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David Katz, M.D. Headshot

For Whom the (Health Care) Bill Tolls

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It comes down to this: people who can't afford health insurance don't get any. People who can't afford health care get it anyway when life or limb is on the line.

Insurance companies generally make decisions when all is relatively calm. Even a time of crisis for an insurance company is a slow-motion crisis, such as deciding whether to cover on-going cancer treatment. It lacks the urgency of a bullet hole to the chest, for the insurance company if not the patient.
Rarely, if ever, do people writhe, retch, seize, or bleed on an insurance company's floor. But they do exactly that in ambulances, ERs, and ICUs every day. Insurance companies enjoy the luxury of saying 'no.' Hospitals do not.

My lab, and my practice, are located in Griffin Hospital in Derby, CT. Griffin is a Yale-affiliated, not-for-profit, community hospital. It is also a model for its industry, with no offense to any others that are as well.

Griffin routinely achieves almost unprecedented marks for patient satisfaction; it routinely bests its peer group for clinical benchmarks; it has, traditionally, done well financially; its inclusion among Fortune's '100 best companies to work for' has become little less than an annual tradition; and it is the international headquarters for Planetree, an organization dedicated to patient-centered care that routinely attracts delegations from around the world to see how it's done. Not too shabby for a fairly small hospital in one of the smallest cities in one of the smaller states in the US.

But my hospital -- my well-run hospital -- is now hurting. Confronted by the recession that we all know is a difficult burden, and the failure to reform health care which some but not all of us recognize as fiscally toxic -- my hospital is hurting. I am confident Griffin will weather the storm successfully. But the challenges and strains are considerable, and undeniable.

Leaving aside this particular patient and its particular prognosis, let's talk about the pathology. Our health care system is what's sick. The rest is just the inevitable contagion that occurs when a spreadable malady is not treated at the source.

Those writhing, retching, seizing, bleeding patients get treated. Thank goodness, despite the egregious deficiencies in our approach to healthcare, for all that make us the stand-out disgrace among civilized countries, we don't just leave people to bleed in the street. Our common humanity kicks in, and they get treated -- even if they have no insurance.

They get treated if they are poor. They get treated if they are not poor, but self-employed and uninsured. They get treated even if they are unemployed. They get treated if they can't afford their co-pay or deductible. They get treated even if the charges will drive them to bankruptcy. They get treated in an emergency no matter what, and the bill comes later.

But when it does come due, it doesn't get paid. So hospitals -- which have to say yes when insurance companies say no -- simply have to absorb those costs. In what other industry do you have to provide services to those who can't pay for them? How can healthcare be treated like any other 'commodity,' when its 'manufacturers' are obligated to give it away for free?

Hospitals may try to pass their unpaid bills on to the rest of us by charging more for their services than they otherwise would. These charges are passed along to insurance companies which, of course, pass them back to us. Are you worried about paying for the care of the uninsured out of your taxes? You are paying for that care right now out of your insurance premiums.

And, since the uninsured and under-insured don't seek discretionary care, but rather wait until they have no choice because they are in a real crisis, the care you (and I) are paying for is ... lousy. We pay to manage a crisis that need never have occurred if only earlier, discretionary, preventive care had been provided. But that doesn't happen, because nobody is paying for that. So the uninsured and under-insured wait for a crisis -- and the huge bill that comes along with it. And then all of us pay that bill.

It's a tax, but not called a tax. It's a tax over which we have no control, a tax not subject to our vote, a tax that is insidious, invisible, and unidentifiable. And, it's a tax that pays for the worst possible kind of care -- crisis intervention for preventable crises. And, yes: it is taxation without representation (unless you have a friend on your insurance company's board of directors who cares about representing you).

Remember the direct cause of the original 'Tea Party' in Boston? Taxation without representation! Health care premiums bloated by the unpaid bills of the uninsured are a tax, and you are paying it now.
For better or worse, insurance companies have more than one means to deal with hospital charges. They can, up to a point, pass those expenses on to us. But their other option is simply to refuse to pay them in full. Hospitals charge Y, and insurers pay X. Once again, hospitals are left to absorb the difference. Why? Because they don't have the luxury of telling a patient retching, writhing, seizing, bleeding up to 'Y' to just knock it off when they get to 'X.' "You've met your insurance company's quota for hemorrhaging -- stop bleeding now!" doesn't seem to work.

The so-called health care system in this country is a travesty, a daily violation of human rights, a quintessential example of taxation without representation, a farce, a tragedy, a national embarrassment. It kills people daily. Sometimes, it also kills hospitals. And if it kills a hospital that was doing a good job, it kills even more people.

If you are worried about taxes and the costs of health care reform, you should ask yourself for whom the current unpaid healthcare bills toll. They toll for thee.

Dr. David L. Katz;

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