for firms not offering insurance are left to try to find an affordable individual policy, which is not easy, these days. Or they may rely on various government programs, assuming that they qualify, or on nothing but their own savings.
Most of the currently uninsured do not offer great money-making opportunities for the private markets, however much competition we might wish to inject there (ironically enough, usually through regulation), but must be covered and treated through government programs, charity or not at all. And when the utterly uninsured finally seek help for a medical problem, it is often late in the disease process and at a hospital emergency room, one of the most expensive patches in our quilt and an inappropriate one as a setting for primary care.
The difficulty in fixing an old patchwork quilt is that the very attempt of introducing another patch will strain the nearby old fabric, thus creating further rips and tears. This is what I see happening with the pro-competition plans. They will not work alone, because competition in health care is seldom about bringing the prices down or trying to cover everyone, for reasons I have discussed here.
Neither is it necessarily contributing to high-quality care: The United States, with its large private health care sector and high expenditure levels, fares poorly in international comparisons of those bluntest of (inverse) quality measures: life expectancy and mortality rates.