Health care crisis

Health care crisis

Area experts discuss the dismal reality of medical costs

By Carla Iacovetti 05/05/2011

“In health there is freedom. Health is the first of all liberties.” – Henri Frederic Amiel (1821-1881)
No matter what side of the fence you are on, everyone acknowledges that health care in the United States is an issue.

Take away one’s health, and there is no liberty. Talk with anyone whose health has been impacted, and they will tell you it means everything.

If the age-old adage “United we stand, divided we fall” is true, America is apparently in a heap of trouble with the current health care crisis, for we are split down the middle. According to a recent Kaiser survey, 46 percent of Americans are not in favor of the so-called Obamacare, and 42 percent applaud it. Even so, there are valid concerns on both sides of the fence.

The issues are complex. Putting health care in the hands of government and raising taxes to accommodate health care budgets are of concern to some U.S. citizens, while at the same time, the number of people who will possibly die this year because they have no health insurance is overwhelming. The Institute of Medicine says that approximately 18,000 persons die unnecessarily each year in the United States due to a lack of insurance.

Here in California, Gov. Jerry Brown has proposed a $750 million budget cut for the Department of Developmental Services, which would affect more than 250,000 disabled residents. Last year $334 million was cut, despite a state law that guarantees services for the disabled. Nancy Lungren, spokeswoman for the department, says, “Nobody wants this. It’s an extremely difficult budget for everybody in California, and we want to keep the cuts as far away from our clients as possible.”

The shortcomings of government-run health care
Ventura County resident Kathleen Rubio, the managing registered nurse at one of the nonprofit cerebral palsy homes in the San Fernando Valley, has noticed a sudden increase of denials for medication coverage from Medicare and Medi-Cal.

Rubio has worked as a health care professional for years, and every month she has to inform physicians when an insurance company refuses to cover a patient’s medication. She says, “Because Western medicine is more treatment-oriented and doesn’t really embrace prevention the way the Eastern method does, we have an issue with sole dependence on pharmaceuticals. Do you have any idea what this can mean to a patient who has been dependent upon a prescription?”

“What we’re seeing, across the country, is a risk of dismantling the system for support for developmental and intellectual disabilities established over the past 60 years,” said Peter Berns, CEO of The Arc, a service provider based in Washington, D.C., with 700 chapters and 750,000 disabled clients nationwide.

Rubio says, “I have been working as a nurse for a very long time, and I have a number of friends who are getting out of the field because it’s gotten so crazy.” She believes that the sudden increase of medication denials is related to Obamacare. Rubio says, “There’s just too much government involvement, and unfortunately, prevention is never a consideration in Western medicine.”

Some of the issues surrounding medication denials have to do with rationing. For example, Medi-Cal will allow medications for a certain amount of time, but once a certain time period has been reached, it will not continue to cover them.

cConstance Zarkowski, an attorney here in Ventura County, has been dealing with health insurance for more than 30 years. She owned a health insurance general agency for more than 27 years and admits that the mandates insurance companies require are problematic.

Zarkowski remembers that during the ’60s and ’70s, hospitals and doctors who needed to be compensated for a patient’s treatment were literally given a blank check. Hospitals would require that a patient who was scheduled for surgery on a Monday be admitted on Friday and stay for the weekend. The extra days were simply covered by the insurance companies.

Zarkowski says, “When we started to have multiple employer trusts develop under ERISA (Employee Retirement Income Security Act) in 1974, it was the first intrusion by the federal government into healthcare. It allowed employers to sponsor coverage and provide benefits for their employees. This, of course, exists today. If you are covered under an employer’s health benefit plan, and you suffer some dire consequence because your medical benefits are denied, the only thing you would be able to recover is the cost of care that was denied. This provides immunity to an employer and the insurance company.”

ERISA required vesting of employee pensions so the employer couldn’t terminate the employee just before they turned 65 in order to save the cost of the pension. It also allowed a large employer to create a trust to pay for medical benefits itself instead of paying premiums to an insurance company. It also allowed several employers to band together in a “multiple employer trust” (MET) to provide medical benefits to their employees and to collect money to pay the medical benefits instead of paying premium to an insurance company.

Trusts and premiums were the outcome of all of that, but because the claims were not being paid, we ended up becoming more regulated. Zarkowski says, “It’s been a downhill slope ever since.”

It is a vicious circle. Health care prices are high, partly because people are being denied something. Premiums have been raised because the government came in and decided that maternity coverage had to be paid for regardless of your age or status. Maternity coverage is now not free, so someone who is 65 is still paying for maternity coverage.

California also passed a mandate that insurance had to cover birth control pills. Wyoming mandates that you cover hair transplants. Just this year alone, more than 20 states have challenged the constitutionality of such laws.

Nobody really understands health insurance. It is so complicated. Zarkowski says, “You have to look at the entire picture. Bottom line, do you want the government to provide your health care like they do in Canada? If you do, be prepared for rationing. There is no getting around it.”

Rationing is already going on with Medicare. In 1965, Medicare, a two-part federally regulated program, was established and made compulsory. At 65, all citizens are automatically enrolled in Part A, which is solely for treatment in a hospital. Part B is supplemental medical insurance that includes a private physician’s services, and the patient is responsible for covering the difference in cost.

What many Americans do not realize is that a Medicare patient who is denied treatment cannot opt to pay out of pocket. Medicare physicians could lose their Medicare status if they treated this patient. Zarkowski says, “You might find a doctor to take care of you, but you will never find a hospital that will treat you. They will never give up their status with Medicare, so you will not be treated.”

Every country that has socialized medicine has rationing. Even our Medicare has it,” says Zarkowski.

CameoMany people are not only being denied their medication but their treatment as well. Cameo Swansonn of Orange County was gainfully employed until nearly two years ago, when she was the victim of a hit and run accident that left her disabled. After several months of physical therapy, her insurance refused to cover all of her medical bills, and then she was laid off. With absolutely no living family members, Swansonn ended up on the streets, floating between the cities of Ventura and Santa Barbara. Her story goes from bad to worse. In and out of homeless shelters, her physical health continues to deteriorate. She has acute ulcerations on her ankles from edema but cannot get the treatment she needs to get better. While her condition is chronic and serious, it is not considered an emergency, so the county hospital will not help her.

Zarkowski says, “Certain hospitals have to treat emergencies. County hospitals will treat someone and then put him or her on a sliding scale. If the person’s income is low enough, Medi-Cal will retroactively cover the bill. With this kind of format, no one really has any incentive to enroll in a health care plan.”

A no-win situation, apparently
It is certain that health care reform is coming at us like a speeding train. What will it mean for 40 million people who will be enrolled in government-managed health care? Who makes up the 40 million? Many doctors here in the States are not in favor of this kind of controlled health care. While socialized medicine works well in Sweden, everyone enrolls, everyone participates, and they are taxed correctly. More than likely, this is not going to happen here in the United States.

Canada has a rationed health care system, but sometimes Canadians come to the United States for treatment. Only in the last few years have Canadians been allowed to purchase private insurance. It is ironic that while many Canadians frequently look to the United States for the specialized care they need, numerous Americans look to Canada’s health care program as a viable solution. In a recent study done at Simon Fraser University in Vancouver, British Columbia, Canadian patients were asked why they traveled out of the country for medical care. Across the board, most responded that they wanted medical procedures not available in Canada.

New York Times columnist, Paul Krugman said, “Does this mean that the American way is wrong, and that we should switch to a Canadian-style single-payer system? Well, yes.” A slew of people agree with Krugman, including Hillary Clinton and Michael Moore, whose recent documentary, Sicko, applauds Canada’s socialized health care system.

There is no doubt that insurance companies have not been doing anyone any favors, and frequently their contractual obligations end up in some sort of legal battle. This kind of endless litigation is not only happening in health care, but also in auto and property insurance.

The recent health care bill signed into law last year says you have to buy insurance, no matter who you are. If you don’t, you will be taxed $700 a year. This bill is not scheduled to go into affect until 2013. In a recent interview released by CNN, former House Speaker Newt Gingrich says, “I think it will be repealed. Probably by March or April of 2013. That would, of course, be mere months after the next presidential inauguration.”

The Patient Protection and Affordable Care Act, which was moved through the Senate in 2009, was supposed to save both patients and the nation billions of dollars, but recent studies show that it is going to cost the nation about $2 trillion over the next decade, while disrupting current health care plans. Perhaps the recent waiver-mania explosion is the reason the current administration is offering some 700 organizations one-year delays to comply with the insurance mandate that was put into place in the fall. The White House maintains that these waivers were instituted to allow companies to continue providing limited-benefits plans (mini-med plans) until the law is fully put into practice in 2014.

These temporary waivers apply to only one provision of the law – the provisions phasing out annual limits. Obama administration official Stephanie Cutter recently wrote, “The waivers last one year. Insurance companies must reapply for the waivers each year between now and 2014. Insurance companies and employers that receive waivers must comply with all other parts of the Affordable Care Act.”

Recently, Steve Larsen, oversight director in the Department of Human Services (HHS) defended the exceptions while confirming that the waivers that cover approximately 2.1 million people represent “only about 1 percent of all Americans who have private health insurance today.”

When Majority Leader Harry Reid finally read the health care bill, he wrote a letter to HSS Secretary Kathleen Sebelius and complained to the administration, saying, “Obamacare’s cuts to Medicare will result in a net reduction in payment to Nevada’s hospitals, when they are unable to absorb such a cut.” Reid went on to question how the calculations for Medicare and Medicaid payments to hospitals were derived, voicing his concerns.

The arguments surrounding health care in this nation are endless and difficult to define. What is certain is that the lack of health care can lead to an assortment of complications and even loss of life. There are far too many Americans who cannot use their freedom to escape life-threatening illness or debilitating accidents. Insurance should provide people with the security that they would receive treatment should a crisis evolve, and not suffer financial ruin. Obviously, how this is implemented has become convoluted. One thing is certain — change is imminent, and to bring health care to those who are in the greatest need is a social action.


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Great article on a complicated issue that will have to be tackled soon, or options will begin to evaporate.

posted by sardith on 5/05/11 @ 08:44 a.m.

I have chosen to pay cash for doctors that don't want to use the insurance system. Most of the times when I have to use a doctor that isn't "Private," I wind up revisiting another doctor because of the lack of care I received... It is indeed a dangerous situation. My heart breaks for those that desperately try and still wind up on the streets...

posted by dmbeltme on 5/05/11 @ 11:28 a.m.

Why isn't anyone looking at the skyrocketing costs of health care? That would be the insurance companies, the hopitals, and the doctors. Is it really reasonable that they can charge whatever they want yet patients have to grovel on the ground for rules that affect only them? As long as insurance companies are for-profit institutions, the rest of us lose. And how about the president of the public hospital in Salinas? Getting millions in pay and bonuses? How much health care would that have covered? As for covering birth control pills, all insurance companies voluntarily covered erectile dysfunction drugs. It took a law to force them to pay for the consequences plus many women use the pill for medical treatment of several serious conditions. It is a rigged system. And those who have made out like bandits in the old system are now the ones complaining the loudest. Eliminate the middleman insurance companies and the problem is solved.

posted by msjetbn on 5/05/11 @ 12:24 p.m.

Greediness proves yet once again to impoverish those most in need!

posted by Bluehaven on 5/06/11 @ 09:03 a.m.

Thanks SLee. It's appreciated.

posted by WriterAtTheSea on 5/06/11 @ 12:07 p.m.

dmbeltme... I have done much the same. My mother was misdiagnosed 3 times at Kaiser. She was told she had a chronic lung disease, but it was something altogether different... and terminal. She ended up finding out what she "really" had at a private clinic in Santa Barbara. Go figure.

posted by WriterAtTheSea on 5/06/11 @ 12:10 p.m.

msjegbn... You make some strong points. I think the insurance companies are problematic for sure. Thanks for your comments.

posted by WriterAtTheSea on 5/06/11 @ 12:11 p.m.

OUCH! Bluehaven. A point well-taken.

posted by WriterAtTheSea on 5/06/11 @ 12:12 p.m.

I think there are also some reasons to be optimistic about healthcare in Ventura County:

1. The California Academy of Family Physicians is working on a "patient centered medical home" pilot with physicians here in Ventura. The goal of the project is improved quality, decrease cost, and improved patient satisfaction. The technology infrastructure that makes it possible for all of a patient's care to be coordinated through a relationship with a family physician is a proven game-changer. PPACA contained many incentives for this kind of clinical integration to occur.

2. 90% of healthcare costs are controllable through prevention. Prevention requires certain lifestyle changes. Among those lifestyle factors correlated with health, Ventura County ranks among the best.

3. Ventura County has a great deal of know-how on managing health care delivery and cost. Our County Executive Mike Powers and the new Assistant CEO Catherine Rodriguez both come from the county Health Care Agency. Healthcare is local, and requires local talent. Ventura has never abdicated responsibility to the state and the feds, and I hope never will.


posted by Devon on 5/06/11 @ 12:28 p.m.

Devon, this is a great comment! Thank you so much for posting this. It's good to know that Ventura County is staying somewhat on top of things with health-care. The medical home pilot sounds very interesting.

I do agree that prevention is paramount. I also think education goes hand-in-hand with prevention. Thanks for the link.

Thanks so much for the encouraging information.


posted by WriterAtTheSea on 5/06/11 @ 09:59 p.m.
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