My "Freedom" Is More Important Than Your Health: Privilege vs. Progress in Health Care

People have been emailing me a piece by Shawn Tully, the Editor-in-Chief of Fortune Magazine, entitled “5 Freedoms You’ll Lose Under Health Care Reform,” which was featured on the Drudge Report last week.  In sending, they've asked for me to respond. I struggled most of the weekend with a response, not because I agree with Mr. Tully – I don’t – but because the world Mr. Tully describes is not one that’s accessible to most Americans, and certainly not accessible to me.  Although he’s been able to tap into the scary narrative of “health reform will cause you to give something away,” he’s particularly focused on what the rich will have to give away, and doesn’t seem to have a real sense of the hazards of the current abusive insurance marketplace.  Every single one of the freedoms he defends either will continue to exist under health reform or, most often, currently only exists to the tiniest percentage of hardworking Americans.

Shoring up the foundation is apparently not a good idea if it rattles the penthouse.  Any student of history should immediately recognize the dynamic – it is the sense of entitlement and privilege standing in the way of progress, yet again.

Now I don’t for a second think that the supporters of Mr. Tully’s work will be won over by my arguments.  After all, Mr. Tully wrote a piece in March of 2008 entitled, “Why McCain Has the Best Health-Care Plan.”  Indeed just about every position Mr. Tully takes in his new editorial reflects something cherished about John McCain’s plan or, in the case of Health Savings Accounts, George Bush before him.  If Mr. Tully had been John McCain’s speechwriter, perhaps the plan would have been better received.  Or perhaps, as always, it’s easier to trigger the public's fear of loss than it is to trigger their hope for a better future, particularly on a topic as complicated as health care.

In the end, I can’t help but look at what he calls “freedoms” and think “Who, exactly, has these now?”

His first is “Freedom to choose what’s in your plan.”  But 160 million Americans don’t have that – their benefits are offered through their employer and determined by their employer.  Millions more have some government program – Medicare, Medicaid and SCHIP, or perhaps the VA or the Department of Defense – whose benefits are determined by law.  The remaining people are either uninsured and have no choice on what’s in their absence-of-a-plan, or are in the individual insurance market.  The individual insurance market is one that Mr. Tully championed explicitly in his support for John McCain’s plan.  However, the experience of those purchasing from this free market ideal on Earth tell a different tale.  A large portion of them do not get to choose what’s in the plan either.  A recent report by the Commonwealth Fund found:

Seventy-three percent of people who tried to buy insurance on their own in the last three years did not purchase a policy, primarily because premiums were too high. In addition, among adults with individual coverage or who tried to buy coverage in the past three years, 57 percent said it was very difficult or impossible to find coverage they could afford, 47 percent said it was very difficult or impossible to find a plan with the coverage they needed, and 36 percent were denied coverage or charged more because of a pre-existing condition, or had the condition excluded from their coverage.

So I’m afraid if you’re not a CEO or in human resources, you’re not enjoying this “freedom,” unless you happen to be the lucky fraction of a percentage who makes a deal with an insurance company for the coverage you want.  The irony with Mr. Tully’s argument is that it ignores that in both the Senate Health, Education, Labor and Pensions bill as well as HR 3200, individuals and employees at small businesses will in fact be able to determine whether they want the standard level of coverage or some additional items at higher cost (the "premium" level benefit options).  Apparently he only counts it freedom if you can remove some of your coverage, not gain more coverage that is currently unaffordable to you.

In this, Mr. Tully’s spirit of self-determinism truly takes an odd shape.  He decries the fact that a minimum standard of benefits will be set by the government.  “The Senate bill would require coverage for prescription drugs, mental-health benefits, and substance-abuse services,” he says – perhaps unaware of the fact that mental-health benefits and substance-abuse services are already a federal mandate.  Freedom to choose your plan, in his mind, means the ability to chuck coverage to save money.  To be sure, both the insurance industry and business have spent several years trying to do just that.  American citizens, on the whole, have not.  It is extraordinarily difficult to go onto the blogosphere, attend a town hall, or find a feature story in the mainstream media whose thesis is, “Woe is me.  I have too much coverage for health care.”

Mr. Tully’s second “freedom” that we’ll lose is the ability to get an individual rating on our premiums.  This is an aspect of health care unique to Americans – and let’s just say those other countries dodged a bullet. “In its purest form,” Mr. Tully writes, “community rating requires that all patients pay the same rates for their level of coverage regardless of their age or medical condition.”  I have to note that for an article that claims to be based on a “close reading” of the bills, Mr. Tully has missed a rather obvious detail: the bills in question would vary rates by age but at a more appropriate 2:1 ratio, rather than the current (infinity):1 allowed by regulation.  Not mentioned by Mr. Tully but getting to the heart of the matter, current regulation allows for different rates on the basis of gender, occupation, and health condition.  Mr. Tully may consider it a “freedom” to have insurance companies charge you more because you’re a woman or have diabetes or a familial history of heart disease, but I call it something else – discrimination.

Instead, let’s call individual rating what it is – a privilege for the young, healthy and fundamentally lucky.  It did not exist until insurance companies decided to rig the game so they could net more young and healthy patients to decrease their "medical loss ratios"  -- yes, it's called a "loss" when they have to pay for medical care.  There is no inherent greatness to having escaped illness or injury by age 25.  Carving out a special perk helps insurance companies attract the healthiest customers, but does not improve the performance of our health care system.  And punishing those not blessed with youth and health to create a special treat for the already fortunate is despicable.

Mr. Tully then spends some time singing the praises of “Health savings accounts,” a freedom that won’t actually get lost in the legislation.  It’s astounding that someone devoted to “close reading” keeps missing major protections in the bill.  The American College of Physicians didn’t miss it, however, including in their FAQ about HR 3200 a question on the topic:  “Health Savings Accounts, as they are today, would be able to market themselves to the public and enroll persons who choose to get their coverage through an HSA.”  HSAs will still be with us, benefitting who they benefit best – the wealthy, for whom the tax deductible nature of HSAs yields more benefits than their questionable health benefits.  Mr. Tully also would prefer to see high-deductible plans protected.  He calls it “freedom.”  I call it “significant financial risk.”  “The Commonwealth Fund survey found that 40 percent of privately insured adults with deductibles of $1,000 or more had problems paying medical bills or had accumulated medical debt, compared with 23 percent of adults with deductibles under $500.”  High deductible plans work best if you have a lot of money to begin with and want to protect against catastrophic costs – again, a privilege of security that few of us currently possess.

Mr. Tully’s fourth freedom is the usual “close reading” technique perfected by Betsy McCaughey in which something claimed to be missed by “most pundits and politicians” turns out not to actually exist.  He claims that private insurance not offered through the Exchange won’t be able to live up to the minimum standard benefits package of the Exchange when required to do so after a five-year period, therefore ending employer-based insurance.  So let me point this out just one more time – the benefits standard in the House bill is set to be “equivalent to the average prevailing employer-sponsored coverage” (page 27).  If employer-sponsored coverage is setting the threshold, I’m pretty sure they qualify.

I’m relieved to acknowledge Mr. Tully is not defending some bauble only available to the fortunate and closed off from the rest of us.  Regrettably, it’s because he’s factually mistaken.

Finally, Mr. Tully does his best to scare you won’t be able to choose your doctor after health reform.  However, he then talks about everything but that. He conflates the notion of a “medical home” – which is strongly encouraged but not actually required – explicitly with HMOs.  He talks about employers paying 8% of their company’s salary as part of “pay or play” if they don’t provide benefits as sounding the death knell for employer-based coverage, even though the Congressional Budget Office calculates that will actually cause a net increase of employer-based coverage.  He then spends a lot of time talking about corporate tax policy.

I’m sorry, did I miss the part where you were actually prevented from choosing your doctor?

Of course, it’s not true.  Those who stay in employer-based coverage will have the same choices they have now.  Those on the Exchange will have the choice of doctors in the networks of their insurance companies, be it Aetna or Blue Cross or United.  Those who opt for the public health insurance option will, we presume, have a similar network to Medicare, where “[m]ore than two thirds (70 percent) of traditional Medicare enrollees say they "always" get access to needed care (appointments with specialists or other necessary tests and treatment), compared with 63 percent in Medicare managed care plans and only 51 percent of those with private insurance.”  Perhaps that’s why Mr. Tully didn’t follow-up – it makes for a scary headline, but there’s no matter to it.

By talking of his five “freedoms” which are more privileges for the fortunate and wealthy, Mr. Tully is proving that “Fortune” is more important to those who wish to kill reform than “basic necessity.”  He also explicitly contrasts with another set of freedoms – the 4 freedoms invoked by FDR.  It shows the true paucity of that which Mr. Tully defends by blocking health reform.  “Freedom from want -- which, translated into world terms, means economic understandings which will secure to every nation a healthy peacetime life for its inhabitants -- everywhere in the world,” is a lofty goal – worth striving for and even dying to achieve.  Health savings accounts are a bauble to provide yet another tax break.  It is not worth asking for the uninsured and the underinsured to die for the benefit of a bauble.

(Photo credit:  leah|rachelle on Flickr.)