The ACP Advocate Blog

by Bob Doherty

Wednesday, January 15, 2014

What my auto accident taught me about Obamacare

Well, I’m back--with my first ACP Advocate blog of the year! After a very restful couple of weeks with my family, including a trip to beautiful (and warm) Key West over the holidays, I came back to the bitter cold (polar vortex, I’m told) gripping Washington, D.C. and most of the rest of the country. Then, just a little over a week into 2014, my new year started off with a bang--literally--as I got into an automobile accident that involved my car sideswiping another vehicle and then crashing my car into a tree at 30 MPH. The car was totaled, but fortunately, I (mostly) walked away from the accident with only a fractured sternum and bruising. Today, just a little over a week from the accident, I’m doing fine--back at work, only modest discomfort.   

I bring up my accident because it taught me some valuable lessons, which I think are applicable to the ongoing debate over the Affordable Care Act. As I blogged in the Philadelphia Inquirer last week, government regulation probably protected me from sustaining a much greater injury from my accident. I encourage you to read the entire post, but let me summarize the salient points: 


1. We all are invincible, until we aren’t. Accidents and illnesses can happen at a moment’s notice, whether you are a 57 year old like me, who always assumed serious auto accidents are something that happens to someone else because of my heretofore spotless driving record, or whether you are a 27 year old “young invincible.” When you get sick and hurt, you will need good health insurance, which I was fortunate to have through my employer, the American College of Physicians, but millions do not. Opting out of insurance coverage, at any age, is just plain dumb. 


2. We may not like it when the government infringes on our personal liberties by requiring us to buy products we think we don’t need, sets consumer safety standards for the products we buy that add to their cost, or requires or forbids us from doing certain things that can endanger us—but such mandates sometimes are necessary to protect us from greater harm. In my case, federal requirements that cars have seat belts, airbags, and front end collision protection likely protected me from far more serious injury, even death. Such mandates added hundreds, maybe thousands of dollars, to the purchase price of my car, but they were worth every penny when my health and safety depended on them. (If I had driven a “grandfathered,” older car that lacked air bags and other federally-mandated crash protections, I may not be here writing this blog today). My local government required that I buy auto insurance, another unfunded mandate on me. It required me to wear a seat belt and shoulder restraint system, another mandate to prevent me from doing something really stupid, driving without a seat belt. Sure, even without such mandates, I would have worn a seat belt and bought auto coverage on my own, but this unfortunately is not true of everyone on the road. 


3. So it is with Obamacare: the government requires us to buy health insurance, because having good health insurance is essential when you get sick or hurt. The government mandates that the health insurance that is sold to us meets consumer protection and benefit standards, like no pre-existing condition exclusions and coverage of essential benefits, so that the coverage actually helps us when we really need it—even if it means we have to pay more for it. Just like the government requires that the new cars we buy have safety features we may think we will never need or use, like airbags, until we do and are glad we have them. 


4. I am fortunate that I already had good health insurance coverage through my employer, but there are millions of uninsured persons that have had no access to health insurance, or only had access to inadequate plans sold on the individual insurance market—until Obamcare came along to set standards for the insurance industry and provide financial help so people could afford it. Contrast my experience last week with those who do not have good health insurance. Here is how I put it in the Philadelphia Inquirer blog: 


“Now, let’s think about what might have been the outcome for someone in the same circumstances as me, but without health insurance and with a much more modest income. Because this person didn’t have health insurance, he might have decided not to go to the ER, he might not have gotten the prescriptions filled because of the cost, making his recovery much more painful (believe me!). The hospital ER might have written off some of his costs by cost-shifting to people with insurance, but he still might have left with a huge bill. He might have missed more days of work without pay. And if his car didn’t have airbags and he wasn’t wearing a seatbelt, he could have suffered a catastrophic life-threatening injury. Now, consider the tens of millions of people who find themselves in the same circumstances but who lacked good coverage before Obamacare. They will now be required to buy and will get government help in purchasing health insurance that by law must include essential benefits. Their new coverage will also meet various consumer protection standards, like a ban on discriminating against people with pre-existing conditions and on lifetime and annual limits on coverage. The consumer protections in their new coverage will protect them from going bankrupt if they need healthcare. These safeguards may even be what keeps them alive. Many of them may not think they need this protection—until they do.” 


Now, I know that some readers of this blog will argue that it is “paternalistic” for the government to require that we buy health insurance that has benefits that we think we don’t need or want. I have argued that setting standards for health insurance companies isn’t really paternalistic, while my friend Dr. Bob Centor argues in his DB’s Medical Rants blog that it is. I will concede his point—government mandates that limit our personal choices or regulate the products we buy are paternalistic, to a point. But when I drove my car into a tree last week, it was government paternalism that likely protected me from greater harm, just like Obamacare’s paternalism protects us by requiring that everyone have health insurance that meets federal consumer protection standards, so that when we get sick or hurt (as we all will at some point), we have health insurance that helps keep us medically and financially sound. 


Today’s question: Do you agree with the lessons I drew from my accident on government’s role in mandating standards that can help keep us safe and sound, even if it limits our personal choices to some degree?

25 Comments :

Blogger Harrison Robinson said...

I don't know if I agree or disagree with all you wrote, but I'm very happy you are okay!
Welcome back.
Harrison

January 16, 2014 at 2:18 AM  
Blogger rcentor said...

First, very glad that you are feeling better and thanks for conceding my debating point on paternalism.
Second, as I stated, paternalism is not necessarily bad. Sometimes we need paternalism.
I believe the debate about some of the health insurance requirements are related to scope.
Clearly, everyone in a car has the potential for benefit from air bags. We all hope to not need air bags, but as you unfortunately learned, when they are necessary they lessen our injuries.
Some of the insurance requirements that raise the price do not have any possibility of helping the insured person. I believe that is the debating point.
The mandate is paternalistic and I agree with that mandate to a point, but the scope of requirements seems worthy of further debate.

January 16, 2014 at 8:25 AM  
Blogger Dr.Bob said...

You generalize. Airbags and seat belts work. Obamacare...

January 16, 2014 at 10:34 AM  
Blogger Duquesne Lacrosse Recruits Beware said...

I agree with rcentor in the balance needed. However, OC's cost shift is requiring zero value and high cost for many by mandating maternity care, substance abuse counseling, etc. From a consumer standpoint, no or low value at high cost simply won't work...unless the "paternalism" graduates to a mandated socialism. Two specific points: 1. What would you have done without insurance? You would have gone to the hospital, been treated, and released. The same as has been happening for a long time. You require insurance because you have assets that healthcare providers can go after. Those with little or no assets (young) bear little risk…no blood from a stone. 2. Want to save lives? Along the lines of airbags, a legislated, common sense mandate…save lives. My daughter was broad-sided on a dark, rainy morning by a driver without headlights on. Really? She’s okay…by inches…how about starting with that kind of common sense, pragmatic paternalism? Your plea for people to sign up for Obamacare just doesn't resonate.

January 16, 2014 at 11:02 AM  
Blogger Unknown said...

I'm sorry, but respectfully, you're letting your emotional involvement with surviving your accident in relatively good shape, cloud your judgement.

The crux of the matter is that in a free society, it should /never/ be possible for some subset of the population, to make "being just plain dumb", illegal. If you, I, 99.9999% of the rest of the people on the planet think something is dumb, it doesn't matter. In a free society, people are free to make (what we think) are dumb choices.

At the same time, in that free society it should never be possible for someone who makes a dumb choice, to obligate those who thought that choice was dumb, to pay for their stupidity.

As an aside, the "I'm mandated to purchase auto insurance" is a non-parallel construct. First, it's quite likely not true. In most states, if you can demonstrate sufficient financial reserves, you can declare yourself self-insured, and decline to participate in the shared-risk pool insurance mechanisms. More importantly, you're only obliged to have (purchased, or self provided) insurance if you choose to participate in driving an automobile on a shared-resource public road, where you, and society, by consensus, have agreed that insurance mandates are necessary. If you and other private citizens choose to build a private road, and not require insurance to operate vehicles on that road, you are entirely within your rights to do so.

The ACA, as implemented, would be the equivalent of mandating that you purchase highway-collision auto insurance, even if the only car that you own is a non-running Model T that you keep on display in a museum.

January 16, 2014 at 11:07 AM  
Blogger spike jones said...

I am pleased you came through your accident OK doctor. The problem I see with O-care is that it requires everyone to buy insurance, then sets prices as well. They overcharge the young healthy males to such an absurd level, we shouldn't be surprised that they opt for a retaliatory IRS audit. Alternative idea: require health insurance, then let the insurance companies determine prices. spike

GA Spike Jones PE, spike66@att.net

January 16, 2014 at 11:16 AM  
Blogger Duquesne Lacrosse Recruits Beware said...

I agree with recentor in the balance needed. However, OC's cost shift is requiring zero value and high cost for many by mandating maternity care, substance abuse counseling, etc. From a consumer standpoint, no or low value at high cost simply won't work...unless the "paternalism" graduates to a mandated socialism. Two specific points: 1. What would you have done without insurance? You would have gone to the hospital, been treated, and released. The same as has been happening for a long time. You require insurance because you have assets that healthcare providers can go after. Those with little or no assets (young) bear little risk…no blood from a stone. 2. Want to save lives? Along the lines of airbags, a legislated, common sense mandate…save lives. My daughter was broad-sided on a dark, rainy morning by a driver without headlights on. Really? She’s okay…by inches…how about starting with that kind of common sense, pragmatic paternalism?

January 16, 2014 at 11:16 AM  
Blogger Unknown said...

with or without insurance patients willget treated in the hospital. but it is better to have one so that you dont get charged for the services rendered to you while in the hospital. the hospital is always in the losing end here if a patient does not have health benefits (doc, nurse, housekeeping, transport, radio tech, CNAs, lab tech, etc). that is why alot of hospitals have been closing and merging for overhead expenses brought by people without health insurance. thanks to Obamacare, people can go see doctors for preventative care, and got to ER without fear of losing their bank accounts to pay for the services.

January 16, 2014 at 12:16 PM  
Blogger Bob Biles said...

The author uses a worthy analogy with the car seat belt situation, but I wonder if he would consider some different analogy? How about the government had mandated that he buy a Volvo, since they have been shown to be a 'safer' car...so the mandate is that every American, whether they drive or not, must own a Volvo! And in fact, the government will provide an incentive for certain people to purchase a Volvo, and will take money from more well-to-do Volvo owners to pay for the first Volvo! Analogies are most always situation-dependent and can go both ways.

January 16, 2014 at 12:20 PM  
Blogger DoctorJoe said...

If the ACA intended to solve the problem of uninsured Americans, then it could have been a fine act. The AFFORDABLE care act has already increased the cost of insurance for the vast majority of Americans, and will result in crippling inflationary costs for health care. Physicians will suffer. Hospitals will go under. 90% of Americans will pay a lot more for lesser care. The government is clueless on how to solve a problem without complicating it and compounding it. There are vast numbers of solutions superior to the ACA. The ACA was over 900 pages long. A tiny fraction of that is related to providing insurance for the uninsured. There are already over 4,000 pages (YES!) of regulations derived from the ACA. Does anyone really believe this is gong to be a good thing. I am sorry you wrecked your car. You seem to have drunk the Kool-aid in the E.R.

January 16, 2014 at 1:10 PM  
Blogger Lila said...

"We may not like it when the government infringes on our personal liberties by requiring us to buy products we think we don’t need, sets consumer safety standards for the products we buy that add to their cost, or requires or forbids us from doing certain things..."

The problem with this statement is that Constitutionally, these are NOT in the same category.

The Commerce Clause of the Constitution allows government to REGULATE commerce. So yes, they can set manufacturing standards for your car, and once you have bought a car, they can regulate how you use it.

However, they cannot legally force us to engage in commerce. We don't HAVE to buy a car at all.

Yes, I know that the SCOTUS ruled in favor of the insurance mandate, 5-4. They did so by inaccurately calling it a "tax." It is not a tax (and Obama himself said it is not a tax) because we are not handing our money to the government for disbursement into national budgetary requirements. We are handing our money to commercial entities in a direct client-customer relationship. Clearly, that is engaging in commerce.

Our outrageously expensive healthcare costs are the root cause of so many Americans being unable to afford either insurance, or out-of-pocket healthcare costs. The way to reform our system is NOT to simply force everyone to buy insurance; we must go after the high costs.

The provisions of the ACA that force insurers to accept and retain people with preexisting conditions or chronic illness are a good thing, but because insurance is a commercial venture, this will inevitably drive up the cost of insurance for everyone. Insurance companies are not there because they love you; they are there because they love your wallet.

January 16, 2014 at 1:50 PM  
OpenID thecoloroflila said...

"We may not like it when the government infringes on our personal liberties by requiring us to buy products we think we don’t need, sets consumer safety standards for the products we buy that add to their cost, or requires or forbids us from doing certain things..."

The problem with this statement is that Constitutionally, these are NOT in the same category.

The Commerce Clause of the Constitution allows government to REGULATE commerce. So yes, they can set manufacturing standards for your car, and once you have bought a car, they can regulate how you use it.

However, they cannot legally force us to engage in commerce. We don't HAVE to buy a car at all.

Yes, I know that the SCOTUS ruled in favor of the insurance mandate, 5-4. They did so by inaccurately calling it a "tax." It is not a tax (and Obama himself said it is not a tax) because we are not handing our money to the government for disbursement into national budgetary requirements. We are handing our money to commercial entities in a direct client-customer relationship. Clearly, that is engaging in commerce.

Our outrageously expensive healthcare costs are the root cause of so many Americans being unable to afford either insurance, or out-of-pocket healthcare costs. The way to reform our system is NOT to simply force everyone to buy insurance; we must go after the high costs.

The provisions of the ACA that force insurers to accept and retain people with preexisting conditions or chronic illness are a good thing, but because insurance is a commercial venture, this will inevitably drive up the cost of insurance for everyone. Insurance companies are not there because they love you; they are there because they love your wallet.

January 16, 2014 at 1:53 PM  
Blogger nvhorseman said...

Every point you brought up is proof that all the BS that those who shout "PATERNALISM" are most likely those that don't want to release their paternalistic characteristics. Society and its safety must move forward. We must progress or be left behind by those that do. We are already behind the eight ball in so many social areas and the plight of the average American Middle Class Taxpayer and the marginalized can no longer be avoided. Government action that HELPS people is good government. Government that gives preferential treatment to certain groups, without societal benefit, is bad government, no matter what group you are talking about.

January 16, 2014 at 1:58 PM  
Blogger bicfj said...

I totally agree with everything you say and in addition I believe that private insurance companies should be removed from healthcare altogether.

Between cherry picking clients for profit and manipulating the care provided to clients also for profit, private insurance companies have obstructed good health care and manipulated congress, also for profit, just about damn long enough.

January 16, 2014 at 2:28 PM  
Blogger bicfj said...

I totally agree with everything you say and in addition I believe that private insurance companies should be removed from healthcare altogether.

Between cherry picking clients for profit and manipulating the care provided to clients also for profit, private insurance companies have obstructed good health care and manipulated congress, also for profit, just about damn long enough.

January 16, 2014 at 2:30 PM  
Blogger Unknown said...

Yes, I whole-heartedly agree with your well-written article... and I am glad that your government-mandated air bag protected you from more severe harm. Thanks for the reminder that yes, we DO need regulations and we DO need health insurance!

January 16, 2014 at 5:22 PM  
Blogger ryanjo said...

Also wishing you a fast recovery. If only Obamacare was as certain as seat belts and airbags! Imagine if you purchased your car, and discovered that the safety features only worked after you paid "the deductible" -- thousands of dollars in payments. And even then, there were few mechanics available to do the work. But at least you have a car...kind of.

January 16, 2014 at 7:48 PM  
Blogger hj reynolds said...

Glad you are doing well after your accident. I was wondering why your health insurance is covering the medical bills. My personal experience has been that my medical insurance declined payment for an auto accident deferring payment to my auto insurance company. I do agree with you that Obama Care is necessary and good for us.

January 17, 2014 at 7:31 AM  
Blogger PCP said...

I disagree with most of what you have to opine on the topic. My profession and its standing are falling everyday as a result of it.

I wish you the speediest recovery.

January 18, 2014 at 11:32 AM  
Blogger Levelheadedness said...

I agree with the author that government requirement to purchase insurance is necessary. I view the requirement itself (not just the penalty) and the related premium cost of a health insurance policy as a form of taxation, which taxes' use is specific to insuring a society's health (at least for those participating in the single nationwide insurance pool even if it is comprised of separate statewide insurance pools).

Unfortunately, doctors are not well versed in subjects such as insurance pricing and statistics and, therefore, do not appreciate that the core of the health insurance reform in Affordable Care Act (aka Obamacare) is a public policy to ensure that financing is available to treat existing acute and chronic conditions as well as to ensure that future events of sickness and accidents are financially covered. Without a mandate requiring purchase of insurance, no AFFORDABLE coverage for medical ailments that a person already has...e.g., any of a variety of chronic conditions... is possible. Unfortunately, most people commonly think of emergencies and acute episodes such as this author's car accident when they think of a need to have health insurance. However, the need for health insurance is actually far more critical for present and future chronic health conditions.

January 20, 2014 at 4:51 PM  
Blogger Levelheadedness said...

I agree with the author that government requirement to purchase insurance is necessary. I view the requirement itself (not just the penalty) and the related premium cost of a health insurance policy as a form of taxation, which taxes' use is specific to insuring a society's health (at least for those participating in the single nationwide insurance pool even if it is comprised of separate statewide insurance pools).

Unfortunately, doctors are not well versed in subjects such as insurance pricing and statistics and, therefore, do not appreciate that the core of the health insurance reform in Affordable Care Act (aka Obamacare) is a public policy to ensure that financing is available to treat existing acute and chronic conditions as well as to ensure that future events of sickness and accidents are financially covered. Without a mandate requiring purchase of insurance, no AFFORDABLE coverage for medical ailments that a person already has...e.g., any of a variety of chronic conditions... is possible. Unfortunately, most people commonly think of emergencies and acute episodes such as this author's car accident when they think of a need to have health insurance. However, the need for health insurance is actually far more critical for present and future chronic health conditions.

January 20, 2014 at 4:53 PM  
Blogger Harrison Robinson said...

If we are required to pay a part of our income to the government, that is pretty much recognized as a tax.
If however we use part of our income for personal business expenses, that part of our income is not taxed. If we sent part of our income to a charity that part of our income is not taxed.

The ACA requires the purchase of health insurance, but if we don't buy it we have to pay money to the government.

Another way to think of this is that the money used for purchasing health insurance results in sending less of our money to the government.

How is that not a tax, with the purchase of health insurance operating as an exemption?

Chief Justice Roberts identified this as a tax.
I don't think that the argument behind this can be easily dismissed.
And it is now the law.

Harrison

January 21, 2014 at 9:29 AM  
Blogger Unknown said...

@levelheaded…

Clearly, a great number of people believe, as you, that spreading the cost of existing problems to other people, is "insurance", but this mis-use of the term is a large part of the disagreement.

"Insurance" is a shared-risk mechanism to cover unlikely, unforeseen events, wherein a group of people who are individually unlikely to suffer an adverse event, pool together to collect sufficient funds such that if one does suffer the event, the are not financially ruined. In any sane society it is a voluntary mechanism, and one's choice to participate in the risk-sharing pool, is based on one's own calculation of costs vs benefits.

What you're calling "insurance", shared payment for existing, rather than unexpected costs, is not "insurance" - it's medical care cost sharing, and should no more be a part of "health insurance", than paying for gas and oil-changes for your car, should be a part of automobile insurance.

January 21, 2014 at 11:31 AM  
Blogger Robert J. Sobel, M.D. said...

Bob,

I hope the recovery is going smoothly. The analogies you outlined have certainly stirred quite a spectrum of comments. The manufacture of automobiles has its parallels, but only to aspects of the health care pie. We are an amalgam of professional services, pharmaceuticals, radiologic tests, procedures, and hospital infrastructure. Furthermore, we are financed through direct pay, employer-based insurance, the individual market insurance, and public insurance. We have created layers of bureaucratic structures to respond to perceived and real perversions in pricing brought about by the nature of health care needs and the interposition of the third party.

In light of this hodge-podge, it still appears hard to develop a truly applicable analogy. Maybe that is why we can put forth such diametrically opposed points of view.

I look forward to you leading more discussion as we move forward in the new year. I still think we can agree that redundant and conflicting bureaucracies could be eliminated.

January 21, 2014 at 7:28 PM  
Blogger ryanjo said...

Speaking of government infringing on our civil liberties, interesting report today about persistent security issues with Healthcare.gov:
"TrustedSec's chief executive David Kennedy...
was able to discover at least 70,000 records with personal information including full names, addresses, user names, and in some cases, social security numbers, just by using an advanced Google search." (http://www.electronista.com/articles/14/01/21/using.advanced.google.search.users.private.information.from.site.accessible/#ixzz2r5ZbW6nA)

Just signup with Obamacare and get your Rx filled at Target for one-stop identity theft.

I can't wait until some ACA body starts rolling out the practice criteria we all need to follow. I'm sure it will be the same quality work.

Still waiting for that ACP post about regret for cluelessly hawking Obamacare. Title it "Shame".

January 21, 2014 at 9:16 PM  

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Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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