On the home front

The Times has an interesting article today, set right here in Maine. It's about the intense pressure the two Senators from Maine (both women, both Republican, and both considered moderates) are facing about health care reform from both sides of the issue. There were a lot of fascinating tidbits.

First off, the reasons why Maine is an interesting case in the broad expanse of American health care:
Though Maine has only 1.3 million residents, the challenges of insuring the entire population are complex. The state has large rural, poor and elderly populations with significant health needs. It has many small businesses and seasonal workers, and few employers large enough to voluntarily offer employees insurance. Meanwhile, most insurers no longer find it profitable to sell individual coverage here, leaving a few companies to dominate the market.
The industrial base for Maine, which was its shoe factories and paper mills, is slowly dying. (One of the few exceptions is Bath Iron Works, which still does a brisk trade in mammoth sea vessels.) Maine's employers simply cannot, as a rule, afford to pay for insurance for their employees. And the dominant insurance company, Anthem (which long ago bought the failing non-profit insurance carrier in the state), continues to raise its premiums and rake in gigantic profits.

The remarkable failure of the free market to meet the health care needs of the state hasn't seemed to dull its shine for Maine conservatives, however:
To Mike Marcotte, an accountant from Lewiston who is insured through his employer, the right thing would be for Ms. Snowe and Ms. Collins to vote against any proposal that includes a public option.

“They need to vote for free enterprise,” Mr. Marcotte said. “Less government is better.”

Mr. Marcotte attended the lunch held in Auburn by the Maine Heritage Policy Center, a conservative group whose leader, Tarren R. Bragdon, told a few dozen attendees that the Democrats were seeking a “significant government takeover of physicians, nurses, hospitals, health insurance and the entire health care system.”
The free enterprise system works for Mr. Marcotte, and that's all that Mr. Marcotte needs to know. That it is failing a sustantial number of Mainers doesn't seem to matter much.

Backing up a bit in the article, there is this interesting passage:
Stavros Mendros, a consultant from Lewiston, is equally wary of insurance companies but his solution is to avoid them completely and risk going without coverage. Mr. Mendros said that when his 4-year-old daughter got sick recently, he took her to the hospital and paid the $1,200 bill, which he said was cheaper than a single month of an insurance premium for his family would be.

“Not having insurance saves me boatloads of money,” he said. “My biggest concern with the government taking over health care is the waiting lists. My daughter didn’t have to wait. I’d rather have a bill than a dead daughter.”
I cannot even begin to understand thinking this blinkered. First of all, clearly Mr. Mendros took his daughter to the ED instead of a primary care office, and thus paid hundreds of dollars more than he otherwise would have. Secondly, public option or no, the ED will be no less accessible under a reformed system. While he can (apparently) afford the $1,200 his daughter's care cost, a large number of Mainers simply could not. Finally, Mr. Medros can thank his lucky stars that his daughter wasn't diagnosed with something like leukemia, with a price tag for treatment greatly in excess of $1,200.

A certain degree of conservative skepticism about public health reform is warranted, as the state's own efforts to cover everyone fell far short. (This was, in part, because of its ongoing troubles with funding.) But the federal government is in a much better position to lower costs than any state-run program could be. Having a public option is the only check on a rapacious private insurance industry, and is a vital part of any meaningful attempt at reform.


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    Mr. Mendros is quite rational. I spend far more in insurance payments than I ever do in medical bills. I get a high deductible plan because my medical costs are lower than the additional yearly premium for lower deductibles. Mr. Mendros is doing something similar, but something I'm not willing to do, which is to have an infinite deductible for a $0 premium. After all, heaven forfend, if his daughter did contract a serious illness, she'd be treated, regardless of his ability to pay. So his family wins (extra disposible income) unless they have a catastrophic illness (which sucks totally no matter what). The odds are in his favor, however foolish and selfish you or I think this behavior is.

    AIUI, and you are the physician, so correct me if I'm wrong, expected medical costs are low once you pass early childhood. If you are healthy, you are likely to stay healthy for decades. The implication? National medical insurance is a way of transferring money from young workers to much more wealthy seniors.

    One possible cure for this would be to track lifetime expenditures for each person, and the government take first dibs on the estate until the lifetime medical bill was paid. This would provide an incentive for people to care about their use of medical resources. For example, when we get Obamacare, I'm signing up for the maximum amount of care I can get. I'll have checkups done at the shortest permissible interval, I'll find a reason to schedule appointments (wasn't that throat scratchy this morning?) so I can be seen as often as possible. Why wait? It isn't as if I'll pay more, and I just might catch problems early, not to mention I'll have a (rationed) appointment in case there really is a problem.

    Finally, as I've said before, Mr. Obama can demonstrate the magical qualities of Smart Government by solving Medicare's woes as an appetizer before tackling Obamacare. Show me this Feds-can-drive-down-costs without Feds-gut-outcomes, and I'm onboard. Words are cheap (as the employment debacle shows), solving problems is convincing. Convince me, Mr. Obama.

  6. Mendros is rational, in that there are coherent reasons for his decision, but he's taking too big a risk. He's risking bankruptcy and also exposing himself to a line of decision-making that will lead him to make unwise choices for his child. He might decide he could do without something expensive and only minorly helpful (maybe speech therapy -- something like that) that would be covered by insurance, and would still be an improvement in his daughter's life. He might also wait too long to get a problem checked out and risk it becoming worse.

    Well child visits are also times you can discuss with a professional your child's cognitive development, behavioral issues, etc.

    And he seems to have an exaggerated view, as Dan mentions, of what emergency care would like like.

  7. Elizabeth, you left out three words: "in my opinion" he's taking too big a risk. I happen to agree with you wholeheartedly, but once you and I start enforcing our beliefs on people who obviously feel different, where will it end?

  8. doesn't maine have s-chip? In Pa. every child can be covered automatically regardless of income, (if the parents choose to enroll) just as every child is entitled to attend Public schooling (again, if parents choose to enroll them, and not in private or parochial). It is the way it should be. And the fees are quite reasonable. For a family of 4 making between $44,000 and 55,000 the total premiums are $86 a month, below that is free. And the coverage is comprehensive. So unless Maine is very, very unlike Pa. then Mr. Mendros is in fact a blithering idiot. And even at top incomes, starting at $55,000 with one child, the premiums top out at $195 a month. so worse case scenario, he is either a complete idiot, or recklessly cheap. Or I could be wrong and Maine is a jerkwater backwater, then I sure as hell don't want to live there.


  9. Ok, I checked, it turns out Mr. Mendros is an idiot (no surprise there) and also completely irrational (again no surprise there, only to the ignorant such as gj is he rational). Maine has an s-chip program, with quite reasonable fees, fairly similar to Pa.
    Ok, let me qualify, Pennsy's program works very well, maybe in Maine it only covers visits to witchdoctors (or worse, Canadian transplants), but again, I doubt it. Maybe the resident doctor can fill us in.