Thursday, May 04, 2017

My Healthcare Story

The House of Representatives, in a razor-thin 217-213 vote, has voted to repeal and replace Obamacare with the AHCA. The crucial amendment to get conservatives onboard was to allow states to eviscerate the protections for patients with pre-existing conditions.

I've mentioned before on this blog that I've suffered from kidney stones. Right now I'm in the process of doing some tests to figure out my risk factors and what, if anything, I should change in my diet or lifestyle to make them less likely (since, as Rep. Mo Brooks (R-AL) was so quick to remind us, any health problems I have are evidence of nothing more than my own degraded character). That's how it should be: when I'm sick, the focus should be on getting me better. My health care should be a conversation between me and my doctor. My investment advisor shouldn't need to play a role.

But the advent of the GOP vote has, of course, made me worry about whether kidney stones qualify as a "preexisting condition." After all, I'm not going to stay at Berkeley forever. So what would happen to me if I need to switch insurance or -- worse yet -- lose it altogether?

Kidney stones aren't the most expensive condition one can have, but they're not nothing either. Since they onset completely unexpectedly, they can send you to the emergency room at the drop of a hat. And they sometimes require surgery to remove (as mine did -- more on that below). My best guess is that it's unlikely that I'd be denied coverage altogether because of my past history, but it's possible that a new plan would exclude coverage for any future stone-related problems. Which sucks, because kidney stones are scary enough without having to worry about how to pay to treat them.

One argument one occasionally hears about foisting more costs onto sick patients is that it gives us additional "skin in the game" that inspires us to make better and more cost-effective choices. So I figured I'd offer a story on that front, because I don't think that makes any sense at all.

As I said, I recently had surgery to remove my kidney stone. But I almost didn't. Kidney stones are strange in that they can lie dormant for awhile -- lulling you into a false sense of security -- before roaring back to life and causing agonizing pain. This is particularly nettlesome because, especially with a smaller stone, it's possible to pass them without realizing it. So if you go through several months with no pain, is it because the stone has passed or is it just playing possum?

My stone was about 4 millimeters, which is on the small side. My urologist told me that a 4 mm stone will pass on its own about 70% of the time. I had been having attacks of pain about once every 1.5 - 2 months since the fall, and it did not seem to be passing on its own. So after the latest bout of pain in January, we scheduled me for surgery in March -- with the caveat that if it passed before then, we'd cancel the surgery.

The weeks pass, and I'm feeling fine. I didn't notice it pass. But again, I knew sometimes they pass without you noticing. Certain elements of how the stone had been progressing in prior bouts of pain made it plausible that the last bout really was the last bout. We did an X-Ray to see if we could pinpoint the stone inside me, but it was inconclusive. My urologist pointed to a vague spot and said maybe that's the stone ... but maybe it's nothing. X-Rays aren't actually all that good at picking up kidney stones. And unfortunately, there wasn't any safe way to know for sure if the stone was still inside me other than simply doing the surgery.

As we approached the day of the surgery, I asked my doctor if he thought we should go through with it. It was not implausible that the stone had already passed, after all. Moreover, I'd never had real surgery before, and was a bit nervous. The procedure entailed full anesthesia, followed by threading a scope up my urethra, into my ureter, and blasting apart the stone with lasers. They'd leave a stent inside me to handle residual bleeding, and that would be removed in about a week. Objectively, it's not so bad -- but you can imagine "having a tube stuck up my dick" isn't exactly on my bucket list, either. And how silly would I feel if I had the surgery and it turned out there was no stone at all!

The doctor listened to me. And he said that it was, indeed, possible that the stone had already passed. We could simply wait another couple of months and see what develops. The problem with that was (a) he still thought it was more likely than not that the stone had not, in fact, passed and (b) there's no guarantee that if I had another attack, they'd be able to schedule me for surgery promptly. Ultimately, his recommendation was to go through with the surgery as planned.

So I did. And when I woke up, I was told that yes, the stone was inside me, and they had successfully removed it. Moreover, he told me that the stone would have never passed on its own. My ureter was significantly enflamed and swollen around where the stone had nestled; it had gotten so narrow that it was physically impossible for the stone to go any further (I gather things were so tight in there that it had also made it no easy thing for the surgeon to even reach the stone with his laser. Good job, surgeon!).

All of this is run-up to the following: My kidney stone surgery cost me, with insurance, a little less than $1,000. That's not chump change. But without surgery, it would have cost closer to $10,000. That's more than a third of the annual salary of your average Berkeley grad student. Had I been paying that money out of pocket, I almost certainly would have ignored my doctor's advice and delayed the surgery. Which, as we now know, would have been the wrong decision. How wrong? I'm not sure -- I thankfully do not now need to know exactly how dangerous a badly enflamed, swollen, and rapidly narrowing ureter might have been.

In short, the only thing having (more) "skin in the game" would have done for me is caused me to have made the wrong medical decision. Because I'm not a doctor. I have no medical expertise. I'm not in a position to make smarter medical decisions just because I have to pay more for them. The most likely result of my having to pay a ton of money for medical expenses is me making bad medical choices. Thankfully, because I had insurance I made my choice for the right reasons -- the sound, professional advice of my specialist doctor who actually knows how kidneys work. And thank goodness for that.

In any event, now I've had kidney stones and kidney stone surgery, which means I may well be in "pre-existing condition" land (albeit far less so than, say, a cancer survivor). Which means that in the GOP world, it's quite plausible that if I leave Berkeley (which I no doubt will) and have to change insurers, I may no longer be covered for at least this particular medical problem. If my kidney stones come back, I won't be able to concentrate on, say, getting emergency pain relief or whether I need another surgery.

My friend Josh Blackman says there is a "contradiction" around the discourse re: pre-existing conditions: nobody wants to exclude them, until people learn that including them increases costs. Which, Blackman says, of course they do -- there's no such thing as a free lunch. I'd note that there's an ambiguity here: requiring coverage of pre-existing conditions doesn't necessarily increase costs so much as it redistributes them -- at least in a system where one can't opt-out of the medical system altogether (and here I'm talking less about a mandate and more about guaranteed access to emergency care. Unless we switch to a system whereby uninsured people are left to die in the streets, we're still "paying" for their healthcare). Persons who are relatively healthy pay a little more so that persons who are very sick pay a lot less, but the overall cost doesn't change (a simplification, of course, but it will do).

As it happens, even with this particular pre-existing condition I don't know whether I-as-an-individual am a net gainer or loser in the protect-preexisting-conditions world (other than kidney stones, I'm a relatively young and healthy man). But either way, I'm absolutely willing to pay my share so that I and others like me -- or not so like me -- can have the healthcare that they need. It strikes me as beyond petty for me to resent the possibility that others might "use" the benefits of health insurance more than I do. I should be so lucky! The best thing that could happen to me is for me to never again have reason to access the benefits of my health insurance other than routine checkups and peace of mind. But if I happen not to be so lucky, then I'll be grateful that I'll get the care that I need to survive and thrive.

There are many, many people for whom the AHCA will impact far more severely than me -- from cancer survivors to persons needing organ donations.to victims of sexual assault. These people will see their lives made much worse if the AHCA passes.

But there are a lot more Americans for whom the AHCA "only" will make our lives a little worse. A little scarier. A little more insecure. A little more unknown. A little less protected.

I had hoped we could beat the AHCA in the House. But House Republicans were determined to pass a bill they didn't fully understand, whose provisions  had not been scored by the CBO, and from whose dictates they exempted themselves. We have 18 months to make them pay for their hubris.

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