Hundreds of dentists and support staff work on patients inside the Virginia-Kentucky Fairgrounds in Wise, Virginia, on July 24, 2009 during the Remote Area Medical (RAM) Expedition. Close to 600 doctors and support staff volunteer their time for free treatment to individuals who have difficulty getting health care. (Photo by Paul J. Richards/AFP/Getty Images)
On Friday, July 21, as our senators were getting their first look at a bill that would have put at least 22 million Americans back into the ranks of the uninsured, hundreds of people were waiting patiently — and had been since well before dawn — at the gates of a county fairgrounds in the mountains of southwest Virginia.
Many of them had traveled from hundreds of miles away and had slept in their cars and trucks, hoping to be among the first admitted when the fairground gates opened at 5 a.m. All had them had fallen through the cracks of a dysfunctional system that Obamacare at best applied a Band-Aid to, bringing many people into coverage but leaving many others out and doing little to control health care costs.
Most of the people at the fairgrounds were uninsured but many others actually had insurance. But their policies — including some bought through an Obamacare exchange — either had such high deductibles they still couldn’t afford to go to the doctor, or they didn’t cover what most of them needed, dental and vision care in particular.
By Sunday afternoon, the third and final day of this annual pop-up clinic, organized by the Remote Area Medical Volunteer Corps (RAM), doctors, nurses and dentists had treated more than 2,000 patients — not in private examining rooms but under tents and in the barns and animal stalls scattered throughout the Wise County, Virginia, fairgrounds, just as they’ve done over a long weekend in July for 18 years.
I’ve often referred to the 50 miles of highway between my hometown of Kingsport, Tennessee, and Wise, Virginia, as my road to Damascus. I learned about the massive clinic 10 years ago while visiting relatives. I went there out of curiosity. I left shaken and changed. I knew that some of the people in those long lines could have been people I grew up with. I knew I could have been one of them if I hadn’t had more than a few lucky breaks along the way.
I also realized that, as a health insurance executive, I was at least partly responsible for that scene. My job then was to help perpetuate a system that was very profitable for the insurance industry and other special interests, even if the consequence was a rapidly growing number of Americans without health insurance or any other means to pay for the care they needed. A few months later I quit my job and became a vocal advocate for reform.
I went back to Wise County last month thinking the crowd might be smaller than it was 10 years ago. If anything, the need has only increased. Yes, Obamacare has brought more people into coverage, but 30 million of us still lack health insurance, and at least that many more are underinsured because of the insurance industry’s years-long strategy — which was actually abetted by the Affordable Care Act — to move all of us, regardless of our income, into high-deductible plans.
Some Republican criticisms of Obamacare are valid, although none of what they’ve proposed so far would address them. Obamacare hasn’t done much to slow the increase in the prices of everything from prescription drugs to a stay in the hospital, and premiums continue to go up for those of us who have coverage.
And there is little hope that the law can get us much closer to universal coverage. In fact, a recent Gallup poll found that the percentage of Americans without health insurance is on the rise again. In the second quarter of 2017, 11.7 percent of Americans were uninsured, compared to 10.9 percent at the end of 2016. That means an additional 2 million people are once again uninsured.
Meanwhile, as growing numbers of Americans are enrolled in high-deductible plans, more of us are skipping visits to the doctor and not getting our prescriptions filled. The Commonwealth Fund, which keeps track of changes in the number of underinsured Americans, says 31 million of us were underinsured in 2014 as insurers and employers continued to push more of us into high-deductible plans. The number of underinsured people in such plans has more than tripled since 2003. The Commonwealth Fund says more than half of the underinsured have problems paying medical bills or are paying off medical debt over time.
It’s little wonder then why many people who line up for RAM’s clinics have insurance, but insurance that increasingly is of little value to them.
So where do we go from here? Although members of the far-right Freedom Caucus say they’ll keep trying to repeal Obamacare, there now is much talk in Washington about a bipartisan effort to “fix” the law. And it is in urgent need of attention.
Even the best run Obamacare exchanges are reporting that premiums will take a big hike again next year. Republicans, of course, are partly to blame. In 2015, Sen. Marco Rubio of Florida quietly inserted language into a big spending bill that halted payments from a fund set up to help stabilize the individual insurance market. That’s the reason many of the small co-op insurance companies failed and several big insurers stopped selling policies on the exchanges.
More recently, President Trump has tweet threatened to “let Obamacare implode.” He could make it happen by cutting off payments that reduce out-of-pocket expense for low-income Obamacare customers. Because that money flows through insurance companies, their anxious executives, knowing Trump could follow through just to see what happens, have decided to increase premiums more than they otherwise would on policies they sell on the Obamacare exchanges next year.
The California exchange, the biggest and arguably one of the best-run in the country, announced recently that rates will go up an average of 12.5 percent for California residents in 2018, in large part because of uncertainty as to what Trump and the Republicans will — or won’t — do.
The other, more significant reason premiums continue to increase year after year, often by double digits, is because of a fact insurance industry flacks like I used to be have successfully obscured for decades: private health insurers cannot control medical costs. Not only that, they have incentives not to even try very hard.
As drug companies, hospitals and other providers raise their prices, insurers simply raise premiums to more than offset the increases. Because most of us (and our employers) have no choice but to do business with private insurers, if we want coverage, we pay what they demand. That means ever-increasing premium revenue for insurers, which fuels their ever-increasing profits. The Affordable Care Act forced insurers to be somewhat more consumer-friendly, but for the most part they are doing business just as they were before, shifting more and more of the cost of care from them to us. The industry’s successful PR campaigns over many years have obscured what in reality is classic market failure.
The talk of a possible bipartisan effort to address some of Obamacare’s shortcomings is coming from the so-called Problem Solvers Caucus, a group of 40 or so members of Congress with roughly equal numbers of Republicans and Democrats. GOP members of the caucus have floated a handful of ideas they believe will stabilize the Obamacare markets they helped destabilize in the first place, but they also want to reward some of the special interests that write big campaign checks.
In addition to setting up a “stabilization fund” to help states reduce premiums for people with preexisting conditions, they would repeal the 2.3 percent Obamacare tax on medical devices that under the law helps pay for the expansion of coverage. They also would exempt businesses with 500 workers or fewer from having to provide coverage to employees and their dependents. Under Obamacare, employers with at least 50 workers must offer coverage.
I would put at about zero the chances of this caucus coming up with legislation that would pass either the House or Senate. Many Republicans appear to have grown weary of dealing with health care because — who knew? — it’s hard. Just last week week, GOP Sen. Chuck Grassley of Iowa, a member of the all-important Finance Committee, said the Senate has given up on repeal and replace and is moving on to tax reform.
The more Americans learned about what the Republicans’ repeal bills would have done — and what they would have taken away from millions of us — the more they opposed them. Even Fox News reported that only 27 percent of voters favored the Senate bill. By the time senators voted on the bill, other polls showed far less support. As for the repeal bill the House passed in May, an NBC/Wall Street Journal poll found that only 16 percent of Americans liked it.
The debate on the GOP bills had the unintended consequence, at least for Republican leaders, of rekindling interest in a Canadian-style single-payer health care system. Recent polls have shown a resurgence in support for single-payer health care, with a majority of Democrats and a significant minority of Republicans now favoring it. We’ve seen similar poll numbers in the past, but what is different this time is that business leaders, including some famous Republican business leaders, are waking up to the fact that private insurers not only are unnecessary and unhelpful, they are part of the problem. And they’re speaking up.
Warren Buffett told Berkshire Hathaway’s shareholders in May that medical costs are “the tapeworm of American economic competitiveness.” The company’s vice chairman, Republican Charlie Munger, went on to suggest that the US should adopt a single-payer system to replace “the Rube Goldberg system that arose by accident.”
Buffett and Munger are not the only voices in the business community fed up with the current system. The ultimate goal of a recently formed group called Business Leaders Transforming Healthcare is a single-payer system. It already has more than 200 members.
Longtime single-payer advocate Bernie Sanders says he will introduce a new bill next month to create a “Medicare-for-all” system in the US. To drum up support, he is planning a six-figure digital ad buy with money from his 2018 re-election campaign.
Although any single-payer plan would require new tax revenue, Sanders and many others, including many health policy experts and economists, have long contended that a single-payer system would eliminate much of the waste in our current system and that most Americans would pay less for government-provided coverage than they pay private insurance companies now.
But as long as Republicans control Congress and Trump sits in the White House, don’t expect Sanders’ bill to be enacted. And even if Democrats retake Washington, enacting single-payer health care at the federal level will not be an easy lift because many Democrats get as many campaign contributions from health care special interests as Republicans do.
That’s why many advocates believe the best route to single-payer is through the states. They note that Canada’s system got its start in Regina, Saskatchewan, not Ottawa.
If single-payer has a chance of succeeding at any level, advocates, this time including motivated business executives, will have to work more strategically and have far more resources than they’ve had in the past to counter what will be a massive campaign of deceptive ads and PR tactics financed by the special interests with the most to lose.
That campaign will be waged not just by insurance companies but also by drug and medical device makers, pharmacy benefit managers and organizations like the American Hospital Association and the American Medical Association. The symbiotic relationship between private insurers and health care providers has proven to be exceedingly profitable for all of them, and they will spend whatever they think it will take to keep our expensive and dysfunctional Rube Goldberg of a system in place. Even if it means growing numbers of Americans being treated in barns and animal stalls.
