Of all the books I’ve read in the last few years knowing I’ll probably disagree with the author’s conclusions, Jonathan Cohn’s new book Sick is easily the most enjoyable. Cohn writes clearly and with compassion — one cannot help but feel for the people whose struggles with the American health care system Cohn so masterfully chronicles.
Cohn captures the reader in the introduction by recounting the tragic end of Bostonian Cynthia Kline. Kline, suffering a heart attack, needed a procedure for unclogging an artery known as a cardiac catheterization. To obtain this procedure she needed to go to the emergency room at Mount Auburn Hospital. Yet on the way to Mount Auburn, the ambulance driver was informed by a dispatcher that the emergency room was overflowing and had no room for new patients. Kline was diverted to Cambridge Hospital, which was not set up to do catheterization. Sadly, Kline’s heart deteriorated rapidly and barely two hours after she called 9-1-1, and despite the best efforts of Cambridge’s doctors and nurses, she died.
Later in Sick, Cohn claims that “the forces pushing health care out of reach for Americans [are] the decay of employer-sponsored insurance, the spread of managed care, the commercialization of private charity institutions [and] the overloading of strained public programs.” However, it is not always apparent how these forces are related to the stories Cohn relates. It is quite possible that he has misdiagnosed the problem with our health care system.
Reconsider the case of Cynthia Kline. It’s not clear how the factors that Cohn cites resulted in an overcrowded emergency room at Mount Auburn. Kline, a schoolteacher, presumably had insurance. Massachusetts spends more on a public program like Medicaid than all but 14 other states. And despite managed care and commercialization, per-capita health care spending in the Bay State is about one-third higher than the national average. So why was the Mount Auburn emergency room overcrowded that fateful day?
A likely explanation is a law Congress passed in 1986 called the Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA requires that “Any individual who comes to a hospital requesting an examination or treatment for a medical condition must receive an appropriate medical screening examination within the capability of the hospital’s Emergency Department.” In short, emergency rooms are now magnets for those seeking free care. Is it any wonder, then, that emergency rooms now have a “tragedy of the commons” quality, overcrowded to the point that some of those with true emergencies, like Kline, will suffer?
Kline’s plight is not the only one in Sick that is the unintended consequence of government policy. Gary Rotzler, an engineer in upstate New York, lost his job in the early 1990s. Although he later found another good job, his new employer classified his as “temporary,” which did not qualify him for health insurance. Gary tried unsuccessfully many times to be reclassified as “full-time” to qualify for insurance. This would have tragic consequences, as his wife Betsy put off seeing a doctor when she had what were the early signs of cancer. She would later succumb to the disease, leaving Gary with big medical bills.
What Cohn doesn’t say is whether Gary ever tried to buy insurance on the individual market. Presumably, with a wife and three kids, he did try. What he probably found was some of the most expensive insurance in the nation. In 1993, the state legislature in Albany imposed community rating and guaranteed issue laws on the individual market, laws that force insurance companies to charge everyone an “average” premium and issue a policy to anyone who requests one. These laws tend to chase younger and healthier people out of the health insurance market since the average premium is more than what they would pay in an unregulated market. Those remaining in the market tend to be older and sicker, which drives the price of insurance much higher. Shortly after New York imposed these laws in 1993, insurance prices in parts of the market jumped between 20 and 59 percent.
In the last chapter of Sick, Cohn notes, “By the early 1980s, nearly 90 percent of Americans had some form of health insurance….Now, the evolution is running in the reverse.” Since the early 1980s, the federal government has, in addition to EMTALA, imposed COBRA, STARK I and II, HIPPA, and the State Children’s Health Insurance Program on the health care system. It also changed Medicare’s payment policy, which had a huge effect on making hospitals more cost-conscious. On the state level not only did some states impose community rating and guaranteed issue, most states also expanded their Medicaid programs and enacted numerous benefit mandates that require insurance companies to cover specific medical conditions. Yet the impact that increasing government involvement in the health care system has had on the cost of health care and health insurance is not a topic Cohn explores.
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H/T to National Review Online