House Calls

Medical and other musings of a plastic surgeon

Lies, damn lies, and statistics- the reality of the uninsured

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“There are three kinds of lies: lies, damn lies, and statistics”

                                                                Benjamin Disraeli


I’ve said it before and I will say it again, statistics on the uninsured in the U.S. are a classic case of the adage about lies, damn lies, and statistics. A recent article in the Sentinel (15 February 2017, page A4) stated that the rate of uninsured persons in the U.S. dropped to the lowest rate on record even as one of the largest providers of health insurance announced that it was leaving the Affordable Care Act exchanges next year.


Humana claimed that the business model for health insurance wasn’t working under the provisions of Obamacare because not enough young, healthy people were enrolling to cover the costs of taking care of the older, sicker persons on their insurance rolls. You can’t mandate that insurers take on all comers, regardless of pre-existing (read: expensive) medical conditions unless you get lots of healthy young people to buy insurance too. Healthy young people, however, are not going to buy insurance because they don’t feel they need health insurance and they don’t want to pay higher rates to subsidize older and sicker people with their insurance dollars. To avoid this impasse, you have to compel people to get insurance so you tax them when they don’t (but you don’t call this a tax). Unfortunately, the Obamacare architects made the penalty low enough that it made more sense for many people to pay the penalty rather than purchase the more costly insurance. How’s that working so far?**

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As to the uninsured, the numbers cited are analogous to the statistics on the unemployed. Because we don’t include those who have literally quit seeking jobs- they have given up in an abysmal job market, this makes the unemployed rate look much better than it really is. In the insurance arena, because we don’t include those on Medicaid among the uninsured, it makes the rate of insured persons in the U.S. look way better than it is.


I have been saying this for so long, as have many of my peers, and been ignored for so long, I don’t know why I bother. I guess it is because of a sense of the unfairness to people who enrolled in Medicaid with the mistaken belief that this was going to provide them with real health insurance. It is also a sense of outrage and disbelief that our elected representatives persist in touting Medicaid as the ideal to which we should aspire in our health insurance.


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I cringe when I see a Medicaid patient in my office. Let me be clear. I cringe for them, not because of them. I will take care of them to the best of my ability because that is what I have sworn to do but I know that my pay for that care will not even cover my costs to provide it and, further, I will probably have to battle for payment in any event because of the onerous paperwork and capricious way that Medicaid pays for services to its providers. Let me give you an example. Medicaid provides a form of supplemental insurance to some patients. The way supplemental insurance works is as a secondary insurance. Many insurance policies, including Medicare, do not pay the full bill for care. The insured has to pay a co-payment of some sort, e.g. 20% for Medicare. Supplemental insurance covers that co-payment so the insured pays nothing.


I had a patient with a Medicaid supplemental policy. Once their primary insurer paid their part, we turned to Medicaid for the co-pay but were denied. Why? Because what the primary insurer paid me was more than Medicaid would have had it been the primary! I don’t even know how or why Medicaid supplemental policies even exist.


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Like the emperor, Medicaid is naked too, when you really look instead of relying on the opinions of those who don’t actually care for patients

I cringe because I know that most patients take it on good faith that when they are permitted to enroll in Medicaid, they now have health insurance. I also know that they will have a hard time finding a physician that will take on their care, will have to travel long distances for care, and that finding specialists to see them will be as difficult as getting democrats and republicans to see eye to eye on any issue (“The sky is blue!” “No, it’s not!!”). Try repairing tendons in the hand of a Medicaid patient and then finding a hand therapist to provide the necessary rehabilitation. Think needle in a haystack.


Medicaid insurance is like insurance in Venezuela or any of a number of third world countries; it is insurance in name only. I would rather we admit that Medicaid is the failure that any physician on the front lines can tell you it is, scrap it altogether, and do something else like provide physicians with tax credits, malpractice insurance credits, sovereign immunity, or other incentives for caring for indigent patients. I think that would work better because, Lord knows, we sure don’t do it for the pay.


So, politicians, media, pollsters, and everyone else, please quit saying that we have the uninsured problem under control because we have Medicaid! (sorry, didn’t mean to shout)


** I still submit, as others have said, that Obamacare was set up to fail from the start and that its purpose was to serve as a stepping stone to universal, government run health care in the style of the British National Health Service. Hillary, as Obama’s heir apparent until the end, would undoubtedly have championed this particular cause. Fine, if that’s what you want, go for it. Just don’t sneak around claiming you have provided insurance when you haven’t really.

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