Wednesday, May 10, 2017

Headwinds

I am sitting at my car repair place, waiting for them to finish the standard service on our car. Their wi-fi isn't the best, and to be honest, neither is my ability to concentrate right now. So I've given up on the work I was trying to do, and am going to try to write out my feelings, with a vague and probably foolish hope that doing so will make it easier for me to concentrate once I get back to my office.

Yesterday, I heard an offhand mention that Trump had fired Comey as I was closing up after my last meeting and dashing for my car. I was late leaving, and needed to get to school as quickly as I could, so that I could pick up Petunia and take her to her art class. Once I'd settled her there, I went over to the nearby coffee shop, planning to write a post about healthcare. But then I really read the news about Comey, and that plan fell to pieces.

It feels like I'm constantly reassembling the shards of my plans these days. I wanted to write about healthcare to share what I'd figured out about pre-existing conditions. This was a very personal investigation. I already know that I oppose the AHCA because of what it does to Medicaid, but I needed to really understand what it would do to protections for people with pre-existing conditions, because I have one. I am lucky: my pre-existing condition is not life threatening, although it could become so if I lose the ability to treat my mild asthma and it worsens. However, I'm also lucky that my maintenance medication is something I could afford to pay for out of pocket, if it came to that: my maintenance inhaler would cost me ~$250/month, and I can pay that. To be clear, that would be more than I spend on groceries to feed my family for a week, but I could do it. I don't know the cost of the urgent care breathing treatments that I sometimes need to help me get over an upper respiratory infection, but since I need those infrequently, I could probably absorb that, too, if forced, particularly since all of the drugs needed for those more acute treatment sessions are old, and therefore available as generics.

But I know myself and I know what the research has shown about people choosing between a medical treatment that feels optional and keeping those thousands of dollars in their pocket, and I wonder if I'd get the breathing treatment less often that I really should. I want to stay insured.

I am old enough to remember not just the days before the ACA, but the days before there were any protections for people with pre-existing conditions. Then we got a law that said that as long as you kept continuous coverage, you could not be denied coverage for your pre-existing condition on an employer-sponsored plan. If you want to read a harrowing account of what that meant in practice for some people, read Kameron Hurley's account of her 2007 experience with diabetes. Unlike my asthma, that is a disease that really will kill you if you don't treat it.

Anyway, I wanted to know if we were back to the pre-ACA days of needing to keep continuous coverage, or if we were going back further still. I wanted to know because if we were going back further still, I'd seriously consider going back to having a "regular" job so that I would have two lines of defense against losing my coverage. And of course, there would be that little voice in the back of my mind suggesting that we could just move to New Zealand and not have to worry about losing access to basic healthcare.

But then I found the Weeds podcast that discussed the latest bill (the episode called AHCApocalypse III) and learned we'd actually be going to something a little better than pre-ACA: insurance companies couldn't underwrite (i.e., deny coverage or jack up rates) for pre-existing conditions as long as you kept continuous coverage, even if you were moving to the individual market. So, someone like me (i.e., relatively wealthy), will be OK.

But a lot of people will NOT be OK. Continuous coverage can be out of financial reach when someone loses a job, and the assistance the AHCA provides to lower income people is less than what the ACA provides. Also, as I heard Ana-Marie Cox explain on a Pod Save America podcast recently, if the pre-existing condition that you're dealing with is a severe mental health issue, there is a very real possibility that you would not have the capacity to fill out all the forms and do the other bureaucratic tasks required to keep your coverage.

One of the other useful things in that Weeds podcast was an aside Matt Yglesias threw in about why libertarian-leaning Republicans like the Freedom Caucus are opposed to the ACA. It is not just the taxes. It is that many of them genuinely believe we should not be using health insurance to cover routine healthcare. They think it distorts the market and is responsible, at least in part, for driving up the cost of healthcare. They think we should have catastrophic health insurance to cover truly unforeseen things and big surprises, but that "routine" things like my asthma treatment, Petunia's best friend's insulin and test strips, having a baby, and the like, we should pay out of pocket. There is a frequent comparison to car insurance, which does not cover oil changes or the sort of regular maintenance I'm waiting to have done right now.

The problem with this comparison to auto insurance is that we can't decide our healthcare maintenance is getting too expensive and that we should upgrade to a new, more reliable body. There is no equivalent of taking the bus for people who can't afford the cost of maintaining their bodies. We have the body we have. We can try to make good decisions and take good care of it, but we can't choose our genetics. We can't control twists of fate that make some children develop type I diabetes. Libertarians are fond of saying that the government shouldn't be choosing winner and losers, and that the market should decide. But leaving it all to the market just doesn't work in the case of healthcare. It is not government choosing winners and losers, it is genetics and luck. Government assistance with healthcare is the community deciding to even out some of the impact of that luck. My asthma doesn't care if I can afford the maintenance inhaler. A diabetic with a low-paying job still needs their insulin, or they die. A woman who gets pregnant is going to be pregnant whether she can afford to pay for prenatal care or not (particularly if some of these same people get their way and an abortion is difficult if not impossible to obtain).

I do not believe that the majority of Republicans, in Congress or at the voting booth, really want the libertarian vision for healthcare. But that is who they are letting drive their policy choices right now, and so that is what we're aiming for.

So anyway, that is what I wanted to say about healthcare. I convinced myself that I can keep trying to build a company, even if the AHCA becomes law. Wealthy people like me will mostly be fine. I'll still fight this law, because a lot of people won't be fine, but I don't have to start a job search.

But after last night, I'm back to thinking that maybe I should start a job search, because trying to focus on the sort of work I need to be doing to actually build a company is nigh on impossible right now. I'm using all my tricks, and I have some good days. But I have days like today, too. I have noticed that I find it easier to put my head down and work when I'm onsite at a client or focused on a client deliverable than when I'm trying to do "my own" things. Can I keep pushing into these headwinds and do what I need to do to make this company viable? If I'm just going to limp along, supporting the company (and myself) with contract work that is not that different from what I would be doing as a full-time employee, should I keep doing that? Or would I be better off cutting my losses and heading back to a company with benefits? I don't know. So far, I've chosen to lower my head and charge into the headwinds. I'm not sure how long I can keep doing that.

9 comments:

  1. Very thoughtful analysis, and thanks for the recommendations of podcasts so I can go listen to them too. You know yourself best, and I think you will know if it's time to have a "regular" job, or to keep going on your own. I'm certain you won't rush into a decision.

    I'd like to gush how amazing you are at grocery shopping to be able to feed a family of four on $250/month, but I don't want to take away from the gravity of the rest of the post. Also, perhaps your husband does the shopping and cooking, I don't know.

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    1. I do the weekday cooking and the regular grocery shopping. I can't really claim credit for being amazing, though. I think I just made a typo! I'll go back and fix that. :)

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    2. Ha! Yes, a big typo. Writing in noisy car repair waiting rooms is not the best, apparently. I spend ~$200/week at the grocery store. If pushed, I could probably cut that in half, but only by pissing off my kids and annoying myself more than I am willing to do. I'm glad you said something, because I'm trying very, very hard to be strictly accurate in everything I say about healthcare right now.

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    3. You are my hero at $200/week. I spend closer to $350/week to feed a family of 5. I do cook, but not every day. The family is very carnivorous (so deli meat for lunches) and a cooked meal is generally a full meal (meat, vegetable, starch) which I cannot always pull off during the week; we get take out or I cook premade stuff from Costco about 3-4 days a week.

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    4. So there's a bright side to my kids' picky eating! I'd guess cheese is one of our biggest expenses, because that's the most reliable way to get protein into them. I think the only actual cost saving thing we do is make our own bread for the kids. We have a breadmaker, so this is not a big time sink.

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  3. If you do decide to go back to a "regular" day job, maybe looking at it as a break from being self-employed will help?

    Like how we need vacations and sabbaticals from day jobs - to get clarity, perspective and to replenish ourselves, maybe a vacation from being self-employed might help you become better at this self-employment thing the next round.

    Anyway, the point I'm trying to make is this: the tone of what you are saying "cutting my losses" - makes me think you feel going back to a day job is some kind of failure at self employment. I would argue that it is not. You just need better perspective, and who knows - after a "regular-job-sabbatical", your next iteration of self employment will be all you envisioned and more.

    On the other hand, if you push some more through the headwinds, maybe a tailwind will find you?

    As Nicole said, you will know. Hugs.

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  4. Socal dendrite10:45 AM

    This was a very interesting and helpful post - thank you.

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