Monday, October 21, 2013

Weighing In: Personal Responsibility

My sincere thanks for the many kind and thoughtful responses to the blog, Weighing In. My intent is never that we will all agree, but that by pursuing discourse in a respectful manner we might be open to information which we may not have previously considered.

I think before we can begin to address to concept of personal responsibility, we have to first understand what the Affordable Care Act entails. Many negative remarks about the plan begin with heated emotion and several exchanges later result in the same person admitting “I don’t really know that much about it.” So, if you would bear with me for a moment and explore the facts, as available through (I hope) bipartisan institutions, we can come to some common ground about what we are actually discussing.

According to a promotional piece by the AARP regarding the Affordable Care Act, services that all insurers are required to cover include:

  1. Ambulatory Patient Services: Care you receive without being admitted to a hospital — for example, at a physician’s office, clinic or same-day surgery center.
  2.  Prescription Drugs: Drugs prescribed by a doctor to treat an acute illness, such as an infection, or an ongoing condition, such as high blood pressure.
  3. Emergency Care: Care for a sudden and serious condition, such as the symptoms of a heart attack or stroke. Under the health care law, emergency room visits do not require preauthorization, and you cannot be charged extra for an out-of-network visit.
  4. Mental Health Services: Care to evaluate, diagnose and treat mental health and substance abuse issues. Many plans don't cover mental or behavioral health services, but that will change under the law. In some states, coverage may be limited to a set number of therapy visits per year.
  5. Hospitalization: Care you receive as a patient in a hospital, such as room and board, care from doctors and nurses, and tests and drugs administered during your inpatient stay.
  6. Rehabilitative and Habilitative Services: Services and devices to help people with injuries, disabilities or chronic conditions gain or recover mental and physical skills. Plans must cover needed therapy and medical equipment, such as canes, knee braces, walkers and wheelchairs.
  7. Preventive and Wellness Services: The health care law requires insurers to cover a range of preventive services recommended by the U.S. Preventive Services Task Force at no extra cost. Preventive or wellness services include immunizations andscreenings for diabetes and certain cancers, such as prostate exams and Pap smears. However, you can still be billed for "diagnostic" tests that doctors order when you have symptoms of disease.
  8. Laboratory Services: Testing blood, tissues, etc. to help a doctor diagnose a medical condition and monitor the effectiveness of treatment.
  9. Pediatric Care: The other nine essential benefits above, but provided to children. Including dental and vision services for children under age 19. The mix of services and common conditions treated are different for different age groups.
  10. Maternity and Newborn Care: Care provided to women during pregnancy and during and after labor; care for newly born children. The law classifies prenatal care as a preventive service that must be provided at no extra cost. And it requires insurers to cover childbirth as well as the newborn infant's care.

Per the AARP “While the law requires coverage for each of these categories of benefits, it does not name the specific services that must be covered or the amount, duration and scope of the covered services.”

It’s in this next section of information where I think the meat of the value to the American people as a whole lies. It’s also the section that Dave Ramsey pointed to when he was talking about how including everybody would raise rates for those who do not fall into these categories. One important thing to note, as far as what many consider “people not willing to work for a living” (and we’ll get to that in a minute), including individuals from the following categories does not correspond directly to people in poverty or unemployed. Most of the people in these categories are among the self-employed, those employed by small business and all those who purchase care outside of employee sponsored benefits (through which pre-existing conditions are often accepted).

Pre-existing conditions are defined as “A pre-existing condition is a health problem that existed or was treated before you applied for coverage under a new individual of family health insurance plan” by ehealth. However, the people who fall in this category include “newborns with birth defects, kids with asthma, cancer survivors, diabetics, those with high blood pressure even headaches and pregnancy, patients who need regular stable health care the most have been denied the coverage they need. Those who currently have insurance are at risk of losing coverage due to a job change, an employer’s insurance provider change, or getting too expensive for insurance companies to cover.” (Doctors for

So, here is how the Affordable Healthcare Act addresses these situations:

  • Stops insurance companies from dropping coverage: Insurers can’t drop your coverage if you become sick.
  • Adds more preventive care: Health insurance plans must cover more preventive care services at no additional cost to you.
  • Extends coverage for young adults: Parents can keep their children on their family health plan until age 26.
  • Stops insurance companies from denying coverage because of preexisting conditions: No one can be denied health insurance because of a preexisting condition.
  • Bans lifetime limits: Health insurance plans can no longer put lifetime dollar limits on the benefits you receive.
  • Bans annual limits: Health insurance plans can no longer put annual dollar limits on the benefits you receive.

I am willing to pay more to have these assurances, and I’m willing to for those in my nation to be able to rely on them as well.

Another benefit of the Affordable Care Act is the 80/20 provision. Insurers are required to return 80% of premiums collected back to insurers either through paying for health care or, if costs are less than 80% of premiums, return that back to insurers. This prohibits insurers from continuing to raise rates to cover administrative costs or make additional profit. This is similar to the electricity and natural gas industry, where local providers are regulated to only make a percentage of profit over what it costs to produce or purchase said energy. In order to raise the percent profit utilities must present cases to their local utilities boards that costs have gone up, therefore justifying a rate increase (though what you pay for a kilowatt hour of energy day to day may vary because how much that energy costs on the open market varies, but regardless of that base cost, the utility’s profit to provide that energy to you stays the same.) In much the same way as we cannot truly "shop" for electricity and natural gas, health care is not a service for which we receive a menu and can choose which services we want based on price in most instances.

The other hallmark of the act is that The Health Insurance Marketplace makes it easier to shop for health plans in your state. All plans are listed in one place, so individuals can make comparisons of benefits and prices. All plans are required to describe what’s included in simple language, so there’s no guesswork about what’s covered.

Now that we've gotten through the nuts of bolts of what we’re talking about, we can get into the more controversial elements of those who may receive reduced rates in order to afford the premiums on these plans. But first, I’d like to take a moment to understand just who that group of people is comprised of.

One concept I hear repeatedly in arguments against many social aid programs is that of personal responsibility of those who may benefit. While, as in any group of people, there are those who will attempt to abuse a system, there are far more whose stories go untold. When any single entity tries to provide an example, it can seem like “onsie, twosies” as the attempt is made to provide a specific example we can relate to. Statistics dull the senses and individual examples can make it seem like those examples are the only ones present.

I recently watched a PBS documentary of two families followed over 20 years as they attempt to stay out of poverty. I would invite you to watch the one hour and 23 minute documentary that follows these two families in their efforts to achieve the American dream. I found it eye opening. Yes, these are but two examples, but their stories ring true of individuals who work hard and take care of their families to the best of their ability. Are these two families perfect? No, but none of us is perfect. However, I think the documentary highlights many of the challenges and opportunities for the working poor and debunks the myth that all who receive aid do so willingly or are a pariah on the system.

According to the US Census Bureau 15% of the population lives at or below the poverty level. How poverty is determined depends upon the number of persons in the family unit. As defined by the Office of Management and Budget and updated for inflation using the consumer price index, the weighted average poverty threshold for a family of four in 2012 was $23,492.

I’m not sure if you’ve tried to live on $23,492 as a family of four any time in the last decade, but it is very, very difficult for a single person (as I can attest), and for the working poor that income is often cobbled together from several part time jobs, meaning additional child care needs, and no health care or other benefits.

So, to try to dissect exactly who makes up this 15% of the population, some facts:

  • The adult population ages 16-64 is estimated to be 205.5 million people by the U.S. Census Bureau. 
  • So, of the 205.5 million persons of working age, 28.1 million live below the poverty level (less than $23,492 for a family of four and much less if you are single).  
  • As of August, the unemployment rate was at 7.3% of adults 16 years and older approximately 11.3 million people unemployed. 
  • When you subtract out the 11.3 million that are unemployed that leaves 16.9 million people that work for a living but do not make enough to be at or above the poverty level which isn't even entirely accurate because ...
  •  Of the 11.3 million unemployed ages 16-64 likely includes some high school students who don’t work, nonworking college students, persons on disability, early retirees and stay at home moms/dads. A percentage of that is non-working poor.

Case in point, there are far more working poor than nonworking poor.

So, when it comes to personal responsibility, I wonder what our expectations are.

A further interesting read would be the follow up piece “The State of America’s Middle Class in Eight Charts.”  As we contemplate one’s ability to sustain income-generating work, we have to consider what work is available. More and more jobs attainable by Americans without college educations are limited to part time work, which does not include health care insurance. As a result, working for a living becomes increasingly difficult.

While it would be nice to argue that individuals wishing to make more income should obtain a college or community college education, if you were struggling to put food on the table, doling out additional funds to obtain an education, or finding the time when you work 60+ hours a week at three different jobs, just aren't an option. Not to mention that not everyone has the gift required to obtain a college degree. Many are gifted in areas that are not as lucrative when they translate to the workforce.

So there are the numbers. As far as those who will receive aid to purchase insurance on the exchange, “The health care law gives people with low incomes new options for getting health coverage. It does this in two ways. It gives states the option to expand Medicaid to more people. It also makes financial help available to people with limited incomes who buy health insurance through the Health Insurance Marketplace.”

If you are interested in these specifics, this is how the ACA expands Medicare, the joint state and federal government program that pays the health care costs for many people with limited incomes:
  • Before the health care law, millions of uninsured 50- to 64-year-old Americans, as well as many younger people, were not eligible for Medicaid, no matter how low their incomes.
  • Your state has the option in 2014 to make Medicaid available to more people. Your state can also decide not to make this change.
  • If your state does make this change, Medicaid will pay most of your health care costs if you: Are younger than 65 and meet income eligibility.
For those that do not have Medicare, available options include:
  • To qualify individuals must be single and earn less than about $15,500, or are part of a couple that earns less than about $21,000. These figures, based on the 2012 federal poverty level, are subject to change.
  • Helps pay for insurance
  • If an individual can’t get Medicaid, they may be able to get financial help to pay for the health insurance through the Health Insurance Marketplace. The amount of help depends on your income.
  • If individuals need insurance because their employer doesn't make it available, they are self-employed or not working, or they have been denied coverage, they can shop in the marketplace in their state.
In the end, whether those in need of insurance "deserve" it or not doesn't really matter to me, but I know some really struggle with the idea of doing for someone what they (think) those individuals can do for themselves.

I tend to relate to the words of Gandhi: "A nation's greatness is measured by how it treats its weakest members." ~ Mahatma Gandhi.

Sometimes weakness translates to behaviors we choose to shame by assuming people's motives or judging their inability to provide for themselves by assuming that it is only for lack of desire that they do not, but weakness is weakness.

Providing access to health care isn't going to buy fancy televisions or designer jeans. It will simply provide access to insurance that can help provide health care to persons who otherwise are not eligible, be that they work part time jobs instead of a full time job, were born with a pre-existing condition and simply have not been able to afford the exorbitant rates charged to those who do not benefit from employee sponsored insurance. And as I said before, we are already paying for that care at a much more expensive rate through ER visits and conditions that could have been caught and addressed much earlier.

But I would refer back to my initial post and reiterate that regardless of all these arguments, there are certain services that further enhance our great nation. Access to education and to health care. Neither of these should be considered a luxury.

The Parable of the Good Samaritan

25 On one occasion an expert in the law stood up to test Jesus. “Teacher,” he asked, “what must I do to inherit eternal life?”

26 “What is written in the Law?” he replied. “How do you read it?”

27 He answered, “‘Love the Lord your God with all your heart and with all your soul and with all your strength and with all your mind’[a]; and, ‘Love your neighbor as yourself.’[b]”

28 “You have answered correctly,” Jesus replied. “Do this and you will live.”

29 But he wanted to justify himself, so he asked Jesus, “And who is my neighbor?”

30 In reply Jesus said: “A man was going down from Jerusalem to Jericho, when he was attacked by robbers. They stripped him of his clothes, beat him and went away, leaving him half dead. 31 A priest happened to be going down the same road, and when he saw the man, he passed by on the other side. 32 So too, a Levite, when he came to the place and saw him, passed by on the other side. 33 But a Samaritan, as he traveled, came where the man was; and when he saw him, he took pity on him. 34 He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, brought him to an inn and took care of him. 35 The next day he took out two denarii[c] and gave them to the innkeeper. ‘Look after him,’ he said, ‘and when I return, I will reimburse you for any extra expense you may have.’

36 “Which of these three do you think was a neighbor to the man who fell into the hands of robbers?”

37 The expert in the law replied, “The one who had mercy on him.”

Jesus told him, “Go and do likewise.”

Note: We are never told 'who' the man who was attacked was. He is unnamed, his country of origin unknown. He could have been a villain. He could have been a tax collector. Didn't matter. He was in need.