As reported in the Des Moines Register, a jury recently found the State of Iowa guilty of illegal discrimination against a transgender man. He had not been allowed to use the men’s bathroom or locker room, and he had been denied health insurance coverage for gender re-assignment surgery. (See link below to Register article.)
It is morally correct and good public policy that our government not discriminate against a people based on their gender identity. But refusal by government or private employers to cover gender reassignment surgery under their health insurance plans should not be considered wrongful discrimination, unless the plans cover other types of cosmetic procedures for people who feel similar dysphoria. People may feel mental distress over their teeth being crooked, or their nose being too big, or many other aspects of their body, but that does not mean health insurance plans should be required to cover procedures to make people feel better about their appearance. We have already seen that requiring health insurance plans to cover almost everything makes the premiums unaffordable for many people. There is nothing inherently wrong with expecting people to pay their own way for cosmetic procedures.
Thanks to Susan Voss for her thoughtful essay about the complexities of our health care system, and how difficult it is to reduce costs. (See link to Register essay below.) I don’t claim to have “the answer”, but I do suggest that the following cost saving ideas be given serious consideration.
Medicare, Medicaid and private insurance should not be required to cover every new drug, product, or procedure that is approved by the FDA. Some are very high cost but provide only marginal improvement over alternatives that cost much less. Also, at least some covered products and procedures would likely be considered not medically necessary by most people.
Consider shortening the amount of time that government grants a monopoly for patents. Patents are not natural property: humans have copied one another since the beginning of time. Our U.S. Constitution allows patents to be granted to encourage inventiveness, but there is no objective reason why a patent must be granted for 20 years. Why won’t five or ten years work? Maybe the length of the patent should be based on the cost to develop the patented item and whether or not government funds were used to help develop the item.
Don’t require limits on out-of-pocket payments such as co-payments, especially for very high cost items. A person should have “skin-in-the-game” if they expect their insurance to cover very high cost items. Today, we see the opposite: drug companies offer to help pay people’s out-of-pocket costs so there won’t be so much political pressure on them to lower their prices.
Allow both pharmacies and individuals to purchase drugs from sellers in other countries that are “deemed” to have sufficient safety procedures in place. If drug companies are free to charge lower prices in other countries, then pharmacies and individuals should be free to purchase the drugs from those other countries.
Allow Medicare and Medicaid to negotiate with drug companies on prices they pay for the drugs that are covered by the programs. Right along with that, Medicare and Medicaid should be allowed to develop formularies (lists of drugs that are preferred over other therapeutically similar drugs), that give beneficiaries a financial incentive to use the preferred drugs and a penalty for using higher cost drugs.
Our health care wants are unlimited. Our ability to pay is not. We, as citizens, should not expect private insurance or our government health care programs to cover everything, regardless of cost. We should expect our government to NOT do things that increase costs, or reduce our choices.
The Des Moines Register recently reported that Wellmark Blue Cross Blue Shield has been accused of violating federal HIPAA privacy regulations in the case of a patient with severe hemophilia. (See link to Register article below.) As reported, a representative of Wellmark was discussing the high cost of health insurance at a Rotary Club meeting last March. She gave an example of an extreme case that was costing $1 million per month. (ACA – Obamacare – prohibits insurance companies from placing any limit on the amount it will pay for patients.) She did not identify the patient by name, but described him as a 17 year old male with hemophilia. Maybe she should not have mentioned the age or sex of the patient, but that information alone did not identify who the specific patient was, and should not be considered a violation of federal privacy regulations.
Wellmark and other insurance companies must be able to cite specific high cost cases that are causing health insurance premiums to rise to unaffordable amounts. How can we openly debate ways to contain health care costs if we don’t know what is causing the high costs? Can we really afford to require insurance companies to pay out unlimited amounts for any patient? I recently heard that the last remaining company to offer individual health insurance policies in Iowa may charge more than $30,000 per year next year for a couple who are 55 years old. Health care wants are unlimited. Our ability to pay is not. We need to debate whether or not government should prohibit health insurance policies from having limits on how much they pay out for individual patients.
Regarding The Register editorial today (11/17/2014) entitled “Obamacare foes are hoping for activist judges” Exactly the opposite is true. It is the Obamacare supporters who are hoping for activist judges to interpret the law differently than it was written. The letter of the law is clear. It states that only people who sign up for Obamacare through state run exchanges are eligible to get subsidies. Obama and his team created this threatening provision intentionally to pressure states to create their own exchanges. But more than 30 states, including Iowa, did not knuckle under to the pressure. The Supreme Court should uphold the law as written, not as Obamacare supporters wish or hope it was written. This is what happens when, as Nancy Pelosi famously said, “we need to pass this bill to see what is in it.”
Contrary to the letter to the Register on 5/28/2013 by Michelle Anderson, “Iowans should have access to naturopathic docs”, we already have open access to naturopathic doctors and medicines. What we don’t have and don’t need is for our government to license practitioners and then require that their services be covered by insurance. Individuals are not calling for licensure in the interest of public safety. Practitioners are calling for licensure in order to have their products and services be a required service under Obamacare. Unfortunately, as long as our government continues to use its power to force insurance companies to cover politically favored medical products and services, there will be many special interests, such as naturopathic doctors and pharmacists, who will try to get on the government gravy train.
Health insurance should not be considered a “human right” as the Register advocated on 1/31/2013 (Health insurance for poor is a human right). When the term “human right” is used in conjunction with a product or service, such as health insurance, (or food, or shelter, or clothing), it implies that government should use its force to take property from some people to make sure that everyone is provided with that product or service regardless of cost. Rights that require the use of force by government to take from some to give to others are called “positive rights.” Positive rights are only possible if some of the people work, create, and save their property – so that it may be taken and distributed to others.
The kind of rights that are guaranteed by the Bill of Rights of our U.S. Constitution, are called “negative rights.” Negative rights do not require any action by anyone else and do not infringe on the rights or the property of anyone else. For example, I have a right to speak , but you don’t have to listen. I can practice my religion but you don’t have to believe. I can form a union but you don’t have to join. I can open a business but you don’t have to patronize it or work for me. Negative rights are are based on the idea that we are each free individuals who own whatever property we create or acquire honestly and peacefully through voluntary social interaction and cooperation with other people.
The current question is whether or not to expand Medicaid in Iowa. The fact that most, if not all, of the funding comes from the federal government does not make it free for Iowans. Money from the federal government is not “free money.” The more fundamental question is how far do we expand Medicaid. The number of people in Iowa on Medicaid increased by 23% from 2006 to 2010. Today, more than one out of five Iowans are on Medicaid. Of course, many more people would like to be covered by Medicaid. Who wouldn’t like to have someone else pay for their health care? Governor Branstad is correct to not expand Medicaid. Instead, we should make sure that we our current spending is being used as effectively as we can.
Doctors and patients will not voluntarily contain health care costs unless that is what patients want. Patients will not contain health care costs unless they have a financial incentive to do so. Until people are required to pay some significant amount out of their own pocket each time they incur a cost, there will be no incentive to reduce costs. Obamacare goes in the opposite direction. It requires that there be zero co-payment for many services. it also reduces the amount that people can contribute to Health Savings Accounts (HSAs). HSAs allow people to buy high deductible insurance plans and also save money in a tax deductible account to help cover the deductibles. If people don’t use all of the money in the HSA, they get to keep the savings for future years, and after age 65 they can use any remaining balance like an IRA retirement savings account. HSAs should be expanded and encouraged. They are a sure way to give people an incentive to be conservative about their health care spending.