This post stems
from both a conversation online with a friend and a series of similar cases
that have come through my office lately. And also, the recent cuts to the
Affordable Care Act (aka “Obamacare”) subsidies inflicted on Americans by the
Republican Party.
Americans -
particularly white Americans - tend to see “socialized medicine” as a bogeyman,
something to fear, the source of all problems, and on and on.
And yet,
Americans depend on the existence of socialized medicine for their survival -
at some point in their lives. In fact, I have found that most people -
including right wingers - really desire socialized medicine. They just can’t
articulate it to themselves, because that would challenge their political
commitments.
There are a few
myths that prop up this belief, and continue to prevent the United States from
joining the rest of the first world (and an increasing number of third world
countries) in adopting true universal healthcare.
I have
practiced in the area of Medicaid law for over a quarter century. Here in
California, we call it “Medi-Cal,” and other states often have their own cute
names, but it is all Medicaid. My focus is getting people qualified for
Medi-Cal when they need nursing home care, and preventing a claim against their
estates for benefits paid. But I also have advised a lot of clients about
“community-based” Medi-Cal, Medicare, and other health insurance related
issues.
I can say with
honesty that the following are true:
(1) When I
am able to solve problems for my clients, the solution is always some
form of socialized medicine.
(2) When I
am unable to solve problems for my clients, it is nearly always because
their real need is a form of socialized medicine that the United States refuses
to provide for its people.
I also practice
law in a fairly Red county. Because senior citizens (55+) are the bulk of my
clients, they skew even further Republican than the county generally. I
regularly get clients wearing Trump hats and railing on about how all their
problems are due to some combination of Democrats, black people, Hispanic
people, and immigrants.
In reality,
their problems, more often than not, would be far worse if they lived in a Red
state, and are caused by a lack of socialized medicine that covers their
situation.
This makes it,
shall we say, challenging to be a lawyer some days.
***
Let’s start
with some truths that need to be acknowledged:
For purposes of
this post, I will use “socialized medicine” to describe a healthcare system
that includes the following:
(A)
Universal coverage of a class of people, regardless of health status
(B)
Government payment of all or part of the cost
This isn’t an
entirely accurate definition, however. It is what most people mean when
they use the term.
An accurate
description (per the dictionary) is a healthcare system owned and operated by
the government - such as Britain’s NHS. This does not include other systems
where there is a single payer (the government) but private ownership of
hospitals and other providers. The latter is the most common form of universal
coverage. It also does not include systems like that of Germany, which uses
tight regulation, mandates, and subsidies in combination with private insurers
to get the same result.
If you want a
quick and easy to understand summary of the systems some different countries
use, this
website is helpful. You might be surprised at some of the countries with
better systems than ours. Just saying.
I use the
colloquial definition of “socialized medicine,” however, because arguing about
what is and isn’t “socialized medicine” is pointless and futile in most
cases.
It is easy to
see, with this definition, that the United States already has some degree of
socialization of its medical system.
Medicare is
socialized medicine.
If you are
eligible for Social Security, and are age 65 or older, you receive Medicare,
regardless of your income, health status, or employment. Everyone is
covered.
Government pays
most of the cost (excluding co-pays and co-insurance), using tax dollars. One
source (but not the only source) is the percentage withheld from wages as
payroll/self-employment taxes. As I will discuss more later, this is one reason
many people see Medicare as different from socialized medicine.
But it is, in
fact, socialized medicine.
If it were not,
then it would be paid by private funds, it would exclude those too sick to be
profitable, and insurance companies could kick you off as soon as you cost too
much.
People age 65
and older are essentially uninsurable. By that age, all of us are at risk for
needing care - and more of it as we get older.
My clients
often fail (or refuse?) to understand that literally the only reason they have
access to healthcare in their old age is because we as a nation have socialized
their medicine.
Medicaid is
socialized medicine.
Medicaid is, in
my opinion, the most misunderstood Federal program. This is in part because the
American right wing has succeeded in demonizing it and those who use it. I
believe as well that a factor is the way that states (including California)
have changed the name of the program.
If I had a
dollar for every person I have heard saying, “I’m not worried about cuts to
Medicaid - I have Medi-Cal.” Not realizing, of course, that they are the same
thing.
There are other
misconceptions, driven by propaganda. The truth?
Most recipients
of Medicaid fall into one of these categories:
(1) Low wage
workers whose employers refuse to pay benefits
(2) Low income
seniors who are retired
(3) Disabled
people, including the mentally ill
(4) The minor
children of those who are either low wage or disabled
The rest mostly
fall into smaller categories, such as college students, caregivers for the
elderly or disabled, or unemployed and unable to find work.
There are
actually very, very few recipients who are able to work and find employment but
do not.
This idea of
people freeloading is a myth. A straight-up lie. Access to healthcare doesn’t
lead to anyone freeloading. Rather, access to healthcare enables people to
treat illness and return to work.
Another truth:
41% of all
births in the United States are paid for by Medicaid. This rate is even higher
in many Red states - Louisiana is the highest at 64%.
Needless to
say, this isn’t because 41% of people of childbearing age are lazy freeloaders
- most of them do indeed work. Rather, it is because younger people are likely
to have lower wages, and less access to benefits.
Another truth:
Nearly all
people in nursing homes are having their care paid by Medicaid. Medicare does
not cover long term care. Few of us have $13,000 a month sitting around waiting
to be spent. Thus, nearly everyone - the obscenely rich excluded - are getting
Medicaid if we need nursing care.
This is where I
usually end up assisting people in obtaining socialized medicine.
Medicaid is
indeed socialized medicine. If you meet the income and asset guidelines (which
vary depending on the specific program within Medicaid you need), you will
qualify, regardless of health. The government pays the cost.
Another truth:
Undocumented
people do not get Medicaid except in an emergency. And remember, this emergency
coverage is there to protect the provider. This means that undocumented
people are denied access to preventative medicine, diagnosis, and treatment
except when they are actually dying or trying to. (Or if they are in a nursing
home, because once upon a time, we didn’t leave old ladies to die on the
street.)
That this is
stupid, cruel, and hateful is true – and I will look at that a bit in the next
post. It is also thoroughly anti-Christian.
The ACA
exchanges are socialized medicine
This is another
area where misunderstandings are rampant.
“I hate
Obamacare - we should get rid of it. I prefer the Affordable Care Act.”
They are, of
course, the same thing. And Obamacare is really just the old Republican plan -
Romneycare - but because a Democrat enacted it, it is bad, right?
(Beyond the
scope of this post is a discussion of the merits and problems with the ACA -
that is a whole topic.)
The ACA
exchanges were intended to fill the gap between middle class people (who are
fairly likely to have employer-subsidized insurance) and poverty level people
(who qualify for Medicaid.)
The GOP,
through its bought and paid for Supreme Court, and legislative undermining, has
chipped away at the ACA. By eliminating the individual mandate (at least the
fines which enforced it), people who were currently in good health could (and
often did) take the risk of not paying for coverage, since they figured they
could always join later when they got sick. And, more recently, but cutting the
subsidies, the cost of those ACA plans will skyrocket next year.
Far too many
people - particularly in Red states - rely on these plans even as they vote to
cut their own throats.
And yet, these
are indeed socialized medicine. The plans are required to cover pre-existing
conditions, take all applicants, and a significant portion of the costs had
been covered by government funding.
As this funding
is withdrawn, and people can no longer afford the plans, a death spiral is
likely to ensue, driving costs further and further higher until the system
collapses.
This is
intentional on the part of the Republican Party, which has also voted to make
massive cuts to Medicaid. The why is something I will discuss later in this
post.
The bottom line
is that a lot of people gained coverage through the ACA, and now stand to lose
their coverage through no fault of their own, but through the actions of one of
our main political parties.
Employer-provided
insurance is socialized medicine
Did this
surprise you? It shouldn’t. If you get employer-provided insurance, it is
universal: you get the insurance regardless of how healthy you are, your age,
your income level.
Not as well
understood is that it too is subsidized. This happens in two ways. First, the
healthier (meaning younger) employees use less, and the extra is used to care
for the less healthy (meaning older) employees.
The other is
less well known. Because health insurance is an “above the line” deduction,
employees do not pay taxes on it. If you count health insurance as part of the
wage paid, then that part of the wage is not taxed. Meaning it is subsidized by
other taxpayers. I
wrote about this a few years ago. The worst part is that high income people
get more of a subsidy for their health insurance.
Employer-provided
insurance therefore does indeed qualify as socialized medicine - and that is
why we all want it, and even make job decisions based on obtaining and keeping
this coverage.
ALL of us
benefit from socialized medicine, whether we have private insurance or not
This too is a
huge misunderstanding that many people have about our healthcare system. It too
is the result of a deliberate propaganda misinformation campaign by the right
wing.
Have you or
anyone you loved done any of the following:
(1) Ridden in
an ambulance to get to care?
(2) Been
treated in a hospital?
(3) Been
treated in an emergency room?
(4) Received
healthcare at a rural hospital or clinic?
(5) Needed care
in a nursing home?
Guess what? You
have benefited from socialized medicine. Because without it, none of these
would be able to survive.
This is where a
huge misunderstanding comes in. The purpose of socialized medicine isn’t just
to pay for care. It is to ensure that the providers of that care get
paid.
When you call
an ambulance, why does it come? Well, because the company that provides that
ambulance knows that it will get paid, whether or not you have insurance.
(There are a few exceptions, but they are relatively rare.)
Emergency rooms
are required by law to treat anyone who comes in (more about that later), and
they can only do so knowing that they will get paid.
And what about
after the emergency room, when you are admitted to the hospital for care? That
too is only possible because of socialized medicine paying the providers.
Going even
further, rural providers - hospitals, clinics, doctors, labs, and more -
typically treat a population that is lower income than average, with a majority
often on Medicaid. Do you think that such a provider could afford to give away
more than half their care without being paid? Of course not. Without socialized
medicine, these providers would close.
As would most
urban hospitals as well. The only ones that could afford to exist are those
that were in places where few people are low wage workers.
My wife is now
in management at one of our local hospitals, and has been in on meetings with
the local and regional CEOs. And it is ugly - they are literally talking about
which hospitals they are going to have to close with even the cuts that the
Republican Party made this year. If the ACA exchanges collapse, that is more
uninsured people who will have zero coverage except for emergency
Medicaid……which is also on the chopping block.
And yes, this
problem is even more serious in Red states. Rural healthcare in particular
could very well disappear entirely from much of Red state America.
This assumes
that the OTHER socialized medicine, Medicare, stays intact. Without that, the
senior population would mostly lack the ability to pay. That would pretty much
completely collapse our system entirely. Only the obscenely rich could afford
to fly to Europe every time they needed healthcare.
Note that when
these go away, ALL of us suffer. The ambulance won’t come for us either. The
emergency room will be hours away and too crowded to see us. If we get sick on
vacation, there will not be a hospital or clinic to treat us anywhere
nearby.
At that point,
we will be living in the equivalent of a failed state, a third world nation
where getting sick or injured means death or disability, not treatment and
recovery.
I already
mentioned above that nursing homes rely on Medicaid for long term care
patients. And on Medicare for pretty nearly everyone there on a short
stay.
***
Recurring
Client Scenarios
I wanted to
talk a bit about some scenarios I see in my office all the time. These are not
specific cases - I have removed identifying details - and they happen again and
again and again and again.
Scenario #1:
Client is in
their late 50s or early 60s, and becomes ill with a chronic serious disease
that needs long-term treatment and care.
Think of things
like cancer, heart disease, autoimmune disease, joint degeneration.
As a result,
they miss some work, and the employer fires them or lays them off. Now they get
that COBRA
notice informing them that they have 60 days to sign up for gap coverage or
they lose all health insurance. And this gap coverage costs thousands of
dollars per month!
So, they come
to me, and all I can tell them is that they are over the income limit for
Medicaid (due to unemployment payments, or a spouse’s income). At least we have
the ACA, right? Well, those costs just went WAY up - perhaps almost as much as
COBRA payments.
What do they
do? If they are sick enough, the “best” option they have is to go on Medicaid
with a really high “share of cost” - that’s a co-pay they have to make
before Medicaid covers anything. For a single person, that means they “get” to
keep $21,597 per year of their income (2025 limits - they change each year),
which is all of $1,800 per month, not enough to pay average rent even in
Bakersfield. So, do they lose their house? Or die of treatable cancer?
Yes, this
fucking SUCKS! And this is the stupidity we put up with as Americans.
Scenario #2:
Client is in
their late 70s, increasingly frail, and becoming forgetful. They cannot safely
live at home.
The best place
for them would be in a Residential Care Facility for the Elderly (RCFE) - we
commonly call these Assisted Living, Memory Care, or Board and Care.
Alas, these
places can cost $3,000 per month or up to a lot more than that. Client only has
$2500 per month in income.
So, the only
option is a skilled nursing facility, which Medicaid will pay for. And, which
costs Medicaid a lot more per month than the RCFE would cost.
So, client gets
a worse situation, the government pays more. It’s a lose-lose. At least there
is Medicaid to pay for the nursing home. If that goes away, what? People die in
their homes from neglect?
Scenario #3:
Young couple is
engaged. They get a little ahead of things, and get pregnant. They have no
employer-provided benefits, although they do both work. They want to go ahead
and get married, but are worried about paying for the pregnancy - even an
uncomplicated one is tens of thousands of dollars, and if something goes wrong,
they would be financially destroyed.
What are their
options? Well, prior to the ACA, not much.
Private
insurance would turn them away because of the pre-existing condition. In fact,
most plans wouldn’t cover a pregnancy until two years of payments had been
made. Yeah, that’s helpful.
Medicaid? Well,
that is problematic if they make “too much” money.
The “best”
option? She quits her job, and they remain unmarried so his income doesn’t
count. And indeed, I have advised clients in this situation to do just that.
Have your children, get married after you are done.
Note that this
could be even worse: imagine they were already married? The best legal
advice I could give them would be to get divorced. And yes, that is crazy!
The ACA, at
least, gave options: get insurance through the exchange, with subsidies based
on income, making coverage at least somewhat more affordable. This is what the
Republicans decided to take away this year.
Scenario #4:
Parents have a
child who is profoundly disabled and needs constant care. This includes
surgeries, in-home nursing, and more. A LOT more. And this need for care will
not end when the child turns 18.
Most private
insurance does not cover all of the care needed. Often, not even close. So what
is a parent to do?
Well, Medicaid
currently steps in, even if the parents have too much income and assets to
qualify for benefits themselves. And when the child turns 18, they will qualify
for Medicaid for the care they will need for the rest of their lives.
***
I could add to
this list, of course. The people in other states who find that their entire
savings will be spent on nursing home care, or claimed in an estate claim,
literally making them worth more to their heirs dead than alive. The people who
are suddenly laid off, jeopardizing their access to life-saving medications
like insulin - where even the delay in applying for Medicaid or ACA insurance
could kill them. The undocumented workers who are ineligible for Medicaid and
ACA who end up in the ER and hospitalized with life-threatening conditions that
could have been prevented had they had affordable access to primary care and
diagnosis.
Our medical
system is fucked up and cruel and stupid.
It also
costs us twice as much per person than the rest of the first world.
That above is a
fact. We pay far more to cover fewer people. And we also get outcomes that are
no better - and are often far worse (maternity and infant mortality, for
example) than the rest of the first world.
Every one of
the scenarios I listed above would be solved with universal socialized
medicine.
Every single
one.
Imagine if,
when you lost your job, your insurance kept on going, whether or not you could
afford hundreds or thousands of dollars per month. Imagine if you could get
cheaper, less institutional living and care arrangements near the end of your
life. Imagine if pregnancy and starting a family didn’t risk financial ruin
because your employer refused to provide benefits. Imagine if we treated
nursing home care like other healthcare, and paid for it, rather than trying to
financially ruin the elderly as punishment for getting old and frail. Imagine
if working class people didn’t go without healthcare because they couldn’t
afford it. Imagine if we didn’t cruelly punish the people who harvest our
crops, build our houses, mow our lawns, and a lot of other necessary yet poorly
compensated jobs by denying them healthcare?
We could do ALL
of this - the rest of the first world does, after all - but we refuse to.
Why is that?
I’ll talk about
that in the next post.