First, the good news: kudos to our legislature for focusing on primary care. Thanks to the work of Senator Pam Luria, Speaker Joe Shekarchi, Senate President Valarie Lawson, Attorney General Peter Neronha and many many others, some critical primary care bills – funding a new family medicine residency for Woonsocket, improving primary care reimbursement under Medicaid by $40 million, continuing to fund loan repayment for primary care clinicians, and dialing back prior authorization – passed and became law. We are now two steps forward from where we were a few months ago. Progress. Good progress. At last.
But we are going to need much more than that to fix a huge health care mess. We are going to have to find a way to provide primary care to all Rhode Islanders, and make sure that all of us have a great primary care practice down the street that is open from 8 am to 8 pm and will see you the same day you are sick, that knows you and your family and your community.
To that end and toward the end of the legislative session, Representative Marie Hopkins introduced a very interesting bill that would have allowed primary care practices to charge all their patients ten dollars a month to support the actual cost of running their primary care practices – all the billing, scheduling, reminding, refilling, form filling out, authorizing and other tasks we now ask primary care practices to do, but aren’t paid for.
Truth be told, the actual cost of good primary care is about $60 per person per month. That number buys us the services of a robust primary care team – doctors, nurse practitioners, nurses, PAs, mental and behavioral health workers, community health workers, social workers and so forth, the people it takes to make sure that there is always someone to listen to you when you are sick, the same day you are sick, and spend time with you – but also the people to make sure you get all the prevention and monitoring you need to keep you healthy, and to make sure they have the time it takes to get all this done.
When you do the math, it turns out that primary care practices are actually earning between $17 and $25 from seeing patients and billing insurance, so they are doing for about $20 a month what costs $60 a month, which is why they are going bust. (They spend about 40 percent of their earnings on billing and collections. Yikes!) Anchor Medical died, and 25,000 people lost primary care, for a lack of about $15 per patient per month.
Representative Hopkins’ bill was interesting because it provided a way to help close the gap, at a time when both the state and insurers have real financial challenges. Ten dollars a month isn’t nothing, but it’s less than what most of us pay for coffee or lattes in the course of a month, and far less than we pay for streaming services or for the junk food that makes too many of us sick.
The legislation didn’t move forward, in part because it was introduced late in the session, but also because of important objections.
To my dismay, some of the pushback came from the union movement, which didn’t want its membership, a membership that fought hard over many years for their benefits, to have to pay more for healthcare.
That resistance represents the conundrum of how to fix health care. Unions, like the rest of us, don’t want to pay one cent more for healthcare that is egregiously expensive – I get that.
But if we don’t find a way to pay for what works to control costs and improve health, we’ll keep paying more and getting less.
There’s a mountain of evidence telling us that when everyone has good accessible personal primary care – doctors and nurses who know you and listen to you – the cost of health care drops, twenty, thirty, forty, even fifty percent.
If everyone paid $720 per person per year for primary care, it’s likely that everyone would save $ 7,500 a year on health insurance, which translates to a $ 7,500 a year raise.
No one wants to look under the hood and understand why health care costs as much as it does, because change gores someone’s ox, and that someone usually has lobbyists and political power. No one wants to cast the first stone – to pay a little more for what matters and to help us develop the leverage we need to change this mess – because everyone is afraid to take anything from anyone, remembering that this is Rhode Island, and we’re all related, and we all know a guy.
But in a certain way, healthcare now represents a kind of wage theft – it’s expensive because insurers, hospitals, pharma and others have buried the expense in the packaging of health insurance, and no one has the patience or determination to deconstruct that mess. Which means working people have to pay way more than necessary for health insurance – something like $7500 per person per year extra, money that could come to them as wages they can spend, instead of as a health insurance card that often sits unused in many people’s wallets.
$10 per person per month is chickenfeed. It’s crazy that the union movement isn’t going on strike to demand this kind of change.
One more thing. I offended a trusted colleague by my remarks about lawyers, bankers, private equity folks and many others who are making money off health care and/or think they know how to fix it, made in a prior column. I’m sorry if I offended anyone. That said, we are all implicated, all complicit, and all involved, doctors and even nurses first among the compromised, because we focus too much on our incomes and not enough on our ethical obligation to advocate for the health of our communities, our state, and our nation. Don’t like what RFK Jr is up to with ACIP or what Congress is up to with Medicaid cuts? Then let’s learn from the union movement, put our money where our mouths are, and go on strike. By which I mean, let’s keep up patient care but stop using their computers for a week.
Whining doesn’t fix anything.
And let’s approach the health care mess with some humility. It took us fifty years to build this mess. It will take lots of learning, discussion, experimentation, innovation, the free exchange of ideas, and collaboration to fix it. No one person or one profession can do it alone.
