As medical bills rise, D.C. battle hinges on federal dollars, not health
Frustration about health care reform rhetoric is palpable as Tennessee leaders grapple with high rates of chronic disease taking a toll on both the state’s people and economy.
But competing health care proposals at the center of the war raging in Washington don’t directly address the stated goals of improving the quality of care and making it more affordable.
The bills focus on health care financing more than the issues that doctors, patient advocates and state leaders want addressed and that will require nothing short of a cultural shift.
The prospect of a resurgence in uninsured people — or in plans that carry staggering deductibles in a system still structured for insurance companies to carry most of the cost — worries providers who say costs are already top of mind for patients.
“No one wakes up and says, ‘Oh my gosh, I’m going to have a chronic disease today. I’m going to go out and buy health care,’” said Dr. Jordan Asher, chief clinical officer of Ascension Care Management in Nashville. “They have to be solving the problems they are solving every day, effectively how to survive, but in the confines of a chronic disease.”
Health care — particularly the insurance component — is taking up a greater amount of the average family’s income.
Average annual expenditures in 2014-15 for 45-54 year-olds crept up to 6.6 percent and 10.29 percent for those 65 and older since 1972-73, according to data from the Bureau of Labor Statistics analyzed by Murat Arik, director of Middle Tennessee State’s Business and Economic Research Center, who looked at the change in spending at the request of the USA TODAY NETWORK-Tennessee.
The price tag is much higher for many suffering from illness or injury. And the way that insurance — which is meant to protect against catastrophic financial loss — is evolving toward high deductibles, many people cannot afford care or let bills go unpaid.
The median income in Tennessee in 2015 was $47,275, about $8,500 lower than the national median. Deductibles can amount to thousands of dollars before insurance payments kick in.
Health insurance costs have grown to account for more than 67 percent of what people aged 45-54 spend on health care annually, according to BLS data.
The health care increase, which shows no sign of relenting, comes in addition to increases in housing and education costs, which have soared over the same period, Arik said.
Housing, education and health care are among the expenses taking up bigger chunks of families’ income.
For families, particularly of the middle income variety, housing and health care expenses are squeezing budgets. In the same time period, the average annual housing cost grew from 23.9 percent of income to 29.2 percent.
As families try to piece together their lives, the decisions they make impact health, although a routine trip to the doctor will frequently take a backseat to other expenses.
“[The] problems they are trying to solve every day have little to do with their health issues, but impact their health,” Asher said.
DIABETES: A DAILY BURDEN
Tennessee is what Dr. Al Powers describes as the belt buckle of the Type 2 diabetes belt — a swath of the southeast U.S. that is beset with some of the nation’s highest rates of diabetes.
The number of Tennessee adults with Type 2 diabetes spiked from 5.4 percent in 1990 to 12.7 percent in 2015 — although the number of Tennesseans with the disease is likely higher.
It’s estimated that 25 percent of people across the country with the disease are undiagnosed, said Powers, director of Vanderbilt University Medical Center’s division of diabetes, endocrinology and metabolism.
Researchers found an increase in Type 2 diabetes diagnoses in states that expanded Medicaid in the wake of the ACA, leading to more people going to the doctor and getting tested.
The cost of treating adult-onset diabetes averages out to $2,000 per every person, whether they are diabetic or not, covered by BlueCross BlueShield of Tennessee’s employer-sponsored and individual plans.
Nationally, Type 2 diabetes cost the U.S. $245 billion in 2012 — or one in 10 health care dollars, according to research published in the journal Diabetes Care.
The costs and impacts the disease has on people’s lives underscores the necessity of aligning how people get and pay for care with ways to reshape the cultural behaviors that lead to the disease.
“You have to live those lifestyle changes, take those medications every day. It’s a day-in, day-out burden that people have — they never get a day off,” Powers said. “It’s such an important problem. It’s really a personal problem but it’s also a societal issue.”
A DAD SEEKS CHANGE
Jonathan Eakes is on track to spend about $12,000, or 20 percent of his income, this year on health care — and it’s only July.
Eakes’ family has absorbed two out-of-network emergency room visits that knocked out his $6,000-family deductible. The 30-year-old went once because he thought he was dying from a heart attack — he wasn’t having one. The other visit came after his 2-year-old son fell out of a highchair at a restaurant and hit his head on the floor.
He’s trying to lose some weight as a way to reverse his recent diagnosis of Type 2 diabetes, which he suspected he had because his symptoms mirrored those his mom had early in her time with the disease.
After visiting a few doctors and trying out different treatment regiments he’s on Trulicity, a weekly injection. It’s costing him about $25 a month right now because he found a discount. But once that finishes, the cost will jump to $125 a month under the insurance he has through Saint Thomas Medical Partners.
He recalled thinking every time he went to a doctor to work out a diabetes treatment plan, “Oh my God, I’m going to get a bill.”
“What drives me is saving money,” Eakes said. “I’m definitely going to make a change. I want to get off of [diabetes medicine].”
For many Tennesseans with diabetes, $125 a month is a bargain. The average retail price of Trulicity is $817.96, according to GoodRx. Prices can increase seemingly on a whim.
Cost is never far from the minds of patients, and a factor that physicians and their teams are constantly facing, said Asher. For years patients were shielded from the true cost of treatment through insurance plans’ copays.
CHRONIC DISEASE, HIGH DEDUCTIBLES
What happens in Washington will have widespread ramifications for the state.
Gov. Bill Haslam has made improving the state’s health a priority through various agencies because the poor health across Tennessee threatens longterm economic vitality.
The governor wants Washington to “put the political argument behind us” and address health care costs in the next round of reform. He said that the additional people covered under the ACA is “arguably a good thing.”
Even though out-ofpocket costs are straining budgets, insurance is still the gatekeeper to the country’s health care system.
Each of the proposals now under consideration in the House and Senate is projected by multiple non-partisan analyses to leave more people uninsured — an outcome nearly universally panned by doctors, hospitals, patients and state leaders.
The impacts of costs on families is divorced from the current debate despite a growing class of people who are underinsured, which highlights the dated health care system.
“I worry as a provider that high deductible plans will also create a sicker population on the pure affordability issue,” Asher said. “I’m not saying there shouldn’t be market dynamics [but] if you have a high deductible and no way to pay, you’re effectively uninsured from a chronic disease standpoint.”
The system is designed for treating people when they get sick — and having the government or insurers pay for it — rather than keeping people well, said Emily Evans, a former Nashville Metro councilwoman and managing director of health policy for Hedgeye.
“If I was a governor I’d be rebuilding my entire health system,” Evans said.
Getting people healthy is a priority for doctors and public health officials around the state who are trying a variety of economic, education and public-private partnerships aimed at changing socioeconomic factors that impact health.
Those roots of health are absent from the national conversation.
“Covering fewer Tennesseans will create a sicker state,” Asher said. “The state is going to have to manage that. We’re going have to figure that out. I’m not excited about that. Assuming this continues to go through the state is going to have to step back and think about this from a more holistic approach.”