HSAs, Part I

The Health Savings Account, or HSA, is the centerpiece of conservative health reform today. Much as the new Medicare prescription benefit has descended on seniors, the HSA is a latest healthcare wrinkle that will probably find you whether you want it to or not.

An HSA is a personal savings account that can be funded tax free. The money in the account can then be invested, if the owner prefers, for growth. Any money, whether deposited or interest made on prinicpal, can be applied to healthcare expenses, again tax free.

Sounds pretty benign, but here’s the catch – to qualify for such an account, you have to enroll in a health insurance plan with a high deductible, what the government calls a Qualified High Deductible Health Plan (QHDHP). This means a plan with a minimum deductible of $1,100 for an individual and $2,200 for a family.

High deductible health plans have been around for a long time, and the can make sense for young, healthy individuals who do not see the doctor much. For a cut in premium of several hundred dollars a month, the insured assumes the cost of routine visits. Insurance only kicks in when there is a serious expenditure, such as an appendectomy or orthopedic surgery for a torn knee ligament.

Advocates say HSAs will help patients in several ways. First, they offer a tax break to those who are willing to assume some of the cost of their healthcare through higher deductibles. Secondly, HSAs will allow employers to offer health insurance to more employees, because the premiums employers pay for high deductible plans are so much lower. Finally, they argue that consumer driven healthcare, that is, healthcare in which the patient decides what to buy and how much he wants to pay for it, will drive healthcare costs down. A patient who has to pay for a tetanus shot out of his own pocket, for example, will shop around to find a good price. The weakness of the current system, HSA fans argue, is that patients never see the entire bill. They are not aware of the full cost of their care, and so have no incentive to shop around, or to dispute unnecessary expenses.

As a practical scientist, I am not against giving the HSA idea a whirl. HSAs will probably reduce healthcare expenses a little and will likely make insurance more affordable for some people. I am in favor of trying anything that will improve healthcare. The problem is, I think the benefits of HSAs are limited, and that this concept is only a temporizing measure that may slow but will not prevent the long term healthcare problems this country faces. In the interest of brevity, I will not tackle every concern I have with HSAs now, but will spread them out over several articles. I will spell out my biggest concern here and now.

HSAs will not extend healthcare to everyone. If we assume for the moment that HSAs will in one way or another reduce health costs (which is not proven), it follows that the savings can be used to insure more people. This is a good thing, but “more people” is not everyone. Though HSAs will make it easier for workers to afford insurance, it does nothing for the unemployed. The insurance may be cheaper, but you still have to buy the it, or get it from an employer. Let’s say a full policy costs $600 a month and a high deductible plan costs $350 a month. A premium of $350 a month, or $4200 a year, may be an affordable option for someone who drives trucks for a living, but for a cashier at Denny’s who makes minimum wage, it may still be unaffordable. Extending healthcare coverage to a greater number of people is a good thing, but not at all the same as extending healthcare coverage to everyone.

Here I think is the greatest disconnect in the healthcare debate. There are some people who think health insurance is a personal right that should be extended to everyone, regardless of their ability to pay. There are others who think it should be available to everyone as a choice, but it should not be legally mandated. The choice people believe that our only responsibility is to make access to healthcare inexpensive enough so that everyone has a fair shot at getting it. The rights people think as long as someone is left out, for whatever reason, that injustice is being committed.

I am a rights person.. As a doctor, I spend most of my life’s waking hours helping people overcome the scourge of disease. The care system I am part of can help anyone and everyone, and I am opposed to any approach to healthcare that would leave anyone out. It does not make sense to me that a system dedicated to helping people should select who it helps depending on his or her ability to pay.

Purists like to look at the Constitution and the Bill of Rights and say there is no mention of healthcare as a personal right. No, there is not. But our country is built on the assumption of equal opportunity and social mobility. The freedom to compete on equal footing with others and rise out of poverty is the very heart of the American Dream. We do not consider it just that a child who grows up in the ghetto should be required to go to a terrible public school while one who lives in a wealthy suburb gets to go to a good one. This does happen in America, but that is not to say that we endorse it as right.

In the same way, access to quality healthcare is very important if individuals are to compete on a fair playing field. Why would it be fair that a man from Upper West Side New York can have his asthma properly treated, allowing him to continue to work, while a minimum wage earner in the Bronx goes untreated, resulting in missed work days and eventually in the loss of his job?

From a Constitutional standpoint, it is not obvious that everyone should have healthcare insurance. But from a moral standpoint, it is. Allow me to turn the question on its head: If everyone is not entitled to health insurance, who should be excluded? Should the lazy, or the uneducated, or the immoral, or even the downright evil be excluded? In out country even imprisoned murderers have access to doctors. It is one thing to say that a lazy unemployed man should be denied luxury housing, or a car, or a steak dinner. But how long, in the richest nation in the history of the world, should he be allowed to cough up blood before he gets an X-ray? If the U.S. can’t afford to care for everybody, then hang it up – no one can. The problem is, poorer nations can afford it, and they do.

Giving everyone the opportunity for good healthcare isn’t just good ethics. It is good business. As I noted above, a large part of the American Dream is about giving everyone who wants to try a fair shot. Good health is a basic possession that frees people who want to better themselves to go out and do just that. By giving everyone healthcare access, we unloose the full creative force of America. A healthy workforce is a productive economy. I think even the staunchest conservative would have to admit that our economy would benefit from a work force that is medically fit.

And that is the problem with the HSA. It offers healthcare to more people, but not all of them. Both morally and economically, it falls short.

My Big Fat Green Gas Guzzler

I’ll admit I suffered a twinge of liberal guilt when I bought my last car in November. I went for an Infiniti G35, one of Infiniti’s low-end models but hardly anything to be ashamed about. Moon roof, 280 horsepower, standard leather interior. Its drawback is relatively poor gas mileage – about 18 in the city. My last car was an Infiniti, and after I bought it I promised myself my next vehicle would be a greener model. Maybe one of those hybrid jobs.

Hurricane Katrina threw me off of this plan, as she has off of so many others. She killed my old G35 in its infancy, after only 15,000 miles and 18 months of service. I knew when I left it behind I would never see it again. But I was afraid to evacuate New Orleans with my family in two cars – we might get separated in the traffic – and the other car was larger and could carry more stuff. That is another story.

When I came back after the storm and verified that my poor car had taken on 12 feet of water, I reacted like someone who just lost a beloved pet. I had to have another one, just like the last. The green promise went out the window. Oh, I tried. I thumbed through many a car guide. I even subscribed to the on-line Consumer Reports new car guide and ran every model I could think of against the G35. Had to have it. It was more a matter of putting things back the way they were, than any consideration about what was the best car. So I bought it, and screw the environment.

Lucky for me, my petty liberal guilt was assuaged by a column in the Wall Street Journallast week. In speaking about so-called “green” houses, the author, architectural critic David Akst, pointed out quite acerbically that green is relative. He noted that most green homes are single-family dwellings with high square footage. What is green about a 15,000 square foot house, he asks, even if it is solar heated? You still have to chop down and process trees, chemically treat wood, manufacture paint and plastic to build a house. The bigger the house, the more natural resources have to be consumed.

Green is small, a mobile home, for instance. No one with the resources to build green builds modest. Green houses are usually ostentations mansions, and thus a waste of building materials. A real green building is a tenement with 600 square foot apartments, or a house with 3 families living in it. Efficiency makes something green, and efficiency does not mean solar power. It means people living modestly, in close quarters.

Akst makes the point that people who design and live in green houses often make lifestyle choices that negate the benefits of the houses. For instance, a green home that is a 2-hour commute from work is hardly green, is it? Even if the owner buys a hybrid car that gets 60 miles per gallon, the wear-and-tear of the commute uses up the car, meaning more frequent oil changes, battery changes, new tires, and in the end, a new car at an earlier date.

Which brings me to my green gas guzzler. I live in a small country town, and my office is literally next to a cow pasture. My house is 7 miles from my office, and I can make the drive in 9 minutes flat. I fill up my tank once every 3 weeks. Who is greener, I in the country gas guzzler or the Los Angelino who lives 25 miles from work, takes 70 minutes to get there, and owns a hybrid but still has to refill the tank every weekend? Even if he carpools, the Angelino will have a devil of a time keeping up with me. And if I turn off my air conditioner and open my moon roof, well, he’s whipped.

So I am green after all. Not green because my car gets low mileage, but green because I have made a lifestyle choice that permits me to use less non-renewable resources. Green is not about what you choose to buy. That is mindless, consumerist thinking. Green is about how you choose to live.

The Chocolate Crescent

By now people nationwide are familiar with New Orleans Mayor Ray Nagin's comments on Martin Luther King Day. For those who haven’t heard, I’ll summarize. Nagin got in trouble for two separate comments. First, he said that Hurricane Katrina hit New Orleans because “God is angry with us.” Second, he said that New Orleans was a “chocolate city” before the storm, and would be a “chocolate city” again.

The “chocolate city” remark probably has gotten the most mileage, because it is the easiest to ridicule. Referring to black people as “chocolate” is in some circles mildly demeaning, and in others is used endearingly. Sometimes it has sexual overtones, as in “I’m gonna get me some chocolate tonight.” Either way, it was an oddball way to open a political address. I doubt Nagin meant anything by it. I think it was just an attempt at humor. All politicians need to attend a comedy workshop, where they can learn the golden rule of comedy – LEAVE IT TO THE PROFESSIONALS. If you don’t know how to be funny, don’t try. There is no easier way to look stupid than to make ill-timed stabs at humor.

As for the “God is mad at us” argument, this is really peculiar. More than one religious conservative has taken his licks from the media for issuing the old the-victims-must-have-deserved-it argument. For him to have touched this tar baby seems colossally stupid. What was he thinking?

I happened to hear part of Nagin’s speech live on the radio, so I can tell you what he was thinking. He was trying to pull of an imitation of Martin Luther King. His speaking style and vocal intonations were straight from the pulpit. He even went into a long and sometimes confusing reverie about seeing Dr. King in a dream and asking him his opinion on how things were going here on earth. It was hard to tell sometimes if Nagin was talking, or if he was paraphrasing the advise of his imaginary Dr. King. And of course that is leaving aside the question of if Ray Nagin would even know what King would say if he were alive. Does he really know?

Nagin is a businessman by trade. Martin Luther King was a Baptist minister, and one of the best orators this country has ever seen. Nagin would have had an easier time strapping on a pair of Nikes and imitating a Michael Jordan highlight reel than trying to approach King’s speaking style. I still get chills every time I hear the “I Have A Dream” speech, and I have heard it hundreds of times.

In trying to imitate King, Nagin drove himself into a difficult situation. He tried to weave King’s powerful sense of faith in God and divine morality into his words. Dr. King’s speeches were all about morality, and faith, and purpose, and he did it better than just about anybody. Mr. Anybody Politician can’t just put that mantle on like a Santa Claus suit and prance around for everyone’s pleasure. King got shot for saying what he said. If you are going to imitate the Reverend, you had better be sure of yourself.

Nagin was just fooling around. He was doing an imitation for a mostly black crowd, a supportive crowd, and he was trying to make them feel good. He was telling them what they wanted to hear. But Martin Luther King never told people what they wanted to hear. He told them what they needed to hear, and the heck with the consequences.

Ray Nagin is not an articulate man. He dresses sharp, looks good, appears bright and educated, but when he opens his mouth the words come stumbling out like drunks out a Bourbon Street bar after last call. In a way, he reminds me of George W. Bush, who also looks like he should be articulate but isn’t. W has one huge advantage over Nagin – he has advisors who tell him what not to say.

If Nagin wants to study great oratory (and who doesn’t!), I refer him to Harry S Truman. Truman was not a great writer or orator, but he was effective because he knew his limits and spoke plainly and honestly. Truman rarely put on airs. He played himself, and had a very successful run doing it.

Ray, meet Harry. Harry, this is Ray.

The Worst Gift Ever Given

I kept it in my right desk drawer. Frequently overlaid with misplaced papers, unwanted drug samples, and forlorn drug-rep paraphernalia was the worst gift I ever got. My desk and my office took on 8 feet of water after Hurricane Katrina, so I only have my memory of it; but my memory in this rare case is perfect: It was a 5-inch tall gray ceramic skull, a Halloween trinket, glazed to a high gloss. It had amber plastic orbits and a divot near the apex, right at the sagittal suture, for the insertion of a candle. It was, in a word, tacky. I kept it to remind me that I could never get a worse gift. My little  Yorick humored me.

As with any gift, its value was derived not simply from the value of the object itself but also from the circumstances of the giving, which I will now relate.

I had a patient, whom I will call Charley, that visited me from time to time for his diabetes. Charley would call my office to make an appointment for refills on his insulin almost every month, which tipped me off already of a scam in progress because I never failed to write him less than 3 refills for that medication. He would amble into the office, and when the door closed, the real reason for his visit would slowly emerge. Vicodin. The love of his life since his wife left him. Charley was very overweight and not well acquainted with bathtubs. Though he was always polite and respectful, it goes without saying that we did not always come to a mutual understanding about his pain needs.

Charley claimed disability from back pain, but, like many disabled patients in my old neighborhood, he sometimes worked side jobs to make ends meet. I did not necessarily hold this against him, since disability in Louisiana rarely pays more than $500 a month, a small sum that would scarcely cover my grocery bill, let alone his.

When Charley gave me the gift of the ceramic skull, he told me he got it for my kids, and that he stole it. Told me straight faced like he was supposed to do it. He had taken a job unloading trucks at the Dollar Store, a job he admitted he was paid "under the table" for. At the end of the work day he just slipped a couple of these fine items into the trunk of his car for gifts to family and friends.

Perhaps I should have been touched by his generosity. In a way I guess I was, but when I began to tally the value of the gift in my mind, the negatives ran so great in relation to its value that I clearly discerned that pound for pound, this was the crummiest gift I had ever gotten. First, it was a piece of junk -- it came from the Dollar Store, which pretty much told me what it was worth. Second, it was stolen. Third, it was stolen on the job by an employee who was working illegally (no taxes paid) and against the terms of his disability agreement, which requires that the recipient does not work. Fourth,  he was unloading trucks at this illicit job, which told me that he was less disabled than he was letting on. Fifth, he intended for me to pass this stolen gift on to my children. And last, and not at all least, I knew he was giving me that gift to butter me up for future Vicodin requests.

I wonder if a police officer was ever offered a 25 cent bribe? Or if an individual ever tried to claim a tax deduction on shoplifted clothing donated to the Salvation Army?

Needless to say, this choice bauble and I were not to be separated. It was my first non-drug rep bribe! So it sat in my drawer, and sat and sat, and from time to time I would dig it out and behold the new low in the world of pathetic gifts. I would laugh and put it back. It remained in its particle board sarcophagus until the flood waters of Katrina came and took it away. Alas, I miss poor Yorick! 

Book Review: The Known World

I have added to my book page a review of the last inhabitant of my nightstand: The Known World by Edward P. Jones. You can read my review here.