Narrative Matters: The Power of the Personal Essay in Health Policy

CHAPTER 2: DOLLARS AND SENSE: HARD FINANCIAL REALITIES

CHAPTER 2 DOLLARS AND SENSE HARD FINANCIAL REALITIES
Gouging the Medically Uninsured: A Tale of Two Bills Irene M. Wielawski Tea, Biscuits, and Health Care Prioritizing Marthe R. Gold Doctors Have Patients, Governors Have Citizens Richard D. Lamm Hooked on Neonatology John D. Lantos Here Comes Trouble Karen Roberts Shopping for Long-Term Care Deborah Stone On Being a Grantmaker Michael Lerner
Gouging the Medically Uninsured A Tale of Two Bills A health journalist encounters the gap between what providers charge insured patients and what they charge the uninsured. Irene M. Wielawski N ot long ago my son had surgery to repair four small hernias. They were lined up in a row, extending vertically above his navel. Like so many of the weird things teenage boys come home with, this one left his father and me scratching our heads and, when the drama was over, very grateful for health insurance. Andrew is a budding Ska trombonist, playing a style of music that combines reggae and rock. He had just played his first club gig with a band of high school boys whose performance style calls for energetic dancing while playing horns, drums, guitars, and keyboard as loudly as possible. Andrew gave it his all and, literally, the surgeon told us later, came close to blowing his guts out. Hernia repair is a routine surgical procedure, and so it was for Andrew. Only after he recovered did we come to appreciate the edge insurance had given us in negotiating the health care system and how differently the system responds to patients without insurance. Underlying this divide is a Byzantine pricing structure that reflects widespread discounting for patients with insurance, while obscuring the actual value of health services. Health professionals exasperatedly roll their eyes when asked to explain it. “Crazy.” “Government in action.” “A paperwork nightmare,” they say. Less recognized are the inequities this pricing system imposes on those least able to bear up: the medically uninsured. These paVolume 19, Number 5: 180–185. September/October 2000. Based in part on material gathered during the author’s six-year evaluation of Reach Out: Physicians’ Initiative to Expand Care to Underserved Americans, a grass-roots health reform program sponsored by the Robert Wood Johnson Foundation. tients are being charged as much as twice what the rest of us pay for exactly the same medical service. Pricing Run Amok I would not have paid as close attention to the routine insurance company missives that filled our mailbox in the weeks after Andrew’s surgery had I not, some months earlier, met Frederick Paquette, a sixty-two-year-old uninsured carpenter in Sacramento, California, who also needed hernia surgery. I had interviewed Paquette in my capacity as a medical journalist, tracking a grassroots health reform experiment. The hardship of being uninsured and having to pay out of pocket for medical treatment is an old story. But since the failure of national health reform, Congress and the Clinton administration have all but abandoned the uninsured , even as their numbers creep steadily upward, rising 40 percent in the past decade to 44.3 million people. But the current pricing situation, in which those least able to pay are being charged the most, gives the story a cynical new twist. Overcharging the uninsured is one of the many unintended and largely overlooked results of our decade-long obsession with curbing health care costs. Powerful interest groups—government, employers, insurers, hospitals, medical equipment vendors , and health care professionals—have fought vigorously to protect their interests. The uninsured, with no organized voice, emerge as losers. Health care pricing is famously inconsistent. Urban versus rural, north versus south, slums versus hilltop—each has a different pricing structure. The situation brings to mind one of those houses jerry-rigged with additions to accommodate the space needs of a growing family. The result is, well, space. Unfortunately, the bathrooms are nowhere near the bedrooms, the kitchen is blocked off from the dining room, and Junior has to climb out a window to practice his curve ball against the garage. Space, yes, but in a completely illogical framework for family life. So goes the tortured history of modern health care pricing, where the true value of any service is hidden behind walls of outdated federal regulation, complex reimbursement formulas, and discounts driven by the competitive marketplace of the 1990s. “It’s like one of those things that just grows and grows...