What's at stake in the health care debate has almost nothing to do with health care in rural America. It has to do with profit.
On Monday night, America’s Health Insurance Plans, an industry trade group, called out the U.S. Congress, and drew a bead on health care reform. AHIP told us that health insurance would become very expensive under reform — apparently expecting the nation to dance as the group shot at our feet.
It’s a gunfight, all right. With all the shooting, however, nobody is addressing the health care issues that affect rural Americans. Let me explain.
Any health policy expert, and anyone else who is paying attention to the rumble that is passing for a health care debate, has known for months that health insurance is going to get more expensive as a result of reform. Why? The keystone for reform is community rating — a.k.a., “guaranteed issue” — rules that would require health insurance companies to insure anyone who wants insurance and charge them about the same rate, regardless of age, health, or gender.
That’s what health insurance was originally supposed to do – take a little money from a lot of well people, and use it to pay for the care of a few sick people. But that’s not what insurance companies do now.
In the early 1980s, insurance companies figured out that if they insured only well people, they’d get to collect money but wouldn’t have to pay it out. Getting to keep all that money would make them more profitable. Meanwhile, people who get sick become poor, and qualify for government insurance – for Medicare and Medicaid. The insurance companies get to keep the money from well people, and then taxpayers pay for those who get sick. It was a pretty good racket.
But reform threatened to change all that, and make insurance companies take care of everyone. As soon as you make insurance companies take care of the sick, they’ll pass those costs on to the people who pay the premiums — and so the costs of premiums will go up. 
The Senate Finance Committee passed out a health care reform bill Tuesday. The Senate faced the insurance industry, and blinked. We knew that all along, and so did they. But it felt unfair to most Americans that some people paid way more than others for health insurance. Meanwhile, those who might actually get sick often couldn’t find health insurance that was anywhere near affordable.
So Congress began to work on changing the system, thinking that fairness was worth the extra cost. Insurance companies were willing to play along because Congress was going to combine insurance reform with an insurance mandate, the requirement that everyone had to buy insurance or pay a big financial penalty. Insurers stood to gain 50 million new customers from that deal, and they calculated that having to cover everyone, which might cost them some more money, was worth doing if they got 50 million new customers, and lots of potential new profit, in the bargain.
The deal looked good…until someone in Congress who could add figured out the following: We were about to require uninsured truck drivers and librarians, hair dressers and cement finishers, fishermen and family farmers, people otherwise known as voters, to spend $15,000 per family per year on health insurance they would rarely use, or face a $4000 tax penalty. Congress tried to control the cost increases with ideas about insurance cooperatives and a “public plan,” but neither had ever been used successfully to control costs. The “public plan” is very likely a political non-starter (although backlash against the insurance companies hired guns might actually give the “public plan” new life).
Doesn’t matter. Neither insurance cooperatives nor the public plan are likely to make much difference to rural Americans. People living in rural places need good doctors and good hospitals, good dentists and good physical therapists, good drug stores and good home nurses close enough to home so they are all of some use. What we don’t need is expensive health insurance that can’t deliver the services rural Americans need and use.
There was talk about giving some people incentives to help cushion the financial blow, but it didn’t take a rocket scientist to figure out any Senator or Congressperson who voted for such a scheme would probably never get elected to anything ever again. Think added costs and higher taxes.
Congress looked this deal, which was great for the health insurance companies but not so good for anyone else, right in the eye, and Congress blinked. The Senate Finance Committee changed the deal. Now there is a $750 penalty (instead of $4,000) for families of four earning $160,000 a year who don’t buy health insurance. That is to say, the Senate Finance Committee made the mandate go away.
But they left the new rules for health insurance companies in place. Insurance companies don’t get 50 million new customers, but they do have to think about paying the health care costs of people who are actually sick. (To be fair to the poor health insurance companies, Congress weakened the community rating standards, and let insurance companies keep charging some people 5 times as much as other people. As any 3-year-old knows, having a temper tantrum is a perfectly reasonable response to someone taking away your cookie.)
See why the insurance companies (through America’s Health Insurance Plans) are stamping their feet and stirring up dust?
It’s too early to know the outcome of this fight. If we are lucky, Congress will hold firm and not give in to the health plans. But the health plans have a lot of money, and lots of lobbyists. Stranger things have happened.
There is a saying in Africa: When elephants fight, the grass gets trampled. Neither an insurance mandate nor community rating will fix health care in the US. Insurance is the problem, not the solution.
The country needs a health care system, not just health insurance reform. We need to provide primary care to all Americans, because primary care costs next to nothing ($300-500 per person per year, compared to health insurance, which is $5,000 to $6,000 per person per year) and if we provide primary care to all Americans, we’ll have a system that is fair, a system that is affordable, and a system that is about health for everyone, not profit for corporations.
It’s time to end this gunfight before anybody else gets hurt or killed.
Michael Fine, M.D., the top ranked family physician in Rhode Island (ten years running, in Rhode Island Monthly's Best Doctors in RI), is an author, community organizer and health policy expert. Dr. Fine is also the managing director of Health Access Rhode Island, a network of family practices that provides affordable primary care to people without insurance.