This battle has been going on for ages, and it’s not likely to end any time soon. With rapidly rising health care costs, everyone is searching for a cause. Medical providers and health insurance carriers like to point fingers at each other, but the underlying causes of health care inflation are probably a combination of factors that involve both groups. We do overuse our health care system – alot more health care than most other countries. Doctors could probably provide fewer treatments without seeing a decline in patient health. But at the same time, health insurance carrier administration costs – everything that is not spent on medical claims – increased 118% between 1996 and 2006. Doctors feel shortchanged in the deal, as they are seeing more claims denied and lower reimbursements, while health insurance carriers are spending more money than ever on non-claims expenses.

The ultimate losers in the whole battle are Texas residents, who have to work with both doctors and insurers in order to have access to health care. A system with more transparency, better communication, and less red tape would benefit patients and lead to less bickering in the health care system and ultimately more focus on patient care, which is what the whole thing is supposed to be about in the first place.

There are 2.1 million low-income adults in Texas who earn too much to qualify for Medicaid, but less than 200% of the federal poverty level.  The proposed program was supposed to provide a measure of care for these people, and to start shifting the focus of care from emergency treatment to preventive care.  Unfortunately, uninsured residents are a lot less likely to seek preventive care and treatment for minor ailments, and tend to end up in crowded emergency rooms only when a situation has become dire.

The plan that was to be implemented later this year has been criticized for not providing enough consumer choice in plan design, and also for providing too little care for the critically ill.  It would have allowed five days of inpatient hospital care per year, which would be plenty for most people but not even close to enough for the seriously ill.  The Texas Hospital Association has been critical of such gaps in coverage, pointing out that for catastrophic illnesses, five days of hospital coverage will barely make a dent, and hospitals will be stuck with the expenses.  But who’s paying for it now?  Hospitals and emergency rooms all across Texas are suffering under the weight of a population in which nearly 28% are uninsured.  Obviously there were some flaws in the proposed health care plan, but wouldn’t it have been better than nothing at all?

Research has shown that even cheap gifts like pens and paper have an influence on doctors prescribing habits. It makes sense that if a doctor sees a particular drug name every time she looks at her desk, she will be more likely to think of that drug when it comes time to write a prescription.

I applaud SMDC’s clean sweep approach. It’s high time that pharmaceutical companies stopped being able to worm their way into doctor’s offices with gifts and lunches and trinkets. Medical treatment should be a collaboration between the patient and the doctor. Health insurance companies and pharmaceutical companies have way too much of an influence on treatment protocol, and the focus needs to shift back to looking at what is in the patient’s best interest. If a generic drug will do the job just as well as a name brand, it’s to the patient’s financial advantage to prescribe the generic. And pharmaceutical reps who tell doctors otherwise really have no place in the offices.

I hope that SMDC’s idea catches on. It would be nice to see hospitals and doctors across Texas and the rest of the country turning away from pharmaceutical company gifts and freebies, and focusing instead on the peer-reviewed research about new drugs. That seems like the best way to provide quality patient care while minimizing conflicts of interest.

Under the new proposal, a private Texas health insurance carrier would contract with the state to provide health insurance for the children.  Courts could order parents to buy the health insurance for their children, and income levels would be taken into consideration to determine a parent’s ability to pay for the policy.  Since the system would be set up through the state, courts would also be able to payroll deduct a child’s health insurance premiums from a parent’s paycheck.

Any program that aims to reduce the number of Texans without health insurance (currently 5.5 million) is a good start.  But I have to wonder why the state wants to set this program up through a private health insurance carrier?  Texas, like every state in the US, already has a government-run health insurance system – Medicaid – in place for the poorest of its citizens.  Why not just expand that program to cover the uninsured children that Abbott’s proposal targets?  The state could still payroll deduct premiums and court order parents to enroll their children.  By eliminating the middle man (a private health insurance company) it seems that the program could be more cost effective.  No private health insurance company is going to submit a bid unless they will be able to make a profit from the contract.  If Texas were to just add more people to the current state health insurance program, more of the funds could be used to provide health care services for the currently uninsured children, instead of creating dividends for the shareholders of whatever private health insurance carrier the state picks to run the proposed program.

There are plenty of barriers that Texas has to overcome to improve the health care numbers.  Between 2000 and 2006, Texas had the fastest growing illegal immigrant population of any state in the US.  And a full third of the state’s residents under age 65 fall into the poor and low income categories, with only the poorest of those qualifying for Medicaid.  And then there’s always ignorance on the part of the public.  Jason Robertson’s article includes a mention of Mesquite resident Gloria Newton, who works 72 hours a week at two jobs, one of which offers health insurance for $35/week.  Ms. Newton says that she could afford the premiums, but she considers the health insurance to be of little value because of its $1500 deductible.  So she chooses to go without.  In the absence of a universal health insurance system, people like Ms. Newton will continue to be uninsured unless they get a serious wake-up call in the form of a major illness or injury to themselves or a loved one.

The grassroots group Health Care For All Texas is trying to implement a single payer system to provide health insurance for all Texans as one group, administered by a nonprofit organization.  The group detailed their plan at a Texas legislative meeting in 2006, but so far no legislation has been proposed.  Indeed, providing health insurance in Texas for everyone will be an uphill battle.  Mass, which implemented a universal health insurance system in 2007, was starting with 94% of their residents already covered by employer sponsored health insurance.  In Texas, that number is only 74%.  But just because something is challenging doesn’t mean that it can’t or shouldn’t be done.  Texas must face the current health insurance challenge head-on in order to solve a situation that is becoming more and more a problem for all residents, not just the uninsured.  The uninsured are still receiving health care, often at over-crowded emergency rooms across the state.  And the cost of their care is passed on to Texas health insurance carriers and insured patients in the form of higher premiums and copays. 

It will be interesting to see what health care changes come about in the next few years on a national level, and how those changes effect the Texas health insurance system.  Hopefully the number of uninsured residents will start to shrink, and emergency rooms will be able to provide services for true emergencies, rather then functioning as primary care facilities for uninsured patients.

There are many reasons for the health insurance crisis in Texas.  Small businesses in Texas are less likely to offer health insurance to employees than their counterparts in other states.  Income limits to qualify for Medicaid are much lower in Texas than in other states ($4822/year for a family of three, compared with $10,000 in FL, $18,000 in CA, and $25,000 in NY), leaving plenty of families who earn very little money unable to qualify for state funded health care and equally unable to pay for private health insurance.  $4822/year is $402/month.  Once you pay for housing, food, and gas, you’ve probably already gone into the red.  Health insurance premiums just don’t physically fit into the equation.  Another problem adding to the uninsured mess is that Texas forfeited $900 million in federal aid for the Children’s Health Insurance Program over the last six years because it wouldn’t or couldn’t come up with 28 cents for each 72 cents that the federal government was offering.  The result?  Far more uninsured children per capita in Texas than in other states.  Texas has also had a population growth rate twice the national average since 2000, which has placed even more of a strain on an already ailing health care system.

Because of the sheer volume of uninsured people in Texas, emergency rooms are past the point of overcrowding.  Patients – both insured and uninsured – must often wait hours to be seen, since the uninsured often use emergency rooms as primary care facilities.  And the cost of treating those uninsured patients is passed on to the insured population.  According to a December editorial in the Waco Tribune-Herald, the average family’s health insurance premium is $1551 higher than it would be if there were not an uninsured population whose treatment becomes bad debt for hospitals.  Here’s the scenario – uninsured patients are treated in emergency rooms all across Texas (and indeed, all across the US, but more so in Texas) and the hospital doesn’t receive compensation.  So in order to keep from losing money, the hospital increases fees for everyone – the majority of whom are still paying, insured patients.  And when insurance companies have to pay more for services, they charge more in premiums.  So we’re all paying for the fact that Texas has such a large population of uninsured residents.