Hot Cancer Summer and Skin in the Game

I have cancer, but that is not what this post is going to be about. I don’t have a prognosis yet as I just found out Monday. The rest of this week is tests and consultations. It is those, and how we treat Americans in the health care system, that I want to discuss.

Yesterday, I was nearly faced with a terrible choice. It looked as if my insurance company would not approve the CT scan that I need to determine if the cancer has spread. That meant either postponing the CT scan and thus the surgery consultation and this my treatment until some indeterminate time in the future or pay for the entire thing myself, upfront, with no hope of being reimbursed. Fortunately, I could have paid for the test out of pocket if I had needed to, but even more fortunately, through a combination of the doctors involved, their office staff, and my own intervention with the insurance company, we got it approved at the last moment.

But imagine if I had not. Imagine having to make that choice — financial heath or physical health. Imagine not having the money to be able to make that choice. And even with approval, all of my treatment is going to cost me. Most things will only be covered up to seventy or eighty percent. If I need surgery, which I almost certainly will, that will be thousands of dollars out of my pocket. All so I can have “skin in the game”.

That innocuous term is what economists call the ability of insurance companies to profit off our illnesses. In economics land, it is supposed to keep people from overusing the health care system and to make good, rational choices when deciding on where to get their health care. It is unique, or close to it, in liberal democracies and other developed nations, and it is one of the evilest things about our health care system.

Health is not a consumer product. People either need it or they do not. I do not have the option of choosing where to get the CT test. First, because there is no competition for these services in my area — almost everything is owned by one health care system for hundreds of miles. And even if there were, time is of the essence my doctors tell me. Waiting weeks to go somewhere else is detrimental to my long-term health. And overuse of the system? What if I had not gone to see the doctor for my very mild, apparently not cancerous symptoms because of the cost of a visit? Or not gone to the emergency room as they instructed after that visit (long story) because of the much greater cost of that visit? I would be in even worse shape than I am today.

I appreciate that this is still a better situation than before the ACA. I am old enough to have lived in the Before Times. I spent most of my twenties without insurance because it was completely unaffordable, and lack of proper care likely damaged my back permanently, and lead to at least one very serious heath incident that could have been prevented with early treatment. I remember getting insurance that wouldn’t cover pre-existing conditions. I remember choosing which job to take based entirely upon the quality of the health insurance. I remember a life with no limits on how much I had to pay but limits on how much the insurance companies could pay to treat me over my lifetime. things are indisputably better now.

But they aren’t good.

Health insurance may be affordable for almost everyone now, but health care still is not. As a nation, we spend almost twice as much as any other peer nation on health care per person and in terms of GDP share. And those countries have universal care with much, much lower cost for patients. Yes, some of them manage their systems poorly, resulting in waits for some non-critical care. But ask anyone who has had to wait for insurance company approval about waiting for non-critical care. Besides, if we spent the same amount of money we do today on care, we’d likely be able to provide gold-standard care for everyone.

The ACA was a boon to the country, but it does not go far enough. It does not go far enough because it is based on the flawed premise that making access to care contingent on payment would lead to lower costs and better outcomes. It is a think tank idea, an economists dream that has nothing to do with how people actually interact with a real, live health care system. It needs to change.

The idea that people need economics to understand the seriousness of making correct health decisions is obscene, the kind of nonsense only an insurance executive or an economist could love. I don’t need the artificial constraint of payments to help me make good medical choices. I need access to doctors and tests and treatments and regular checkups. I am not going to comparison shop for the best CT scan price, not when my doctor, who knows the disease, tells me I need to get in as soon as possible. But maybe I don’t find the cancer because I cannot afford the regular visits. Or maybe I don’t get the scan, because I cannot afford the copay. Or maybe I don’t get the scan in time because my insurance company takes too long to approve. All so that the magic of prices, of skin in the game, can control my behavior.

It is cruel and unnecessary and unrealistic. I don’t need high prices to have skin in the health care game. I already have skin in that game — it’s my actual fsking skin.