From the Gee, Didn't See That Coming Department:

The Globe reports that "the minimum requirements for coverage under the state's new health insurance law [will] cost $380 a month on average for an individual, more than $100 above recent estimates." 

Factor in the Big Dig Effect and by the time the plan is actually ready to roll, the cost should be somewhere between $800-$1000 a month for basic coverage, with 200% copays.

Everyone will die.  I don't mean because of this new legislation.  I mean, regardless of it.  But not everyone will suffer from a long-term disease or a catastrophic illness which will require constant care, frequent visits to the doctor, and lots and lots of prescription meds, before they do.  Problem is, we don't know exactly who will and who won't, although we're getting better at predicting it. 

The debate is really not about whether the "collective"—"society," "the public," "taxpayers," whatever you want to call "us"—will have to help bear the cost of caring for the sick and infirm among us.  The question is not whether anyone can afford care for a chronic condition, because the truth is no one can.  The real question is who will administer the transfer of funds. 

This is why the bugaboo of "socialized medicine" is always popping up in the insurance debate.  Because the choice is between the government regulating costs and managing payments directly or funneling them through private  firms (who will certainly be very happy for the business the state government—through its recent mandate—is throwing their way).

The fact is, with the new legislation the government will still provide free care for those under the federal poverty line (roughly ten percent of the state's population, according to census numbers), and will offer subsidies for those at up to 300% of the federal poverty line—individuals with an income of $29,400 annually. 

But, as I've said, it's those who hover around that line who have decided they don't believe in, or need, or cannot afford health insurance who will be hit hard by the new legislation, which effectively hands insurers 160,000 to 200,000 new customers in this bracket who can't refuse their policies (those who hold out will be fined "roughly $150 a month," according to The Globe, although the way things are going, by the time the fines are finalized, they'll have doubled as well).

Those 160,000 to 200,000 lower-middle-income folks, many of whom may feel they are managing their healthcare and reducing their health risks through diet and lifestyle, and who may—who really knows?—be paying out of pocket for regular—preventative—outpatient care, and finding this approach effective and affordable, will end up paying, by current estimates, a staggering $4,500+ yearly*.  For what will likely be a virtually worthless policy, no less.

The assumption underlying this legislation, which I have never personally heard countered in the debate, is that the uninsured are not engaging in their own regular, preventative care, which is certainly true of a percentage of them.  The insinuation is that their unwillingness to buy insurance is what's in large part responsible for higher healthcare costs (which are, of course, borne by tax-payers), incurred when they encounter a condition for which they require urgent care that may have been prevented if they had gone for regular check-ups, which presumably they would have done had they been insured. 

If this is the logic underlying this legislation—and I believe it is—it's flawed in a number of its assumptions. 

One is the assumption that regular trips to a primary care physician will reduce the likelihood of catastrophic illness or the need for urgent care.  I hate to use my dear old dad, may he rest in peace, as an example again, but he was diagnosed with stage-four lung cancer of the type that if caught early can be treated with some success, despite the fact that he had a primary care physician he saw frequently and a pulmonary specialist that he saw regularly as well, neither of whom caught the cancer in its incipient, more treatable stages. 

My mother's breast cancer—diagnosed shortly after my dad's death—was of the type that doesn't show up on a mammogram, so that all those regular mammograms she submitted to were useless.  And, largely because the alternative detection method (ultrasound) was not covered by her insurance, it was not used.  She discovered the lump herself when it was in stage-three. (My mother is a survivor, but she lost both breasts.)

Both of my parents were well-insured and went to their primary care physicians frequently and without fail.  Both had treatable conditions which developed over time which neither of their physicians caught until the critical—or catastrophic—stages.  It could of course be that this is not as common an occurrence as it seems to me, and my family's experience is exceptional.  But the implication on the part of proponents of this legislation that regular check-ups are a virtual guarantee against preventable diseases is, frankly, wishful thinking.

But let's go ahead and assume regular check-ups are more or less a good thing (which I still do).  Another major assumption is that the uninsured don't go for check-ups regularly.  This may be a flawed generalization, too.  This is related to the assumption that those who currently don't get regular check-ups will when they're insured, simply because they're insured.  There are many factors at play in the latter of these assumptions.  There are money issues, of course, but there are cultural, social, and psychological issues, too. 

So little has been done to educate the public about their healthcare options that this legislation will likely be viewed as an inconvenience or a flat-out penalty, rather than a well-intentioned move on the part of a beneficent government to prod citizens to take a more active role in their personal healthcare.  It's an important point, because proponents of this legislation have argued that, more than anything, the legislation is really for the health and welfare of those 160,000 to 200,000 lower-middle-income folks without insurance whom they assume are neglecting their healthcare because they currently lack insurance.   

But let's look at the math—the real, rather than the imaginary numbers.  Say you're an individual under 40, with no chronic conditions and a reasonably active, low-risk lifestyle (i.e., you're not a mentally ill heavy drinker, smoker, or drug-addict with an irresistible urge to jaywalk and an irrepressible appetite for trans-fat).  With proper diet, and exercise at least three times a week, and no chronic conditions to manage, you'll see a doctor once a year for a routine check-up for between $150 and $300.

Without dental insurance, but with proper daily dental care, you can see a dentist every six months and pay from $90-200 for a check-up and cleaning (a filling goes for around $125 at my dentist's in Back Bay, whom I pay out of pocket).  That's an annual cost of $180 to $400. (Alternatively you could go to one of the dental schools in town and get a cleaning for free—that is, if you don't mind getting a good jab in the gums a few times over the course of the cleaning.)

My eyecare costs me between $100 and $300 annually, I'd say.

So, let's add it up.  If I pay out of pocket for my own preventative care, barring any unforeseen cases of leprosy, bird-flu, or plague (it's coming people, trust me—and T-riders will be the first to go, poor dears)—I'm paying roughly a grand a year for my personally advantageous and socially responsible preventative care.  

And with your fantastic new insurance plan I will pay $4,500 annually?   Plus copays, of course.

That's quite a deal.  Glad someone's looking out for me.

Yes, sure, I understand what I'm really paying that other three-and-a-half grand a year that's not going to my preventative care for is the possibility that sometime in the future a piano will fall on me, crippling but not killing me.  At least that's what the insurance firms want you to think is bound to happen, while at the same time they're gambling on your living a long, long time and making many, many payments, waiting for that piano, before it actually does fall on you.  And then, of course, they would rather it landed two inches to the right, and completely smooshed you.  They don't want you to suffer.  Because when you suffer, they suffer.

And while I'm waiting for the piano to fall on me, doing my pilates every morning, eating my organic vegetables, having that wee glass of red wine to keep my heart healthy, watching my weight and managing my stress with yoga, my premium payments, aside from enriching insurance company execs who invest them, will go to cover the costs incurred by pianos falling on other people who don't have the sense to just die, who can no more afford the cost of their continued care than you could were you in their shoes.  And eventually you will be.

Or will you be?

That's the $4,500-a-year question, innit?  Because what if after faithfully paying your insurance premium for ten years—what if after $45,000 bucks, and no significant, much less catastrophic health issues, your piano finally does fall.  Completely and utterly obliterating you—snuffing out your whole existence in a fraction of a second, without your even knowing what hit you? 

Well, it's Game Over.  You: zero.  Your Insurance Co.: 1.

And think of all the fun things you might have done with that forty-five grand you're out now.  All those things?  Your insurance Company's exec is doing them instead of you. 

Let's get one thing straight.  Insurance is not a universal, foregone conclusion.  It is a particular worldview.  In fact, some cultures reject the concept and convention in favor of "social insurance." 

I will use my father's catastrophic illness as an illustration, again. 

By the time he was diagnosed, his prognosis was dire.  He had six months to live.  His oncologist encouraged him to try various forms of chemotherapy, knowing full well that his condition could not be reversed nor effectively improved by treatment.  Although the word "palliative" was used, his treatment was not palliative in the medical sense. It was palliative only in the more figurative sense of "concealing the gravity" of his condition from him, making it all but impossible to reckon with openly and honestly.  And when you've got six months to live, you can do a lot more with it if you can accept it than if it's the elephant in the room.

Fortunately—and unfortunately—my dad was, as I said, well-insured.  Fortunately, because I can't imagine the cost to my family otherwise.  Unfortunately, because perhaps, had he not been so well-insured, he would not have been put through the futility of a treatment that caused more pain, until the very end, than the disease itself, and all to no purpose.  The staggering cost of my father's unnecessary and utterly ineffectual treatment was all avoidable, but at least his insurance paid for it.  
 
The thing of it is, my dad had more than enough "social insurance" to see him comfortably and peacefully through to his last days.  I took six months off to look after him.  My mother, my brothers, his daughter, my aunts and uncles, his grandkids, his neighbors, his church were all there.  Needless to say: at no cost.   

The experience of a community coming together to take care of one of its own was nothing short of inspiring.  My encounters with the medical establishment during that time, on the other hand, were, um, how can I put it?  Not.  His oncologist was a scourge.  Popping in for a minute-and-a-half to prevaricate.  Prescribe.  Repeat.  The nurses were at least useful—or some of them were.  The home hospice nurse was. 

The hospital experience was vaguely medieval.  When my dad landed in the hospital, which he did two or three times over the course of his illness, the nurses clearly already had their hands full and wanted you to know they weren't about to do you any favors.  One night, alone in his room, my dad fell out of bed, and was not found by a nurse until morning.  Incoherent and unable to get up off the floor by himself, he spent a good part of the night there.  Only because he had been badly bruised in the incident were we told, and then by someone who was not involved.  It was an FYI, not an admission of incompetence, or an apology. 

It was really the orderlies and attendants who offered the most practical and necessary assistance on a daily basis.  The biggest help came from the tough little no-nonsense broad—Phyllis was her name—who dropped in three times a week to help bathe him and change his bed clothes. She was all of four-foot-seven, and when someone’s that small, if they aren't cute, they’re just ornery, and she wasn’t cute. She whistled her s’s through her teeth. She came in, whipped him into shape, whipped me into shape, did her thing, and was off to the next house-call, God bless her.

I mention the orderlies, again, because they were actually a help in this difficult time.  I am convinced, after almost three years of reflection on my dad's illness, that he could have lived out his dying days better without any meddling from the medical establishment at all. 

But why waste all that great insurance, right?

Personally, I think requiring insurance is like imposing a religion on people who don't necessarily share your premises about life and fate.  Of course the more risk-conscious (to put it kindly) a society is, the more sense it will make to insure against potential catastrophe.  The assumption being that the insurance, by paying for medical intervention, will help to mitigate, not exacerbate, that catastrophe.  But will it?  That's the gamble.  And the insurance racket is based entirely on that gamble.   
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*Unless they resist, in which case, their wages will be garnished to the tune of $1800 a year.  I don't see the incentive to join when the penalty for holding out is about a third of what you'll pay by submitting.