Thoughts on health care, freedom of choice and business models

Two stories in the Star Tribune the other day bumped into each other and made me think. The first, "GOP works to salvage health care plan" (March 15), concerns the raging national debate regarding repeal and replacement of the Affordable Care Act, and the analysis of the new Republican plan done by the Congressional Budget Office.

Nobody knows for sure the actual number of people who will lose their insurance under that new plan, or the shift in burden it will bring from one population to another, or how much the deficit will be reduced. But all would agree that they are all large numbers.

The Republican plan underscores an essential American truth regarding an individual's right to choose — in this case the right for an ostensibly healthy citizen to choose not to purchase health care coverage.

There is much debate over the impact this freedom of choice will have on overall insurance costs, although a general understanding is that costs will go up for those who choose coverage. That is a basic and irrefutable tenet of the concept of insurance — smaller pool, higher costs.

The question I have not heard debated is what happens when those who choose to stay out of coverage get sick. Let's say the number who lose/choose not to be covered is 24 million. We all know that, actuarially, some not-insignificant percentage of them will become sick. Not even the most callous Tea Party Republican will argue that they made their choice and need to live with it (or die with it, as the case may be). We have laws and we have history that tell us they will be admitted to the hospital, will undergo tests and procedures, and there will be a bill.

We all pay that bill. So what started as choice for the young and healthy becomes a real and collectible bill for the rest of us.

For those who pay the added expense of an unbalanced insurance market the cost of care becomes burdensome. Burdensome such that some postpone or forgo that screening mammogram or the colonoscopy at 50, or choose not to have that small lump looked at because deductibles are so high that people are essentially funding their own primary care.

These are the unintended consequences of personal choice. A hefty price to lower the deficit.

A second article in the paper that morning, "Private payers get priority at Mayo," quoted the CEO of Mayo Clinic indicating that, all things being equal, the clinic will "give preference to patients with private insurance over those with lower-paying Medicaid or Medicare coverage."

I do understand the business model that depends upon a particular payer mix to maintain sound financial performance. I also see the well-worn slippery slope inherent in policies that compare patients and provide service based on criteria such as private, employer-sponsored insurance vs. Medicaid and Medicare.

I'm a nurse by training and I cannot remember two patients who, "all things being equal," were the same. When Mayo came to the Minnesota Legislature hat in hand to ask for state-sponsored support for a "Destination Medical Center," I don't remember taxpaying citizens being asked: All things being equal, would you like your tax dollars to go to the Mayo Clinic or to your neighborhood community clinic or Hennepin County Medical Center?

Life is full of polarities. The principle of freedom of choice has been key to making this a great country — but not at the price called for in the Republican plan. And while it doesn't make any difference how an organization desires to provide its services if its business model is not sustainable, a sustainable business model falters if it does not honor its mission of ensuring "the patient comes first."