HEALTH CARE/Joan Retsinas

A Guide to Chimera-Land

The dinosaurs seem trivial. They ate, slept, killed, wandered – but remained in their distinct shapes. Even Goliath was no big deal – a large monster, but recognizable. David could see his foe.

Today our landscape swarms with chimeras – multi-headed, many-armed creatures that grow heads, devour, spin off, grow more heads. Consider: Altria, initially Philip Morris, used to own Kraft Foods, which owned General Foods – until it spun them off. Chemed owns Roto-Rooter, as well as hospices. General Electric owns television stations. Newspapers belong to “media” conglomerates. Some chimeras live in cyberspace: we can’t see them, measure them, confront them: they hover, blanketing us without smothering us. And the descriptive indices we normally use – like price earnings ratios – don’t apply. Think Amazon, Uber, Facebook, Ebay, Google.

Healthcare is just as chimerical. CVS wants to buy Aetna. CVS already houses Minute Clinics. Supermarkets sell pharmaceutical drugs. Hospitals own visiting nurse associations, hospices, and physician practices. Now some hospitals plan to manufacture generic drugs. Walmart doesn’t yet — yet — own physician practices, but it sells pharmaceutical drugs and medical supplies.

Today Amazon, Berkshire Hathaway, and JPMorgan plan to morph into healthcare, as a nonprofit insurer/provider to their employees – a new amalgam that will dwarf the others.

We live in a time of giants. We need a guide.

1) Recognize that the good old days were not so good. Whatever nostalgia we harbor, the past was not idyllic. Remember huge swatches of the nation uninsured, rising costs, and dismal results. To recite a trite-but-true factoid, we Americans pay more capita for health, yet are less healthy, than our European counterparts. Do we want to retreat back 10 years? 20 years? I don’t think so.

2) The latest wrinkle is not truly old. Employers have historically been central to health insurance in this country. The first Blue Cross plan arose when the Dallas School Department joined with a local hospital to offer pre-paid hospital insurance to teachers. The Dallas newspaper followed suit. Employers wanted to give their employees a benefit; the hospital wanted to fill empty beds. The government encouraged this union by allowing healthcare to be part of labor negotiations, by authorizing payroll deductions, and by allowing tax deductions. The alternate insurance was an indemnity plan, sold to individuals, that paid out money, not hospital-days. Eventually Blue Cross plans grew too expensive for some employers, who responded with the early Health Maintenance Organizations. Indeed, today most large employers “self-insure,” using insurance companies as third-party administrators.

3) Rising costs are a crisis for all of us. People insured via their workforces pay for health insurance, but, given the tax deductions, they don’t recognize that “premiums” constitute part of their wage-package. Co-payments and deductibles, moreover, have soared, even for stellar policies. This Administration’s zeal for Model T policies (axing the “standard benefits” package of Obamacare) will leave many enrollees with higher out-of-pocket bills. The costs for drugs in particular have risen. We can expect greater increases: Medicare beneficiaries will soon see a return to the much-feared “doughnut hole.”

4) The traditional ways to cut costs have not made us healthier. To date, the cost-cutting has focused on two tacks. First: cut utilization. Make us see our physicians less, make our physicians order fewer tests, refer us less often, reduce our hospital stays. “Less” care is the mantra, coupled with initiatives to make us healthier. Those admonitions to buckle up, stop smoking, and eat vegetables are supposed to reduce the nation’s healthcare tab. Second: reduce providers’ incomes — though the rise of for-profit entities, with executives taking home multi-million dollar bonuses, has negated that tack. Uncle Sam, where bureaucrats earn bureaucrat-level salaries, has also tried to tamp down the money going to physicians, hospitals, and nursing homes.

5) The new way – maybe call it the Aetna/Hathaway/JPMorgan tack – is to cut the middle men – the agents, the pharmacy benefits managers, the cadres of insurance employees. The United States does not have one-payer universal health insurance, but the microcosm of these three companies will approach that model, for employees.

We don’t know what the future Berkshire/Amazon/JPMorgan chimera will do. Speculation abounds. Will costs plummet for employees? Will “quality” soar? Will other companies follow suit, blending into this chimera? Will “healthcare” evolve into a for-profit subsidiary of the very profitable producers?

We must watch. As Teddy Roosevelt noted, big industry’s drive for gain may easily squelch the public’s welfare. When the country passed the first pure food law, Roosevelt called it “a recognition of the fact that the public welfare outweighs the right to private gain.” The government, on behalf of us, should monitor this new chimera. The goal is two-fold and clear: lower costs, with better care. Will the Berkshire/Amazon/Morgan deliver? Our government has shown little interest in these goals; maybe this chimera will deliver.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, March 15, 2018

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