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Our "Flawsome" Health Care System.

Updated: May 16, 2023

As reported and opined on across the media landscape.

Warning: This post makes references to politics. Given current events, this shouldn’t be a surprise. However, I recognize that my selection of issues and reports here may reflect positions not held by some readers. Also, this post is in not intended to be a thorough review of the plusses and minuses of the U.S. healthcare system.

The other day I ran across a compound word whose origin reportedly traces back to the entertainer, producer, and actress Tyra Banks: "Flawsome." It’s a straightforward word combining “Flaw(ed)” and “Aw(e)some,” to refer to something that is either:

  1. Awesome, in part because of its flaws; or,

  2. Both awesome and flawed at the same time.

In the following sentence, definition #2 applies: “The U.S. health care system is flawsome.” Increasingly the emphasis is placed the first syllable.

For decades, those paying the costs of health care in the U.S. have been burdened by the “flaw” in “flawsome,” both in terms of the overall costs and the costs associated with unnecessary or ineffective care, unnecessary or ineffective administration, and, yes, excess profitmaking. Meanwhile, policymakers, journalists, “opiners” (such as myself) and others have done a thorough job of examining and elucidating the factors behind our broken system. Health care consumers (i.e., you and me and every other U.S. resident), meanwhile, have appreciated the “(awe)some” part of the word, with that awesomeness producing world-leading longevity (at least until recently), along with world-leading innovations in medical care, procedures, and medications.

In the last 10-15 years, the “flaw(s)” in the system have become of great concern to nearly everyone. None of this is real news, of course. But a few recent stories / events have caught my eye and brought into sharp focus the very real impacts of our “flawsome” system.

News item #1: We’re paying more and living less.

Writing for The Atlantic, Derek Thompson proclaimed that “America Fails the Civilization Test.” Or, as I’ve started to think about it, “Live Fast, Die Young” seems to be our motto… in that while we’re one of the world’s richest societies, among our “peer nations” we’re now dying younger — at almost every age.

As Thompson puts it, “The average American my age is roughly six times more likely to die in the coming year than his counterpart in Switzerland."

Thompson cites data analysis done by data journalist John Burn-Murdoch of the Financial Times. The later puts this in perspective by observing that “one in 25 American five-year-olds today will not make it to their 40th birthday.”

There are of course many contributing factors here. Thompson writes of his discussion with Burn-Murdoch, which begins with the former speculating that guns, drugs, and cars largely account for our lagging longevity. Burn-Murdoch, however, sees the issue as primarily one of poor health (not surprising to those of you responsible for managing employee health care plans). However, he doesn’t put the blame squarely on individual behaviors (poor diet, lack of exercise, etc.). Burn-Murdoch reports that income is a notable predictor, which results in less access to physicians, less healthcare coverage, and other social determinants of health.

But more interesting to me is the “big picture” assessment by Thompson. America, he explains, is caught in a lurch between oversight and overkill, sometimes promoting individual freedom, with luridly fatal consequences, and sometimes blocking (or from my perspective implementing) policies and products, with subtly fatal consequences.

It’s a compelling observation, and an interesting read.

News item #2: Some of us are willing to risk our lives searching for affordable care.

Axios, a digital news service, reported on how Americans, particularly those who live in Texas, are increasingly looking south of the border for health care. (While the article cites Texas as a major origin point for these “medical tourists,” California is another notable origin point.) From a dollars-and-cents perspective, it’s easy to understand why:

First, parking is easy, and cheap: $2 to park your car on the American side, and $1 to walk across the Progreso International Bridge into Nuevo Progreso.

Once there, Axios reports, those in need of dental care can receive a deep cleaning, wisdom tooth extraction, root canal, and six new crowns for $2,730 Compare that to more than $6,000 without insurance at a Dallas-area dentist. Even with insurance, the cost savings could still make (dollars-and-cents) sense for many.

But there are very real risks. Again, according to Axios, the U.S. State Department lists the Mexican state of Tamaulipas, which includes Nuevo Progreso, on its do-not-travel list, due to the risk of crime and kidnapping there. Axios highlighted that this isn’t a hypothetical, reporting that in April, four American medical tourists were attacked and kidnapped in the Mexican city of Matamoros, south of Brownsville.

Obtaining affordable medications is of course another reason why Americans travel south (or north) of the border. While the State Department also warns of the potential for receiving tainted medications (when obtaining them from Mexico), the cynic in me wonders if that’s really a concern. Could it be, perhaps, a form of protectionism for the pharmaceutical industry?

Of course, I have no way of knowing… nor do the estimated 2 million Americans who do this every year. (Estimate provided by a 2020 University of Florida Health study.).

What I do know — based on personal and professional knowledge (but not personal experience; I’m too risk averse) — is that among those obtaining healthcare services and medications outside the U.S. are people who have employer-sponsored healthcare coverage.

And while I've worked with clients who are aware that some of their employees obtain treatment and medications in Mexico, it's something no employer wants to talk about publicly.

News item #3: Healthcare has become more political than ever.

Remember “Hillarycare” — the dead-on-arrival Health Security Act of 1993? Without getting into the weeds, that proposal was designed to provide Americans with universal health care coverage: To reinforce that, it was designed to provide universal coverage, not universal care.

A battle royale was fought over this proposal: Conservatives and libertarians opposed it; there were alternative proposals put forth by Democrats; and the various players in the health care industry hated it all. Ultimately, Hillarycare never advanced to the House or Senate for a floor vote.

While it may be that my memories of Hillarycare have faded, the recent political battles involving health care make the former seem like a mere kerfuffle. At least for employers who provide health care benefits to their employees, particularly multi-state employers with self-funded plans.

Much has changed since 1993, the year Hillarycare died, and the same year I started my HR consulting career. Among the changes I’ve observed — and often helped implement — are the wide-spread adoption by employers of these provisions in their health care plans:

  • Domestic partner eligibility.

  • Birth control pills considered an eligible expense and available with low copayments. (Fun fact: many employers added this provision to their plans when Viagra came on the market.)

  • Coverage for abortions. (Coverage for treatment provided in the case of a miscarriage has never, as far as I know, been in question.)

  • Transgender benefits.

And many employers — at least those responsible for the administration of their benefit plans — rejoiced when the Supreme Court issued its Obergefell v. Hodges ruling, which made same-sex marriage legal nationally. Regardless of any personally held beliefs, life got simpler for employers as it was no longer necessary to calculate the value of the same-sex partner’s coverage on an after-tax basis and input income on it.

(I still remember designing IVR enrollment systems and paper enrollment forms: The complexity of capturing coverage levels was ridiculous, particularly for employers who wanted to be precise, at the individual covered dependent level, in their tax calculations.)

It’s been a fascinating journey observing these changes unfold; seeing some of the staunchest opponents come to realize that, at least for their organization, adopting these changes was the right thing to do.

One measure of the magnitude of this shift is the Human Rights Campaign Foundation™ Corporate Equality Index. Based on recently released data, there are 840+ companies that score a perfect 100, as compared to the 13 that achieved this when the Index was first launched in 2002. More than half the Fortune 500 are among this group, with a handful earning a perfect score for 20 years.

These companies want to be on this list; they work to be on the list: Not for glory (okay, maybe a little), but for what it means to them in terms of creating equitable and inclusive workplaces and providing all their employees with a sense of belonging.

And today that difficult work is getting even harder.

I don’t have enough space in this post to include even a “representative sample” of the articles being written about the impact of the overturning of Roe v. Wade or the spread of laws and proposed laws at the state level severely limiting abortion rights or banning transgender care. (Axios, again, provides an at-a-glance look at the transgender care bans.) There’s even some concern that the Dobbs decision (which overturned Roe) opens the door to overturning the decision that legalized same-sex marriage.

And what isn’t being widely reported is the impact these decisions, laws, and potential laws are already having on employers.

The first challenge is a fundamental one: How do employers provide benefits that are equitable across their entire workforce, regardless of the state in which the employee works and/or lives?

What should they do when, in some states in which they operate, certain health care services and treatments are banned, but their plans provide coverage for such care?

Do they pay the travel expenses for the employee (or the employee’s family member) to receive care in a state where such services are legal and available? Are they breaking a law if they do so?

(Legislation at the Federal level was proposed earlier this year that would guarantee the right for individuals to travel across state lines for reproductive health care.)

Does the state in which the company is headquartered impact its ability to provide coverage for services that are banned in that state, regardless of where the plan member seeking these services lives?

As challenging these issues are, there’s also the impact of these bans on the health of individuals enrolled in employer plans, and the plans’ claims costs. And the very real concern that the individual impact will be disproportionately felt by BIPOC and lower-income employees.

Here’s just one brief article highlighting this concern. As Employee Benefit News (among other media outlets) reports, Black women are three times more likely to die from childbirth than white women. Complications from pregnancy not resulting in death also disproportionately occur in black women. As with other health care issues, Social Determinants of Health (including access to quality care) are already playing a big role in who is and who isn’t receiving the care they need.

Item #4: At the most painful of times, our system often creates more pain.

This last item doesn’t fall under the “news” heading, but rather is an opinion piece authored by a veteran ICU nurse and published in the Atlantic. In The Medical Care that Helps No One, Kristen McConnell writes about the “futile care” she and her colleagues often deliver, and which causes both confusion and trauma for the patients’ family members.

As I wrote on LinkedIn when I recently shared this article, we must do better for those receiving care and for those who love them:

Having had experience with end of life care and decisionmaking — the first time on behalf of my Dad, the second on behalf of my spouse — I strongly believe our overall approach needs a significant overhaul.

A good place to start could be a rethinking of what "do no harm" really means, particularly given the tools now available to extend life seemingly indefinitely, as the author of this piece so eloquently outlines.

What I do know is that having to make an end-of-life decision regarding my spouse 4 times in less than 48 hours (the first 3 in the span of 30 minutes in the middle of the night) was harmful to me and of no help to my husband. It did, however, generate additional revenue for the hospital.

A Final (Flawsome?) Thought

While there are some who believe that there’s no room for politics in the workplace, and that corporations shouldn’t take “sides,” the fact is politics has always been the business of business. I recently watched a documentary on the Vietnam War that included a segment on the involvement of some companies in supporting the anti-war movement. And, yes, those that did speak out incurred some criticism.

Today, though, the "war" that’s playing out and directly impacting employers is a high-stakes culture war. (Exhibit A: The Walt Disney Company’s (now-expanded) lawsuit against Florida Governor Ron DeSantis, and a DeSantis-appointed board's subsequent countersuit.)

Corporations have much to worry about while operating their businesses. Among those problems and concerns are how to provide comprehensive, equitable, inclusive, and accessible HR programs in a competitive, compliant, efficient, and cost-effective manner. It’s never been an easy task, but today it’s harder than ever; harder than it should be.

As the items I've shared highlight:

  • Social determinants of health — over which employers have little control — account for at least 50% of their employees’ health, reducing longevity and increasing claims costs. These rising costs have put pressure on employers to keep employee cost-sharing reasonable; still, some employees may need to become medical tourists to access care they can afford.

  • All too frequently, futile care is provided, which helps no one, and in fact induces trauma and adds unnecessary costs for those footing the bills.

  • Lastly, political issues are impeding employers’ efforts to provide benefits — benefits that have become standard — equally to all their employees across the U.S.

We know the problems. Is the answer that it’s time for employers to expand and increase their efforts in reshaping the nation’s policies — at all levels of government — that have a material impact on the health of their employees and on their businesses?

Yes, I'm suggesting an expansion of and increase in lobbying efforts by employers regarding health care in this country, the policies that impact the wellbeing of their employees and families, and the resulting administrative and cost burdens employers incur.

It may not be a perfect solution. Call it “flawsome,” even. But lobbying for change is better than accepting our flawed current state as our fate.

I invite you to like (or otherwise react to) or comment on this post here.

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