ADVENTURES IN MEDICAID: A TALE IN THREE PARTS
1: The Customer
So we know a midwife. She has two kids and a stay-at-home husband since she works about 60 hours a week. She makes enough to provide a middle-class living for her family and pay a mortgage a good hour's commute from where she works. She doesn't make enough to provide insurance for her family of four, however; I don't know what rates they were offered but my Obamacare insurance for a family of 3 was $800/mo for catastrophic with a $10,000 deductible.
Her stay-at-home husband recently came down with - wait for it - Stage 2 Lymphoma. Let's assume for the sake of argument he's a mass murderer who doesn't recycle - his presence in her household allows her to work and contribute to the economy so it makes sense to try and keep him alive regardless of his personal merits. Let's also assume for the sake of argument that she pays taxes so keeping her working is beneficial in the long run because she puts money back in the system. But let's also assume for the sake of argument that keeping a father alive and his family solvent is good for the long-term fabric of society so yeah - maybe we oughtta try and treat his cancer despite the fact that the cheapskates didn't protect themselves.
Unfortunately she makes too much money to qualify for medicaid, and she doesn't make enough to afford insurance, and her husband has cancer. So the move recommended to her by state-funded social workers was to quit her job, stop seeing patients and drop below the poverty line in order to qualify for state aid. So. How 'bout a couple rounds of chemo with a side of food stamps? Because that's the structure we have right now: if you're earning a living, you're not earning healthcare and we'll take away your healthcare if you try to earn a living.
2: The Provider
So we're going to take medicaid at the birth center. Right now, the state program pays approximately 20% of our costs for a birth, and that's assuming the birth happens at the birth center (statistically speaking, about a 75-80% likelihood). If the mom transports, the fees paid by the state cover about 5% of our expenses. It makes zero sense for us to take state money but good of the community, helping out those that can't help themselves, warm fuzzies, whatever. My wife was the only midwife we knew of that successfully navigated California's byzantine medical codes to actually get reimbursed by the state for home births, so why not?
Doesn't matter what it costs to cover a home birth. Let's call it a buck. The state right now is paying 20 cents. There are a couple companies negotiating with all the midwives to carry that contract for the state; they're offering a 12% increase over the current rate of 20 cents, bringing things all the way up to a whopping 22 cents! Sign the deal, right?
Except we know for a fact that the same companies pay two dollars in Oregon.
And we know for a fact they pay eight dollars in New York.
And we know for a fact that the cost of delivering a baby in all three states is effectively the same.
But we know that calling around to everybody saying "don't take the deal" is collusion and a violation of everyone's contract with Medicaid.
But we also know that some of the contracts that have already been signed don't show a 12% increase; they show a 20% DECREASE.
3. The insurer
So the government has X money and it's up for bid. For that bid, you provide all the health coverage that all of the state's clients "need." Those "needs" are dictated not by doctors but by elected officials whose decisions are assisted by appointees and lobbyists.
The money on the table is there to cover a select population whose boundaries are also determined by elected officials, whose decisions are assisted by appointees and lobbyists. In order to raise money, you need to raise taxes somewhere. And in order to spend money, well - really. Companies like Valeant are taking your generics and making them brand-name again. At a federal level you've been banned from negotiating prices.
And your budget is good for a year, and you bid on that year. Yet here you have these fucking midwives who are literally throwing a price increase in your face because for some dumb reason they think they're entitled to some crazy number that some other state legislature saddled you with. And here you have social workers actually advising people who could have bought insurance but didn't to quit their jobs so that their healthcare has to come out of your budget.
And you're the bad guy.
I could go on - the pharmaceutical company is jacking prices because it's got shareholders to keep happy and the market is shorting its stock and it's getting killed in Europe where subsidies allow its competitors to crush it. The shareholders are trying to earn enough money to pay for their retirements which is becoming impossible because the HFT firms have arbitraged all the beta out of the market. The HFT firms are trying to eke out a living on the crumbs left over from the giant banks, who do most of their work in dark pools, and the giant banks...
well, actually, fuck the giant banks.
The real problem is that the closer you get to the human, the easier it is to be human and the further away, the less sympathy you have. The higher your view, the more you see corporations and profits and the less you see the people whose lives matter. All the way through, though, it's money money money money money and it comes from the simple fact that if we value people's health, we shouldn't make them pay to keep it, particularly when the playing field is anything but level.
I used to pay $800/mo for $10k deductible catastrophic for my family of 3. No pre-existing conditions, hearty and hale, all of us healthy as fuck. Then I got my hours in the Union and now I pay $600 a year for $0 deductible comprehensive for my family of 3. Should my family grow to four, that number goes up by $50. The lotion for my kid's eczema? Went from $200 a bottle to $4. Same bottle. Same kid. Same pharmacy, same doctor, same prescription.
What we got now is marginally better than what we had (I had no insurance between 2004 and 2009 because there was no law requiring insurance companies to sell private-carrier insurance in Washington; you either got it through work or you straight-up didn't get it at all). It's a long damn road from acceptable though. It is so god damn fucked up and our collective consciousness is so broken that it's upsetting to think about.
But the thing that people forget is it's fucked up all the way through. By determining that market forces should determine national health, we are forcefully unhealthy.