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Health Care 301: Ration This

For over two months, my family and I have had to confront a medical emergency and navigate various corners of our health care system. But over nine weeks later, we have some good news: My dad finally made it home.

It’s a huge relief that he’s finally home, but that still doesn’t mean our lives are suddenly perfect. In fact, just this week, my dad had to work through yet another health care headache.

Just when things were looking up…
health care
Photo by Andrew Davey

My dad should have had his first outpatient appointment with his cardiologist on Monday. The day after he left the third hospital for the rehab center, the third hospital’s cardiology clinic called to notify me of his appointment. I then told him and the rehab center, so they could arrange for his transportation in case he was still staying at the rehab center on the 27th.

Flash forward to yesterday: While I was on the phone with my dad, he told me that the rehab center staff told him that the third hospital had to postpone and reschedule his cardiology appointment. “But why?,” I asked. “Why did they postpone?”

“They still need insurance approval,” he replied. Oh, yes. That’s right. Once again, my dad’s Medicare Advantage HMO plan is haunting us.

The “Advantage” falls apart all over again.
health care
Photo by Andrew Davey

As I explained last December, Medicare Advantage is the hybrid arm of the federal government’s health insurance program for seniors and some Americans with disabilities. Medicare still oversees it, but it’s offered and operated by private insurance companies. While some Medicare Advantage plans differ, my dad has the most common plan available in most regions: A health maintenance organization (HMO) plan where patients access a network of doctors and additional health care providers for a low pre-set fee, but are penalized with higher costs for seeking “out of network” care.

Last November, my dad was moved from the first to the second hospital because the first hospital where he was immediately treated after the heart attack was “out of network”, and the insurance company insisted that his heart surgery be performed at an “in network” hospital. Even after he was transferred to the third hospital due to his eye infection, the insurance company continued to insist that he return to the second hospital for the heart surgery.

As we ran into more and more excuses for more and more delays, I lost my faith in the second hospital. So did my dad’s medical team at the third hospital, hence why they filed an expedited appeal and ultimately succeeded in performing his heart surgery there.

Breaking News: We’re already rationing care.

For decades, right-wing movement leaders and corporate lobbying outfits have been scaring Americans away from a more tightly regulated universal health care system by claiming, “Rationed care! Rationed care! ‘Big guv’mint will ration your doctor away!” 

They nearly succeeded in torpedoing the Affordable Care Act (ACA, or Obamacare) with this argument. And more recently, Democratic presidential candidates like former Vice President Joe Biden and former South Bend (Indiana) Mayor Pete Buttigieg have been caught using new versions of this argument against U.S. Senators Bernie Sanders (I-Vermont) and Elizabeth Warren (D-Massachusetts) for supporting “Medicare for All” single-payer health care.

When we spoke with SEIU 1107 health care workers last weekend, they sounded the alarms on a very different form of rationing. SEIU 1107 Executive Director Grace Vergara-Mectal spoke of her members’ doubled-up challenge of fighting for their patients’ health care along with their own. As she explained, “When you’re in the hospital, you dedicate yourself to the patients. But if you don’t have enough staffing and you have so much workload, you have to figure out how to do your job.” 

Believe or not, these health care workers sometimes have to go to the negotiating table to fight to maintain or expand health insurance benefits that employers often prefer to pare back. In addition, they negotiate with their employers over workplace conditions, such as nurse staffing ratios, that affect patient care. As Sunrise nurse and SEIU 1107 member Jody Domineck explained to us last Saturday, “Southern Nevada has a health care worker shortage. We see a lot of challenges here, and these challenges trickle all the way down to the individual hospitals.”

Are our rations truly better than theirs?

For all the hand-wringing among Republican and Democratic politicians over “rationed care”, the fact of the matter is that America already has rationed care. We ration care over cost: how much providers are willing to pay for, how much insurers are willing to cover, and how much patients can afford. If we as a country do ultimately commit to building some kind of universal health care system, we will have to accept some kind of rationing or else risk on a much larger scale Taiwan’s current health care conundrum where patients, providers, and the government must make difficult sacrifices to sustain what’s otherwise a nearly unlimited “health care on demand” single-payer system. 

What makes rationing decisions different in the U.K., where they have not just single-payer but also a wholly public National Health Service (NHS), is that the NHS streamlines the process and has one set of public officials deciding who needs how much care at which time. The Netherlands, however, has a mostly private system like ours, and general practitioners (as in, primary care/family doctors) are required to act as “gatekeepers” to determine whether their patients can obtain specialty treatment(s).

Yes, it feels and sounds frightening to many of us Americans who are accustomed to “freedom of choice”. But as I’ve already explained here and in previous installments of this series, our alleged “freedom of choice” in health care rests entirely on whether we have health insurance and what our health insurance (if we have any) actually covers.

Rationing is only a “dirty word” here because we won’t come clean on how it really works.
health care
Photo by Andrew Davey

Back in California, my dad is back at home and is back to calling his HMO to schedule future doctor appointments. So far it looks like his third hospital cardiologist appointment will finally happen next week, but we still don’t know for sure, as the third hospital remains “out of network”.

He was sent home last night with some eye drops and a “temporary” walker “on loan”. As per usual, we’re waiting for his permanent walker to arrive at the house, and we’re waiting to see which additional prescriptions and outpatient care that his insurance will cover.

As you can see, my dad has already had to contend with rationed care. From the procedural hurdles he had to clear to obtain heart surgery at the third hospital to his next doctor appointments, he’s had to learn the hard way that “freedom of choice” is nothing but a gilded illusion. If we truly want to fix these inherent imbalances in our health care system, then we need to drop the illusion and acknowledge reality.

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