Reading Karen Tumulty’s compelling narrative about her brother’s illness and misadventures in the U.S. health care system in this week’s issue of Time reminded me of Fast Food Nation, the deservedly popular book that chronicled the evils of the fast food industry but ended with a conclusion as flat as a McDonald’s hamburger. It pretty much said you don’t have to eat Whoppers if you don’t want to.
Tumulty, a national political correspondent for Time who has covered health care before, told the serious and underreported story of those 25 million Americans who have coverage that nonetheless leaves them uninsured when a devastating and or even a not-so-devastating illness strikes. It’s a problem that could happen to any of us at any time, and it happened to Tumulty’s brother Patrick. She told of her brother’s battle with kidney failure, and the insurance traps he fell into while trying to get treatment.
After he lost a job with health insurance, Patrick took the experts’ advice and bought a policy in the individual market. Continuing to believe that he would get another job with benefits, he kept buying a series of six-month policies from Assurant Health, a company that specializes in insurance for small businesses and short-term policies for those between jobs. What Patrick didn’t realize was that each time he re-upped for another six months, he had to satisfy the company’s health requirements just as if he were buying a brand new policy. When he needed the coverage to pay his medical bills, Assurant refused, saying that his kidney condition was already pre-existing when he got his latest six-month policy.
Tumulty’s story poignantly shows what happens when patients fall through the cracks of the insurance system. She points to the shortcomings of other options for people in similar predicaments—such as the Texas Medicaid program, which she calls “notoriously stingy.” In San Antonio, where he lives, Tumulty’s brother qualified for a special program that is available only to patients with very low incomes. But even though he can get relatively inexpensive care, Tumulty points out that it is not seamless.
The lack of seamless care is one of system’s failings, many experts believe. Patrick must navigate between his kidney specialist, who prescribes medications and treatments, and the program’s bureaucracy that must approve them. That’s hard for him.
Time readers get a clear picture of the problem. But the magazine only advances fuzzy solutions. Tumulty devotes some paragraphs to what she says are the two major paths to reform. One is the Obama approach, which she sums up as forcing employers to offer coverage to their workers with subsidies and other incentives to make the policies more affordable. That’s it—no mention, let alone explanation, of a public option that could compete with private insurers—which will be the major flashpoint in the debate. How would Patrick fare under that option?
She talks about McCain’s proposals, which are very much alive in the Congressional mix—taxing the value of employer-provided insurance, which proponents hope will encourage people to leave their employers’ health plan and seek coverage in the individual market. Yes, the one that snared Patrick. Tumulty does say that consumers often lack the power or information necessary to make their own choices, and hints that McCain’s approach may be tough for many patients. But, she says, “there are ways to fight back.” In the end, she pushes the Texas Insurance Department to make the insurer cover some of Patrick’s bills—a partial solution, at least for him. But most patients don’t have savvy relatives who know where to file complaints and have a national media platform at which to write about them.
Tumulty’s story didn’t fully explore the crucial connection between the accompanying consumer tips box and the rhetoric about bringing people affordable coverage—especially those people who must buy in the individual market. The box warned consumers that high deductibles (Patrick’s policy carried a $2,500 deductible) could leave them uninsured; so could limits on benefits and services and the pre-existing condition clauses that let companies like Assurant Health off the hook. Cheap, affordable policies contain these provisions. That’s what makes them cheap. Time could have really scored had it connected a few dots and framed the trade-off between cheap, affordable policies and the skimpy coverage that leaves people stranded in health care never-never land when illness strikes. That will be another flashpoint of reform.
The magazine did present five options for reform, such as preventing disease, realigning doctors’ incentives, reinventing hospitals, adopting electronic medical records, and covering everyone. They echo the conventional wisdom. But their presentation was so sketchy that it would be hard for any reader to really understand them. Did “Cover Everyone: It’s Cheaper” mean an individual mandate that certainly will be expensive for some of the currently uninsured? Most readers wouldn’t get the recommendation to “pay for holistic success.” I’m not sure what the writer meant. And the suggestion that hospitals are medical “cafeterias” that should not all provide the same services is not likely to fly with hospitals that are fighting viciously with each other to win patients who need the most lucrative services. Plus, trying to steer patients to centers of excellence for various procedures has already been tried by the HMO movement—and consumers resisted. They wanted to go to hospitals close to home, even though the cost may have been higher and the quality lower.
Time’s failure to be more forthright about solutions may reflect the magazine’s internal dissent, or it could mirror the lack of national consensus about how to solve the problems Tumulty so vividly illustrates. There appears to be only a rhetorical consensus—things are bad and something must be done. Which raises the question: Are we headed toward a Fast Food Nation-style conclusion, which posited that food consumers could choose whether or not to eat Chicken McNuggets? When health care consumers get really sick, they usually have no choice. That’s the problem.