HEALTH CARE

Reflections of a Small Business Nobody

August 15, 2009

He’s been with the company for 28 years, has never missed a day of work, and took reasonably good physical care of himself.  He was a member of our company plan and then had a stroke. The stroke was the most common, an ischemic stroke in the left cortex of the brain which affected quite dramatically the right side of his body, his prominent side, as well as interrupting the billions of communiqués between the co-equal and vastly different left and right hemispheres of the brain.

In short he could not tie his shoes, pull up zippers, manage buttons, chew food on the right side of his mouth, speak, inhale or exhale fully, read, walk, or stand without pain, dial a phone number, type, hold a bar of soap, or shave.  Most of these systemic failures would dissipate after months of self correction thru therapy or lessen in their dramatic impact on his life. But rehabilitation which he concentrated on in peculiar ways would take many months and likely years.

For all the rest of the chickens in our company health care plan, this single employee, after his stroke would cost all of us a whole wad of cash. Due to his illness, our company premiums across the board were increased by fifty percent. (More about him later).

Our plan was already high cost.  As our employees grew of age, we have little turnover, the risks increased for coverage. Like ageing cars, our values were worn, the electrical systems recalcitrant, and our undercarriages were starting to show rust.  Not good!  Attention to all drivers over 50, “DRIVERS, start your colons.”

Add to our aging demographics (our little grouping of 20)  to the next generations frantic life styles and the following generation in their  unlimited expansion of being (obesity) and one can deduce why health care costs are increasing and likely to do so for some while.

By maintaining an environment where people stay, oddly we suffer by having an insurance plan which is more costly making us less competitive with our peers who view turnover of employees as a plus to the bottom line. National retail chains our competitors offer health care packages but have employee turn over rates in the 70% per annum. They insure air and promises, not actual people.

Of course all of our costs are built into the cost of goods that we supply, but every business owner of whatever size avails themselves to the market and  what we can freely pass on to the customer and remain competitive is clearly limited: So much for passing through the costs.

But even with loyal long term employees and what we think is a pretty good plan, we have too many who refuse to sign up.  They cite the cost as one reason but the principal reason for not joining is that “no one buys health insurance so why should they?” They take the view that healthcare is a non-fungible benefit (entitlement) which may be ignored by a chosen few based on the mercurial whims of our political leaders. Not having to pay medical bills is a form of Lotto for which taking a gamble of not having insurance is a gamble worth taking.

So they believe that health care is available and might be free if needed. Just show up at the emergency room and take the gamble.  They also believe thru perception that a bill for care that might arrive at their home is a bill that can be largely ignored. Even though I caution them against this thought process too many are still willing to take the risk of not being insured.

As an employer I can not force them to insure.  But I do know this.  If any of these employees are faced with medical emergency and receive care, large and excruciating bills will likely follow and change theirs lives with unbearable financial burdens from which they can’t escape or recover.

Huge debt then turns into such an emotional burden then spins into psychological impairment to an employee’s ability to perform their work. Any employee who is so financially underwater to the point that clarity or a finality of the obligation can not be seen is an employee who is trapped. Trapped and financially burdened employees are not an asset to any employer.

When congress suggests that small businesses must have insurance plans I invite them to join mine.  But I don’t want all members of congress.  Just the ones between the ages of 25 and let’s say 40 years of age.  No, smokers, diabetics, overweights, or those with pre-existing conditions are allowed.  Robert, Arlen, Teddy, I love you truly!  But we just can’t fit you in. Maybe we can join your plan. You have a choice of ten plans.  I’m curious whether DC has ten providers approved.

Our plan which is renewed every year based on recommendations from an insurance advisory group is based on the company contributing the first $150.00 in premium costs and the remainder being paid by the employee. Any employee who wished to continue with an exiting plan or buy their own plan was welcome to do so and the company would contribute the same $150.00 per month towards their choice of plans.

Let’s return a moment to Drools, a name he had adopted. Our immediate reaction was to remove this contingent liability from the company plan and place him into a policy of his own.  But that effort was for naught.  Not a lot of insurers out there were interested in such an arrangement.  When I say insurers, what I mean is insurers that are approved and permitted to write insurance in the District of Columbia. If you are of the opinion that shopping for health insurance is just a “hop, skip, and jump” on the internet express well, you are daft.  The company must be approved by “THE GOVERNMENT”, in this case, The District of Columbia.

Having anticipated such a catastrophe some years ago, we attempted to find a health care policy with a very high deductible of $2500.00 which would emphasize safety from catastrophic and financial crippling costs. We were not successful in this effort.  Our hope was that a high deductible would so reduce our premium costs that we could cover all of our employees with or without their consent.

In terms of how we would handle health care costs associated with the first deductible costs was contingent on shopping our plan and looking at the costs and then form a policy of contribution based on that outcome. But stopping this endeavor was the restrictive marketplace i.e. DC itself.

What we need is this:  We send our health disc to an insurance company.  They in turn furnish us a quote based on the deductible that we want.  In that quote the companies furnish a list of what they will not cover and where we might get additional insurance to cover the conditions that they refuse.  Our quandary is not what is covered but what is not.

What most people are unaware of is that Government IS involved in your health care with cities, counties, or states placing specific requirements by (insurance commissions) on insurance companies to insure specific risks and maladies or the Companies are not allowed to sell in the state, county, or city. The best of free market principals are negated.

Now that’s an arrangement that is fraught with such a litany of conflicts where the “perceived common good” emoted up by caring  members of Insurance Commission, gives way to such accelerated costs that  the “affordable stage” is overridden and left in the dust.

The very best of intentions come at a cost. Healthy competition is lost.

If you view city, county and state Insurance Commissions as omnipotent as you should, then you  might ask whether the costs associated with health care for their employees is equal, higher, or lower then the same coverage for non-government employees (we’re called civilians) for plans approved for purchase. The question rightly asked is whether the benefits of municipal coverage sucks or restrains the coverage for non government players?

If you believe that congress is going to override all the “special” interests of the states in one unread, last minute before vacation, unexplained piece of legislation, I’ll release the trial lawyer who is safely placed in my country cabin’s latrine with Sears catalogues to keep him occupied and up to speed. Sue ready he is!

Just to take a breather, when our citizens say they can’t afford health insurance, does anybody ask, well, what can you afford?  I’ve yet to hear the rebuttal. My guess is nothing is an answer in too many quarters.

Might we call this concept a lead into dynamic rationing?  In more specific terms, money from A is collected to pay for the services to B.  Gee! That’s a great concept. Who wants to join the B team? Everyone I would guess.

This is part of the undercurrent of fear that erodes confidence in government plans. We have grown weary of a bill passed with a well hidden paragraph largely ignored that suddenly morphs into a sub-rosa penalty when interpretated later. That is called “special interest”. The purpose of fuzzy written legislation is to invite litigation for interpretation in forum shopped jurisdictions. There is no perception of fair here or there.

Washington DC. my city, is a city with a population studded with a horrific  number of HIV candidates, where random shooting not so long was more recreational then criminal and diabetics is a veritable plague on our population.  We have a city wrought with poorly fed kids and adults alike with dysfunctional   agencies attending to these endless humane needs and failures.

Given our local government’s predilections you might safely gather that “coverage for every ass ache imaginable” has worked or will eventually worm its way into required coverage. Now just for a moment, put on your insurance company hat and try to express your enthusiasm for underwriting Health care in this city.  Do I hear a one handed clap? Can you imagine how a federal plan however circumspect can and will collide with states rights?

Wrap around yourself the concept of “worse case scenarios”.  And then I want to imagine a plumber, electrician and carpenter. All three are gifted tradesman.  Ask all three to visit your physician’s 35 year old home for fairly extensive renovations.  You’re without the original plans and all three will poke around the house and try to come up with bids on their respective assignments.  Each will “try to guess” what the work will entail with the emphasis on guess.

Without the original plans or some previous knowledge of the home, each of these craftsmen is invariable forced to calculate the “worse case scenario” and bid accordingly.  Would an insurance underwriter for the District be faulted for doing the same? Could the physician, a surgeon, even with x-rays be able to predict the cost or outcome of his plumbers operation before piercing the skin? Except in cases of gross errors, physicians must be protected from “under the skin” efforts. Humans as the physicians house are studded with endless physical anomalies.

If one was to choose a time to introduce a dramatic change in health care to the Americans people, 2009 could not have been a worse choice.  We have had just about as much dramatic events as we can stand.

It was just a year ago that we (collectively) begin to realize in writhing detail the colossal collapse of our financial edifices including housing and the markets.  Our Government not only was unaware of the impending doom but was an active participant in the markets tanking with policies that took place thru two administrations.

One only needs to look at Fannie Mae & Freddie Mac  as they allowed (coaxed) unqualified buyers into the housing market and forced only so eager banks to change their lend to asset ratios to soar from 10% to 30% thru two administrations.  Simply put, payments for loans could not be met.  Millions of borrowers were not qualified forcing Banks to go further to cover their bets. They had made stinkpot loans. To cover their asses and make some “easy money”, they went defensive.

Their defensive actions helped create a financial parallel universe of credit derivatives, credit defaults swaps as well as other financial exotics that neither buyer nor purchaser understood.

The father figure who oversaw this deleterious fiction was none other then Allen Greenspan our Federal Reserve Chairman of many years who stated in October of last year, “I made a mistake”. Methuselah Moans Market Meltdown While Congressional Committees hum” Nessum Dorma “to the visitors in the gallery.

His acolytes of course were none other then “The most August (that’s when they leave town) deliberative political body of the free world” and the variety of financial committees who undertook the responsibility to protect their constituencies while listening to years of endless blather.

What did they know and when did they know it?  Zero!  Know what?

When the going gets tough, of course the tough get going. In the last 10 months, we have had the Tarp funds, the Cap & Crap, bail outs for AIG, Citi, BankAmerica, Chysler, De Soto, (I’ve always liked De Sotos), General Motors and  now Cash for Clunkers all of  which should have been sent to Cuba in return for third party enhanced interrogations.

So are we prepared to move into healthcare?  You Betcha!

ALL IN!  CONSIDERATIONS FOR EVERYONE TO DISAGREE WITH

From the Executive it would be soothing to hear the simple statement that Health Care coverage is the responsibility of every citizen and each citizen will be required to join a plan in two years.

It is incumbent for parents to have coverage for themselves and their children as long as the children remain in the home and or still dependent on the parents. The rule here is simple, whoever you claim as a dependent must be insured.

The obligations of the parent can not or should not be shifted automatically to some other entity until the child is able to leave the home and provide for themselves. Health of the child can not be conveyed from parent to a government guardian.

Further, the President should commit that any healthcare plan that eventually make its way onto his desk when be the same plan that will apply to him personally as well as all employees of the White House both Senate and Congress its’ employees and all federal employees . It is his goal that the health plan approved will be eventually copied by all states and municipalities.

The President should also request that the first action of Congress on their return from their August recess is to agree to join without exception the same plan that they propose to the country.  That should be Congresses first action.

This decision by the President and the Congress is the absolute starting point for any further debate. Without such an assurance, the debate should end.

All health insurance policies will be tax deductible dollar for dollar.  Each policy will have a set deductible based on the estimated annual income of the individual.  This deductible will be withheld from the employees first two weeks of full employment and will be taxed at the employees normal rate. In effect, the policy will be fully tax deductible while the set deductible amount will be taxed.

The amount of the required deduction may be reduced but to no less then the mount required to pay for one Physicians visit per annum per dependent. If the deductible amount is partially or fully used during the calendar year, it must be replaced in the following year and the replacement amount will be taxed at the employee’s normal rate.

An annual physician’s visit is requisite for all children from birth thru their 18^th year and for everyone above the age of 45.  Those from 18 to 45 must visit a physician at lest once every two years.  Failure to do so may cancel the deduction on the health care policy costs.

The physician can increase or decrease the set annual visits based on the condition of the patient.

Using two weeks withholding as a required taxable minimum, higher paid citizens of course will have larger deductions.  Using two weeks only as an example, an employee making $52K would have a $2,000.00 deduction for annual replenishment if used and someone making $250,000 would have a $10,000.00 deduction and upward before calling on the policy for reimbursement.

All Physicians who must accept insurance, are required in their check ups to rate the condition of the patient and send that information to the patient and Insurance Company. It is important that the Physician to differentiate between those in poor health due to unavoidable conditions and those in poor health due to lifestyles that may be corrected.

Poorly rated individuals if able have the responsibility to change their life styles or have their deductible amounts increased. Federal and State governments will co-equally share and assist citizens with pre-conditioned health issues not of their fault.

Physicians must be able to give both a written report and a computerized health disk to each patient.

Physicians, and most do, have the responsibility to care for their patients.  But they must be protected for their judgments.  As a standard course Physicians must insist and encourage the point that the patient has the right to seek another opinion. This should be a separate and single document verbally explained to the patient. That will hold true when the Physician rates his patient in poor health or when the patient inquires about further testing.

If the patient is unhappy with the rating or insists on further diagnostics the patient has the option of getting a second opinion or getting further testing at his or her expense.  The physician can not and will not be liable for their judgment when the patient has additional courses of action.

If the patient seeks another opinion or decides on additional testing they will pay for a second opinion and the cost of additional testing unless the second opinion varies from the first or the testing requested indicates a negative result. If the second opinion contradicts the first opinion then the second opinion is applicable.

Physicians who casually and continuously approve additional testing in which testing shows no negative results may find the licenses at risk. No shopping for “yes”.

Put the rules to a test with limited impact.  Start with having the rules apply to all foreign guest workers.  Most are probably insured by their companies; many are here for short visits under 3 years and have few households with dependents while the majority is young and healthy allowing coverage with high deductibles and some cost but not great cost. Allow cross state insurance companies to bid with an emphasis on coverage for pre-existing conditions.  Put that into effect one year from passage and get the results one year later.

Drools rehab started every day at 5 am with a vigorous regimen at the gym with emphasis on improving his motion, reaching a blood pressure 135/140 and taking deep breathing exercises to prepare the brain.  To feed the brain, he used auditory stimulus by enlisted Verdi, Puccini, Boito, Donizetti, and K.D. Lang and an odd assorted other ranch hands.

He was without equilibrium, the busy interplay of neurons speaking fondly to one another. Without this busy interplay he could not stand or walk freely.  He was bereft of the fluid motion which caused the left part of his frame (in his mind) having to support the right resulting in a port listing bringing forth spasms of sudden exhaustion. So he forced thru exercise and auditory wave-length support to massage the conversation to begin.  The left hemisphere at first coyly demurred but over time permitted sufficient brain chatter  to at lest bring the left and right hemispheres to the introductory stages.

The left hemisphere, the damaged area is the housekeeper of the brain. (This is truly an oversimplification)  It handles speech, ego, and organization, defines the placement of the body, judgment, makes decisions, and files and thrives on details, order, and direction.

Drools was in need of these tools of course, but aside from the ego thing which had been diminished over the years anyway, he realized he was in really fine shape. He lived with a woman.

If he could just fix this motion thing, keep his right cheek from sagging like a shar- Pei on drugs, speak without spraying, get his right index finger (which had become his new appendage “Primo”) from floating about aimlessly, then what the Hell! Who needs the left hemisphere? He had woman, and a wonderful one at that.

Small businesses to succeed are allowed little excess labor capacity.  Every employee’s moment, minute, hour requires action, energy, accountability and results.  It is by its very nature tumultuous chaos channeling the efforts of all towards a single goal.

It is a command structure often with sudden and often contradictory direction and “by the gut” emotions.  Such a structure can not permit weakness in its group structure.  Cold calculations and rigidity of human dependency is a necessity not a nicety. Capitalism is rarely nice. Everyone must do!

Drools was not a contributing member. He arrived at work, “completed simple tasks” and watched the financials.  He negotiated two leases deprived of the “history files” locked away in the left hemisphere and was caught off guard when some terms were agreed on.

The first rule of negotiations is that agreement on any term means that one or the other party has seriously screwed up. The best agreements are reluctantly signed with bitterness, recriminations, future threats, name calling and blame to follow.  Hence, we hire lawyers.

Only by the grace of time, 18 months after his stroke was he able to slide into the languid, loving arms of mother Medicare relieving the company’s health care expenses and joining the aesthetic, candy striped world of forms, directions, and a playground called doughnut hole.

Mother Medicare’s exhaustion was apparent.  She acted as if he really didn’t need to be there: that waiting another year would help her from being both penniless and penurious.  The Marlboro Man was next in line.

He observed that his contemporaries  looked pretty darn fit hardly qualifying as the  weak, weary, wrinkled, and worried as is often suggested.  Even in his condition he thought that one half of the benefits if offered for two years would have been just fine. Some months later, he was able to collect Social Security payments and reduced his salary by the same amount.  Almost immediately after payments arrived an annual increase adjustment of 5% was added. He thought that an obscene increase and believed 50% of CPI was sufficient.

Drools had power; power he rarely used. It was still recognized even immediately after his stroke by the pod of 40 legs which like barnyard animals smelled the odor of injury and sent out soothing rescue signals thru the special circuitry of each of their minds. The signals were silent, palpable, energizing, supportive and triumphal. He could detect through their cognitive movements, graceful steps forward to borrow his power and it’s responsibilities until his return. Without a word, permission was granted.

Two did not.  They saw his weakness and attempted to usurp power without the responsibilities. Their clues were subtle:  their expressions changed texture, their tones incongruous, their stance defiant their messages toxic. One day, they disappeared. Eviscerated!

The right hemisphere of the Drools brain was feeling rather lonely for the first 24 months following the stroke.   The damage to the left hemisphere, the dominant half, had brought initially a frosty interplay, brain chatter, between the brains two halves, which had advanced to tepid , an improvement to be sure but hardly satisfactory.  The right kept busy sending scads of info to the left whose job it was to assort, organize, and file but didn’t. The right became increasingly irritated with these sloppy habits.  You want filing?  You can’t handle filing. Just watch this!

The right hemisphere deals in thoughts (not necessarily coherent), sensation, and emotions, as well as complex formations of light so Drools was starting to find some really strange stuff flying inside his little skull. His world became fixated on all movement, and everything moved. His perception cajoled all objects, humans, plants buildings, statues, rivers, skis, wind, rain, sounds, senses, feelings, into equally animated points of stupendous curiosity and joy.  Every object was coherent and alive.

With that came glorious light;  shifting hues, unimaginable colors, a veritable cascade of moving images, a feast of kaleidoscopic hallucinogens howling jangled demented flashing glossies  of earths designs, wondrous and inviting.

The mechanics of his frame clickity clacked, clacked, clickity clacked clickity clacked as he left the porch. His two wheels of locomotion hissing, spewing, and thunderous brought him to his garden. They stared at each other for a time.  He reached out gently, cautiously, with his lifeless right hand and effortlessly stroked the hummingbird’s wing. Partial well…..was an exuberant well.

Arthur Carlson

C. F. Folks   1225 19^th St. Washington, DC, 20036     202 293 0162