Healthcare and Long Term Care Divides

The following information is from Chapter 17 in one of my latest book, Breaking Point: A Boomer's Guide to Protecting Health and Navigating Healthcare.

Polarizing forces within the healthcare and long term care systems have pushed against one another for decades. Arguments around costs, inclusions, exclusions and access all arise from one question: Who will pay? Will it be government controlled healthcare for all (which some call socialism) or market-driven services for some; the “some” meaning people who can afford them.

The United States remains the only industrialized country that does not offer basic health care coverage for its citizens. It pays for some healthcare for certain populations such as veterans, elders and the indigent. This reality results in a maze of hybrid models such as VA system (operated and paid for by the federal government), Medicare programs (government sponsored and privately operated) and market driven approaches (privately run and insured). Some industries are regulated, some overregulated and others with no regulation at all.

Until we as a nation decide that health care services are a basic right (paid through taxes) or a true market-driven system (bought and paid for in private markets), these debates continue.

The Debate of Healthcare for All

Healthcare is not a basic right as both federal and state governments have racked up tremendous debt—debt driven largely by unfunded health care costs through their Medicare and Medicaid programs. The United States funds its Medicare and Medicaid mainly through taxes and borrowed money, which is an unsustainable approach. Without changing these practices, our country will actually go bankrupt.

For healthcare to be a right, our individual and corporate tax rates would balloon to pay for it, and many people and businesses do not want it to happen. Remember, nothing is free and there is a cost to everything. So why have healthcare for all?

Advocates agree that it reduces the risk of a personal financial crisis as healthcare costs are the number one cause of personal bankruptcy; it implements price controls which lower costs through negotiation; it improves the ability for businesses to compete in global markets by removing the cost of employee health insurance coverage; and it ensures continuing coverage for citizens if they lose their job or in national emergencies such as a pandemic.

The Debate of Healthcare for Some

Healthcare is not a market-driven commodity either. A consumer-driven market implies that consumers (that's you and me) shop and compare price and value before making any decisions. Yet, as patients we are not consumers. We do not purchase health care services; we purchase health insurance and then we are on our own as we enter a maze of copayments, deductibles, and inflated bills that follow no financial principles.

Emily is a 62-year-old woman who had coverage through her employer when she was laid off during the pandemic. She has three years before she can qualify for Medicare and makes too much money to receive her state’s Medicaid. She has diabetes, arthritis, and high cholesterol. Her options are to enroll in COBRA ($1150 a month), purchase an insurance policy on her own through her state's health exchange ($850 a month), go without insurance (she is scared not to have coverage), or find another job that offers health insurance (at 62, this one could be a challenge). A month after her layoff, she was in a car accident and ended up in the emergency room, unconscious. This type of scenario plays out daily across the country.

One major difference between the United States and all other industrialized countries is other nations have set forth a purpose and goals for their health care systems, while the United States has no purpose or specific goals for healthcare. As it’s not a guaranteed right, it defaults to hybrid, market-driven chaos. Either we fund health care services through higher taxes, or we turn it over to private markets to sell directly to consumers without government intervention.

Healthcare services have many moving parts within three distinct and diverse segments: health (personally driven and ongoing), healthcare (medically driven and short term) and care (custodially driven and long term); none of the services and payment methods are connected or coordinated. Let’s take a closer look at the key differences:

Health, Personally Driven

This segment is how we live our daily lives, choices we make, exercise we do or do not get and foods we eat. Additionally, where we live makes a different in terms of clean water and air as well as the safety of our environments. Personal health is as much about where we live (zip code) as our family history (DNA code).

Personal health also depends upon public health surveillance systems that routinely detect threats, such as a food poisoning or other outbreaks and respond to crises such as pandemics. Most of these public health services are government driven and paid for by federal and state taxes.

Healthcare, Medically Driven

Healthcare services must be medically necessary for any insurance to pay. Healthcare services are the most expensive and wrap around short term services in hospitals, within physician practices, and with other community-based industries such as home care. These services have a beginning, a middle and an end point with payment and insurance coverage defined and based upon “medical necessity.”

Medical necessity describes a person’s need for specific types and intensity of medical and healthcare services and must be justified by a qualified healthcare provider before health insurances pay up. Medical necessity drives the how long insurance payments continue or if they pay at all. If this concept is hard for you to understand, know that many healthcare professionals also have difficulty understanding it. Yet, this fine line of medical necessity becomes quite visible when the financial shock of unpaid services becomes your reality.

Care, Custodially Driven

Long term care services address ongoing, chronic care needs resulting from medical conditions such as dementia, heart disease or Parkinson’s disease—medical conditions that disable a person’s ability to care for himself. These conditions develop slowly and do not have an end point. In the United States, healthcare insurances do not cover these types of care needs (bathing, dressing, incontinence, etc.); therefore, the cost of these services is picked up by individuals and families through private pay dollars.

Long term care insurance pays for some of the costs but not all of them. To qualify for Medicaid, a person with any wealth must spenddown assets until he or she is at poverty level. Once extremely poor, then the state funds this care through their Medicaid programs (taxpayer dollars).

So with multiple segments and varying rules and regulations, you can see why you need a guide and in fact should be guaranteed a guide before you say or sign anything. Citizens are guaranteed representation to advocate and navigate the complicated array of judicial services and systems; healthcare and care services are equally if not more complex. That is why we need guides who know what they are doing and can be a resource through the health, healthcare and care mazes. We need healthcare Miranda Rights!

Healthcare Miranda Rights

You have the right to remain healthy and unharmed. If you give up that right, anything you say or do can cause you physical, financial, and emotional harm. You have the right to a qualified advocate; if you cannot afford an advocate, one will be assigned to you at no cost. Do you understand these rights as I’ve read them to you?