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What the Devil won't tell you

Morlock: What price Mom's life?

View of health reform from inside the ICU provides much clarity

A week before I am starting this column, mom walked into my room with really bad stomach cramps. They were debilitating. The question we asked each other at 4:30 a.m., Thursday was if she needed ibuprofen or would aspirin do? At 4:00 a.m. Friday morning I got the call from the surgeon that she was on life support but could still make it.

She's been on a ventilator for six days. The woman who was once virtually unbeatable at Trivial Pursuit, worked on the cutting edge of the computer graphics industry, raised a son on her own for 20 years and cut a swath through Upstate New York men 10 years her junior now stares at the wall with dead eyes. Tears run down her face because she can't blink. She's got a tube down her throat feeding her air, another up her nose pumping a brown food solution into her stomach and another coming out of you know where that drains into a clear plastic cube growing more yellow by the hour.

None of this is bad news considering she wasn't just in need of ibuprofen, but dying there in her bed from a busted colon. She's making slow, steady progress back to the day she can yell at Trump on the Internet and television.

But as I've been sitting with her in the dark, stroking her hair and telling her what President Trump has done today, two thoughts are inescapable. It doesn't require much imagination to project myself and everyone I know eventually reduced to a puffy corpus of saline with eyes fixed on a wall we may not be able to actually see. Yes, everything I ever was and every experience you, dear reader ever had could become that one day. Every love, every hope, every fear, every moment of romance, celebration, tragedy and tedium rendered completely and entirely dependent on the latest medical technology for even a prayer at more hopes, more fears, more tediums and more celebrations.

So I ask you to ask yourself this: What's that worth to you? Put a dollar value on it. We're all gonna go sometime but how much would you pay to keep on living a life worth living?

I bring this up for two reasons. I look at the full-time nurses, the doctors with 12 to 15 years of post-secondary education, the edgy tech monitoring her and the soup of pharmaceutical breakthroughs coursing through her and I wonder: Holy shit what is all this going to cost?

This isn't going to be a bill. This is going to be a house in the Foothills. She's on Medicare, so what we pay will be a lot less than that. But that doesn't mean the bill is being "unpaid." Taxpayers are picking up the tab.

If this were 10 years ago? Where the hell would she be?

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If Mom were to pay for this all by her lonesome and burden no one else with the cost and the bill runs $500,000 … Oy. She would have had to save $12,500 each and every year for 40 years for just this occasion. That includes the year 1978, when she burst into our apartment thrilled to have just gotten a great job paying … $12,500 a year.

The second reason is, Senate Republicans just released their plan to overhaul the entirety of the health care system by leaning on free-market solutions and letting the states figure out how to best serve their residents.

For Arizonans, well, it's time to figure out whether your favorite Aztec god is Tlaloc of the North or Huitzilopochtli of the South because if history is any indications we know how the Legislature responds when given full dominion over its social safety net.

Deal or no deal

In general, the market approach is interesting. Because the numbers are just staggering. I'm trying to think of what would have happened had some administrator sat me down and said "Our premium service will run you $538,000, while our Plan Silver will cost you $462,000 but we do have our Economy Express for $399,999.99." Those numbers are just unreal they are so big. 

It's pure fantasy that we would be able to afford any of it, so why not opt for the Platinum Service I can't afford as opposed to the Economy service I can't afford. Republicans point out that's the problem. The trick is to bring about affordability by creating price exposure that is real to find the true equilibrium between supply and demand.

The only way the free market can lower the cost of her health insurance is if she sees a bill and is incentivized to look for a cheaper option. Then Tucson Medical Center would be forced though competition to cut their price.

Mom was admitted with doctors thinking she had a different problem. A colonoscopy was never part of the deal until it was the only deal on the table. That took a CT scan. By that point, her blood pressure was about 80 over 35. It was 10 o'clock at night. A good half-dozen different bacterial infections were working their way through her insides. She was having a tough time remembering what year it was (they kept asking). And it's at this point that she is supposed to say, “Hold on, bring me a laptop, I gotta do some shopping.”

Patient-centered, market-oriented health care reform means the days of customers not receiving a bill are over. It's only with more price exposure that patients will have the incentive to shop around and save themselves and the system money.

That's because the only five words that matter in free market, when it comes to price control, is “it depends on the cost.” The only way people are going to ask that question is if they personally, carry the risk and are willing to walk away from the service.

What's more, the Republican proposal puts you in charge of your health care by eliminating mandatory services in a given insurance plan. You will have to know exactly the kind of care you may need someday. Will you need an emergency room visit? Depends, what's it cost? Will you need a policy that covers cancer? Depends, what's it cost?

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Customer-centered, market driven deregulation of the airline industry has brought down costs. Has a client-centered, market-driven approach to the legal industry made legal representation affordable? Or are this their a distinct difference in judicial outcomes between the rich and the rest of us?

At some point we say: “Forget it. I won't fly,” or “Nah, I'll just deal with the judgment against me.”

How do you ask that question about whether you live or die? How do we, as a nation, flip the switch on a system it grew up with believing the best outcome is to have insurance cover everything, suddenly (and brother, it can be suddenly) having to ask themselves, “This procedure is worth it if we are on the hook for $40,000 but if it's $50,000, we're going to have to say no.”

Only when enough people refuse the higher price, will the market adjust and provide the service at a lower price.

Adam Smith, who art in heaven, hallowed be thy name

There are other ways to bring costs down. There are price controls, which can create a bunch of bad effects down stream. Then there's pooling a whole bunch of people together and having them all chip in for the day they may need the big procedure. In the mean time, they pay for other people's. That was Obamacare, in a nutshell. The idea was to force everyone into the system – especially the young and the healthy, to foot the bill for services they won't likely need today.

But that plan created by a white, Mormon Republican got pushed by a black Democrat and became an abomination among the right. So now, Republicans have to move further right to satisfy conservatives.

I'm not even bitching about that, if that's what the country wants. But I wonder if the country gets what they are buying. Offering up a “a market-driven, patient-centered approach that puts you in charge of your health care.” sounds wonderful. That's America. Or is it?

Right now we have a market approach where the customer is the insurance provider, who negotiates on our behalf. As a country, we don't react well when Cigna tells us “that procedure you just got isn't covered. Sorry.” When that happens, we don't tend to say, “Well, I guess that put me in charge of my health care and it all falls on me to pay for it, which is good because it's patient-centered.” And I never heard anyone ever say, “Well, my insurance company won't pay but that just means that someday the cost of that procedure will be driven down after I go bankrupt and the hospital realizes it can't charge that much in the future. God Bless Adam Smith.”

Mom, in fact, did do her part in this free-market system. Only in the emergency room with her did I realize the extent of the symptoms she was dealing with and she probably should have seen a specialist. She'd been discussing the rather private particulars of her symptoms with her primary care docs. They didn't seem to be worried but she wondered – I guess – if the $35 copay was too high. So, what she was doing was sending the message to the specialist and her provider that the copay needs to come down. That's how the market works.

So for the want of $35, Medicare is on the hook for a tricked-out pleasure boat.

State of Denial

I doubly fret for Arizona. The Senate and House bills would both devolve Medicaid to the states.

We don't have to look very hard to realize what that means for this state in the hands of the state Legislature. The feds devolved Temporary Assistance to Needy Families to Arizona in the 1990s and had a five-year lifetime limit. The state decided that was too generous and knocked it back to one year; the most strict in the country. Unemployment insurance was devolved to Arizona, and the state has the second lowest maximum benefit in the country. Receiving that $240 per month policy payout used to mean that you didn't qualify for Medicaid in the state's Arizona Health Care Cost Containment System.

The “cuts” to Medicaid are actually a slowing of the increase and conservatives are all over the media right now calling foul on the idea that there are cuts at all. I'm not sure the word “disingenuous” quite covers politicians whose goal is to roll back the welfare state arguing that they are expanding its capacity. They know full well they are reducing the services Medicaid will offer in coming years.

The only reason the Medicaid expansion happened here was the feds promised to foot the bill for 90 percent of it. Now both the House and Senate are proposing to slash that subsidy to the states. Anyone want to take bets on what that means for Arizona's working families now covered by AHCCCS?

Here's a hint. The Goldwater Institute wrote an Op Ed in the Arizona Republic this year complaining that the expansion is expected to cover 650,000 Arizonans. That so many more people now had health insurance is a bad thing (hint: Maybe the problem is the state's low wages and standard of living, which Goldwater's people swore wouldn't happen as we followed their economic model for the last 30 years) to one of the state's most powerful lobbies.

The thing is though, that when patients are treated as customers and have the ability to shop around, they should be able to bring prices down. That's just basic economics. A cheaper health care system in the end would save lives, so long as it is affordable.

Sacrifice

Between now and then, though, there is going to be collateral damage.

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Before you Bernie Sanders supporters starting screaming "socialized medicine," cool your jets. That tech and those magic meds keeping her alive were developed in no small amount because of the profit motive. Do you honestly expect mom's Type A, ball-busting surgeon endured 13 years of post-secondary education so she could get tossed about in the tumult of the median-income crowd? What about the pulmonologist, the anethesiologist and the fleet of surgical nurses who went to work mis madre at midnight to keep her from dying?

There would be collateral damage under a purely socialized form of medicine too, if removing the profit motive stunted innovation and medical breakthroughs.

Losing people that way would just be losing people to a hypothetical and is hard to really quantify.

Letting people die who could be saved for the want of money and in reverence to the free market, well that feels more like human sacrifice on the altar of the free market. It's strikingly similar to the thought behind the Aztec practice of human sacrifice to their gods required to bring about more bountiful returns. I guess our god is the “Invisible Hand.”

Who knew health care could be so complicated?

An ambulance ride, an emergency room visit, a CT scan, a room in the post-critical care unit, dozens of IV's, gallons of painkillers and antibiotics, a late-night, five-hour surgery, eight days on a ventilator, 10 days in the intensive care unit, three days back in the post-critical care unit, a week in inpatient rehabilitation and multiple visits from a home health nurse.

At the heart of any market-driven, patient-centered plan like the one we just got from the U.S. Senate is a question: What's it worth to you to see the sun come up again? At what price would you walk away from the deal?

Blake Morlock covered Arizona government and politics for 15 years, including 11 in the Tucson Citizen. He also worked on Democratic Party campaigns in the field of political communications. Now he’s telling you things that the Devil won’t.


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