Perhaps we should now speak of two varieties of what was formerly known as the “Fog Of War.” The older form is often attributed to Carl von Clausewitz (but never verified), the Nebel des Krieges, or the “uncertainty in situational awareness experienced by those engaged in military combat.” Then there seems to be a more modern form, in which the Republicans fight against “Obamacare” and promise to Repeal and Replace it without inconvenience to anyone. Or, the uncertainty of what to do when the fight stops being strategic and starts being ever so inconveniently tactical.
One of the elements that is truly popular is the ACA provision forbidding insurance companies from denying coverage because of a person’s medical history (the pre-existing condition provisions in policies). 69% of the country favors this provision including 75% of Democrats, 65% of Republicans, and 63% of independent voters. [KKF]
Perhaps this is a popular feature of the Affordable Care Act because 25% of Nevada’s non-elderly population, or 439,000 people could be denied health insurance coverage if the pre-2010 rules were re-established for health insurance companies. [KFF] If a person is without health insurance the problems are well documented.
“Lack of health coverage, even for short periods of time, results in decreased access to care. Adults with gaps in their health insurance coverage in the previous year were less likely to have a regular source of care or to be up to date with blood pressure or cholesterol checks than those with continuous coverage.16 Children who are uninsured for part of the year have more access problems than those with full-year public or private coverage.17” [KFF] (emphasis in the original)
The pattern from this point on is predictable. No health insurance, less likelihood of consistent care, less care begets more serious health problems, and more serious health problems are more expensive, especially if treatment is deferred until the emergency room is required. MEPS has some 2013 data which is on point:
“Average expenses for people who had one or more visits to the Emergency Room were $1423 in 2013, according to the Medical Expenditure Panel Survey (MEPS). Median, or typical, cost was $703. For people ages 45 to 64, the cost was substantially higher on average ($1840). Uninsured people under age 65 averaged $1627 in expenses ($572 median), of which they paid almost 1/3 out of pocket. While average cost for those age 65 and up was about $1500, Medicare recipients paid only about 5% out of pocket. Median charges for children under age 18 were $471 to $477.” (Full chart here)
The standard Republican response is that people ought to have Health Savings Accounts, and/or pay more out of pocket. [PUSA] Therefore, our 439,000 Nevadans would be on the hook for emergency room treatment of approximately in the range of $703 to $1423. Uninsured children? The parents would be liable for costs of at least $471 for that rash, laceration, abrasion…whatever the little critter managed to do to itself. It’s all well and good to babble on about some theoretical notion of Personal Responsibility, but …
Health Savings Accounts and High Deductible Health Plans aren’t for everyone. For example, the median household income in Nevada is $51,847 and the average household has 2.72 people. The average mortgage payment is $1,442, and average gross rent is $973. [Census] Those in Clark County can expect to pay out $177.22 per month on utilities, and another $352.74 on groceries (at least) per month.
We played with some of the numbers back in 2015, and the pressure on average families in the Silver State was obvious then:
“For the sake of the argument let’s propose that the family has one car, which means ownership costs of $517.00, and operating costs in the western region of $236.00 per month. [IRS] Subtract another $753 from the monthly budget. Now we have $1,848 left for the remaining expenses.
Basic utilities in Las Vegas run about $175.56, and in Reno about $130.00; let’s call it in the middle and estimate monthly utility bills of $150.00; now we have $1,698 in the check book.
Now for the groceries. A family of four can just get by on about $146 per week and eat healthier on about $289 on the higher end. [USDA pdf] Let’s settle for the “moderate” plan which will cost our average family of four about $1,062 per month if the kids are over 6 years of age. Now there’s $636.00 left.” [DB]
Without too much more arithmetic it should be clear that High Deductible Health Plans and Health Savings Accounts are a nice idea if (1) a person is generally healthy with no family history of serious illnesses; and (2) a person is wealthy enough to afford to put aside “extra” money each month for the Health Savings Account. Return with us now to elementary school arithmetic.
We’ve been speaking of households in terms of their Median household income. So, we know that half the households in Nevada are earning less than $51,847 per year. We also know that 14.7% of Nevadans have incomes below the poverty line ($24,250 for a family of four in 2015). We also know that 22.8% of Nevadans under the age of 65 and below 138% of the poverty line did not have health insurance at any time during 2015. [TP.org] Speaking about an HSA to those whose households are trying to function with incomes below the median and barely above the poverty line seems almost cruel. It doesn’t do to bellow “personal responsibility” when the individuals and households in question don’t have the “personal resources” to meet this exalted standard.
It’s perhaps even more cruel to imagine the days when an insurance company in this or any other state could decline coverage for previous treatment of: alcohol or drug abuse Alzheimer’s or dementia, arthritis, cancer, cerebral palsy, congestive heart failure, coronary artery disease, Crohn’s disease, pulmonary disease, diabetes, epilepsy, hemophilia, hepatitis, kidney disease or renal failure, lupus, mental illness, multiple sclerosis, muscular dystrophy, obesity, organ transplant, paraplegia, paralysis, Parkinson’s disease, pending surgery or hospitalization, pneumocystic pneumonia, pregancy, sleep apnea, or strokes. [KFF]
Yet, this is precisely what the Republican Congress has in mind … repealing the Affordable Care Act, with it’s protections for those with pre-existing conditions and replacing it with … something…. somehow … some way… in some form… when the only two definitive responses have been “using the emergency room,” and “HDHP + health savings accounts.” In short, back to the bad old days.
No more light on the subject, just more Nebel des Krieges from the Republicans, including Representative Mark Amodei (R-NV2) and Senator Dean Heller. It would be well for them to blow off some of the fog and illuminate precisely what they want to do.