Monday, October 21, 2013

PCACare, Medicare, Obamacare

The PCA: A Healthcare Microcosm

Last week The Aquila Report (which I think should be called The Priscilla and Aquila Report) published an article by Larry Ball titled Thank God for Medicare. In that article Larry tells the story of the collapse of the PCA health insurance plan with the consequent challenges he and his wife experienced getting health insurance they could pay for as they got older and developed health problems. Now, old enough to be covered, Larry is on Medicare. Though Larry thinks the government has no business getting involved in healthcare, and though he thinks Medicare and Obamacare are socialism, he is thankful for Medicare because it provides him and his wife with medical insurance at an affordable price.  

As an old geezer himself who has been under Medicare for a year, I can amen Larry. With Medicare plus supplemental health and prescription plans, I have been well satisfied thus far. The cost for all this has been low in the first year.  I have been able to choose and see my physicians with no deductible and no copays. I have paid nothing  for prescriptions.

That does not mean the system is without problems. It is very complicated. I don’t think I could have navigated my way through it without help from insurance agents. Also, the costs will inevitably go up. I know already that, unless I find another company for drug coverage, my out of pocket costs for prescriptions will be significant in 2014. I do not know yet what will happen with supplemental medical insurance nor what the increases will be for Medicare. Still, I join Larry in saying, “Thank God for Medicare.” My financial situation would be much more straightened and precarious if I did not have it. It’s going to need to be fixed so it won’t collapse, and that will probably require some combination of qualifications for coverage, less care, and higher premiums, but I don’t want the program abolished nor do I hear others who have the coverage wanting it to end.

I believe the PCA experience with health insurance is a microcosm of the United States and healthcare/health insurance.

We have to ask why the PCA insurance program collapsed leaving Larry Ball and many others out in the cold. It was the free market at work. In the PCA, unlike other Presbyterian denominations, making participation in the insurance program mandatory for ministers and churches was never an option. At the same time, as a denominational insurance program, it had to enroll anyone who wanted the coverage. At first, it seemed to work well and was very popular. But, like all insurance programs, the rates were based on experience. As people got sick and needed treatments for serious (like cancer) and chronic (like diabetes) diseases, and the insurers paid the costs, the insurers increased the rates.

It did not take long for some to figure out that some could get much cheaper insurance. Ministers (and their dependents) who were healthy, and whose churches would give them in salary the savings realized by reduction in insurance costs, were motivated to bail out. Churches whose elders and deacons were looking for ways to reduce expenditures (though not necessarily to increase salaries) were motivated to find other insurance plans for their ministers. Agencies of the General Assembly and some larger churches found they could save insurance costs by forming their own groups.

The market worked. Who was left in the PCA insurance program? Ministers and their families who were older or who had health problems, and smaller churches. As the participants in the group grew fewer and the payouts for those left grew larger, the plan eventually collapsed. The result was  that that older and sicker ministers and smaller churches were left out in the cold. The combination of an “every man for himself” mentality together with normal operation of market forces killed the program.

If you had asked PCA ministers, ruling elders, and churches if they would like for every minister and minister’s family to to have health insurance, the majority would have answered, “Yes, of course.” If you had asked them if it were a brotherly duty to see that all were provided health insurance, I expect the same majority would have given an ambivalent answer. If you went on to ask the young and healthy and the churches if they would be willing to pay higher premiums for their own insurance than they could obtain on the open market in order to see all covered, they would likely have responded, “It all depends on how much higher, but not if it is very much.” If you had asked ministers and churches if they would be willing to have a compulsory plan, most would have responded with a resounding, “No!”

The PCA in this case seems a microcosm of the country. There are a few, such as Rush Limbaugh, whose financial resources are large, who can afford to self-insure. Some obtain individual or family policies in the marketplace. Others have coverage in connection with their employment. Others have no insurance. Of that group, those who are really poor qualify for Medicaid. Others, when they are sick enough, show up in hospital emergency rooms where they cannot be turned away but are unlikely to pay.

Most of the American people would like to see everyone have access to “affordable healthcare.” Most would like there to see those with pre-existing conditions covered. The question for those who already have coverage is what covering all people and all conditions will do to their present coverage and costs. Nobody wants less coverage, and no one wants to pay more. If we and our families have coverage, and our costs for insurance and out of pocket expenses are acceptable, and our access to medical care not overly complicated, most of us want well enough left alone. “I’m OK; I hope you’re OK; but, if you’re not, that’s your problem,or someone else’s problem, but not my problem.”

For most people this explains the unpopularity of Obamacare. Most are not opposed because of principle. They are pragmatists. If what they have is working, they want it left alone. If, on the other hand, the glitches in Obamacare are resolved, and if the program begins to work something like it was promised to do, their opposition will go away. My guess is that the issue for most is not whether government should be involved with healthcare but whether government involvement will make things better or worse for me. The only way that those who are in principle opposed to government involvement in providing healthcare can gain sufficient public support, not just for Obamacare to be unpopular, but to overturn Obamacare is if they can make the case to those who have insurance that they are likely to see their benefits reduced, or their costs increased, or their access to healthcare limited, or their jobs put in jeopardy. In other words, if Obamacare is ultimately rejected, it will happen for pragmatic not principled reasons.

The political debate is complicated by lack of forthrightness. Those who want universal healthcare are not willing to say what they really want, which is probably a single payer system and higher taxes. Those who want a free market system are not willing to say what they want, which is that some people will not receive care or at least of the quality they want for themselves. So we get the demagogic arguments. "The Republicans want you to die!" "The Democrats want to take away what you have and raise your taxes!"

Meanwhile, since I’ve got it,  “Thank God for Medicare!”

1 comment:

Curt Day said...

This is a balanced view of the healthcare debate. The question we need to ask ourselves, however, should the provision of healthcare rely on the free market? The answer no does not imply socialism--socialism is used more as a pejorative than precisely. One of the arguments against applying free market principles to healthcare is that healthcare is not often comparable with many commodities that I can choose to buy or not. Often, healthcare is a necessity while many of the things I buy are not. In addition, when we compare the per capita costs of healthcare with that of other industrialized countries, we find that we have the most expensive healthcare with diminishing results.

Finally, with regards to the pervasiveness of the free market in our society, do we want people to only be willing to help others when they can profit from providing such help? If the answer is yes, then be prepared to live in a more dehumanized and exploitive society than what we have today.