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A Canadian reporter looks at Texas healthcare.
December 8, 2003 8:35 PM   Subscribe


 
This is sad and embarrassing for the so called Greatest Country on Earth. I am not a big believer in a welfare state, but a certain level of adequate medical care should be a right and not a privilege.

All the while, insurance companies and their executives are getting richer at the expense of patients and hospitals. I can't believe how much my insurance premiums have gone up in the last few years. Even with insurance, I don't feel entirely protected since my doctor and I are at the mercy of a some asshole at an HMO who can deny coverage on a whim.
posted by Blubble at 9:46 PM on December 8, 2003


This is a crazy obsession -- that "the free market" will solve all of society's problems.

If it's in the society's interests to have a good health care system, then society should run it.

We could have the same argument about education, or auto insurance. Why does everything have to be about profit?
posted by MiG at 10:28 PM on December 8, 2003


For what it's worth, the plight of the uninsured in America is much less dire than we think, according to Professor Tyler Cowen of George Mason University
posted by gd779 at 10:35 PM on December 8, 2003


Oh, and I should attribute that link toAsymmetrical Information , who also weighs in with personal experience.
posted by gd779 at 10:39 PM on December 8, 2003


The immigrant argument is fine. I don't buy the "only insured for part of the year" one, however. You don't choose when you get sick. You don't choose when you get in a car accident. You can be paying into the health care system for 30 years, one day get fired, and you're automatically uninsured. Not to mention that half of personal bankruptcies in the US are due to medical bills.

And Jane Galt's pretty fortunate she could afford the doctor visits. A lot of the uninsured can't even do that.
posted by gramcracker at 10:55 PM on December 8, 2003


remember kids to a 'conservative' socialism = liberal and liberal=bad. if you cant pay out of your pocket you dont deserve to be alive. Too bad for a lot of these 'conservatives' they are gonna all the face of the earth in their 'conservative' paradise because they are already too stupid to make the cut.
posted by MrLint at 11:20 PM on December 8, 2003


Hmm, don't agree with this prediction: In fact I suspect that national health insurance would, in the long run, lead to fiscal pressures to limit immigration, thus damaging the health of potential immigrants.

... but Canada let's in twice as many immigrants per capita than the U.S. I would guess because immigrants are generally in good health and not particularly old, they probably contribute more to health care than they use.
posted by bobo123 at 11:28 PM on December 8, 2003


A medical condition can be reason for denial into Canada, in order to avoid a drain on universal health care. I believe that sometimes people with medical conditions are allowed in if they show that they, or a sponsoring family, can pay for their treatment.

I thought everyone had access to basic medical care in the US, regardless of ability to pay - that there were government programs. Maybe a Canadian's idea of basic medical care is a bit different than in the US.
posted by Salmonberry at 11:34 PM on December 8, 2003


In fact I suspect that national health insurance would, in the long run, lead to fiscal pressures to limit immigration, thus damaging the health of potential immigrants.

Canada is the exception to the rule. Most of the European nations (I'm talking about about government policy and popular attitude towards immigrants) are very opposed to immigration in large part because of the drain that an immigrant population puts on a heavily socialist state.
posted by gd779 at 11:36 PM on December 8, 2003


I thought everyone had access to basic medical care in the US, regardless of ability to pay

That would just make them lazy.
posted by homunculus at 11:40 PM on December 8, 2003


gd779, that article is written for people who really want to believe his conclusions and won't look very closely at how he arrives at them. It starts by isolating a couple of excruciatingly narrowly qualified slices of statistical information which mean nothing in themselves, except insofar as they might seem supportive of his case to someone who's really not paying much attention.

He then moves on to this little gem:
Hispanics have by far the lowest rates of being insured, here are some visuals. 41 percent of adult Hispanics are uninsured, of course many of these are recent immigrants.

Well "of course' they are. I mean we all know that, right?. In other words: "hey, when we talk about the uninsured, we're talking about those brown people AND YOU KNOW AND I KNOW that they don't belong here anyway."

Excuse me while I go rinse the taste of that wretched little article out of my mouth.
posted by George_Spiggott at 11:41 PM on December 8, 2003


George_Spiggott: Professor Cowen appears to be strongly pro-immigration, which usually makes it pretty hard to make the argument that "those brown people don't belong here". But don't worry, I'm sure you can find some other reason to hate.
posted by gd779 at 11:51 PM on December 8, 2003


Oh and just to examine that quote a little further: if 41% of the uninsured are Hispanic, and "many" of them are recent immigrants, what does that work out to as a total percentage? Let's be extremely generous to him and say that 50% of that 41% are "recent immigrants" (putting aside the not-all-veiled implication that it doesn't matter if recent immigrants can't see a doctor): that means that 20.5 percent of these uninsured are likely to be these undeserving "recent immigrants". One in five. Is that a case for doing nothing?
posted by George_Spiggott at 11:54 PM on December 8, 2003


But don't worry, I'm sure you can find some other reason to hate.

Oh yes, the "hater" line. Gosh, never seen that gag around here before. Co-opting the supposed language of your opponent is very popular with the right these days, but they don't do it very persuasively. But then, they don't really expect to persuade anyone but themselves, and that's not particularly hard.
posted by George_Spiggott at 12:03 AM on December 9, 2003


Forgive me, George_Spiggott, but I don't consider you my opponent. You frankly don't rise to that level for me. I simply identified, on the basis of your comment, a trend that I've seen in many members here, both right and left - hatefulness. I just called it like I saw it, that's all.
posted by gd779 at 12:10 AM on December 9, 2003


(Actually I now have to own up to an error in the above -- he said "41% of Hispanics are uninsured", not "41% of the uninsured are Hispanic." Big difference. My bad.)

On preview -- nice little snipe there. Internally contradictory, but you can't have everything.
posted by George_Spiggott at 12:12 AM on December 9, 2003


> half of personal bankruptcies in the US are due to medical bills.

Which of course means that the money has to be made up somewhere thus higher insurance bills. Both sides of the ideological fence can benefit from some type of universal healthcare - the fiscal responsbility crowd and creditors have a lot more to gain by keeping these people from declaring bankrupcy and the progressive crowd can use these statistics to prove that universal healthcare is doable. In the US we spend twice as much per capita on health care.

Its an epidemic already, the problem is when will congress recognize it as one and when will the media and our national will demand a working universal healthcare solution. We're the only western nation without some kind of universal healthcare and the richest.
posted by skallas at 12:47 AM on December 9, 2003


Form the article:

Even though she makes only $650 a month, Perez will still have to pay $40 to see a doctor, probably once a week ... "And I don't think the $40 will be too much of an issue. I think they're willing to make that sacrifice because she looks like she's in quite a bit of pain."

Hey, if she's in so much pain, you could probably squeeze her a bit more, you know what I'm saying?
posted by alex_reno at 1:51 AM on December 9, 2003


Access to health care and ability to pay are two different things. Cowen tosses in access at the end of his short, conflicted analysis when he started by trying to say some people don't deserve to be insured. This is a typical problem of the average Internet pundit -- they fumble toward a barrel of issues but can't grasp any particular one.

I happen to agree that illegal immigrants or those waiting to be become citizens shouldn't be covered by a single-payer health insurance plan. Access to health care is a humane issue, though. Anyone who needs to see a doctor should be able to and be billed accordingly. I'm also in favor loosening restrictions against physician assistants and RNs to give medical advice.

However, the health insurance debate isn't about immigrants, access or a kindly old nurse saying "chicken soup and bed rest". It's about the health of a nation's citizens.

The simple fact is more and more people are getting priced out of the health insurance market and this trend shows no sign of slowing. With health care costs going up 50% over the last three years, HMO profits rising without any return in benefit to consumers or slowing in the rate of health costs, in 10 years the basic fact is a majority of Americans will simply be priced out of the market. Employers, especially service and manufacturing employers, will simply stop offering health insurance as a benefit.

At that point one of two things will happen: the government will be forced to step in by democratic demand or large parts of the population simply get priced out of the market.

If you care about this issue much the worst place to go for information is some random dabbler -- the best might just be Uwe Rinehardt. In a quick Q&A he basically predicted the substance of the article that started this thread and most of the Democratic candidate's healthcare plans.

"But if we have a recession, we will be stuck with 30 to 50 million uninsured and we will ration them quite harshly as we always have. And I think that's the system that I see unless a politician with traction could come along and say, "Enough already." But I think ultimately what'll carry the day in November will be a politician will a very minimalist increment approach to cover the uninsured."
posted by raaka at 2:57 AM on December 9, 2003


join us tomorrow, when a texas physician takes an incisive look inside canadian journalism.
posted by quonsar at 3:52 AM on December 9, 2003


(Speaking of not trusting random dabblers, I meant the "majority of Americans in service and manufacturing jobs" would be priced out the market. Not Americans in general. Although if trends continue the number of Americans that simply forego health insurance should be nearing 60 million. That number would significantly jump when certain employers can't afford to offer health benefits.)
posted by raaka at 4:28 AM on December 9, 2003


For what it's worth, the plight of the uninsured in America is much less dire than we think,

From the linked article:
Many other Americans lack health insurance because they are out of work. True, a good health care system should be robust to macroeconomic disturbances, but with employment and productivity rising, these people do not represent much of a current case for reform.
Well, that certainly convinced me.
posted by Armitage Shanks at 5:40 AM on December 9, 2003


Here's a radical notion: get rid of all insurance related to medicine, specifically the health insurance for consumers and liability insurance for the providers.

Here's why:

1. Liability insurance ("malpractice insurance") provides a deep pocket for lawyers to target, and at the same time reduces the direct impact of irresponsibility by the doctor. With no deep pocket to sue, and with the medical staff's career actually on the line, there would likely be fewer cases of malpractice, and more reasonable settlements would be likely

2. Most of what we pay for insurance is simply to inflate health insurers' profits. If there's an 80/20 plan, that means that the patient pays 20%, and the insuror pays 80%, AFTER the deductible is met. Say you get a bill for $10,000. After your $2,000 deductible, the insuror "pays" 80% of the remaining 8,000, or $6,400. You the consumer will be obligated for 20% of that 8,000, or $1600, plus the $2,000, for a total of $3,600. But the insuror doesn't actually pay that $6,400. They will pay as little as $800 for that. You won't know -- your "bill" still shows insurance payment of $6,400. But behind the scenes, the insuror negotiates smaller payoffs. So you end up paying $3,600, and the insuror pays $800. Looks more like YOU pay 80% and the insuror pays 20% --- perhaps you'd have been better off not paying the insurance?

Basically, my point is that the insurance industry has ruined medical care in the US. Thanks to insurance, we have ridiculously inflated prices for prescription drugs, hospital stays, and all medical procedures.

For a good idea of what health care would cost without the influence of insurance companies, look at veterinary care. We recently had a cat go to an inpatient animal hospital for a week, receive high-end testing for kidney problems, was catheterized, and received round-the-clock care for the entire week. Total cost: $125. Did you know that you can get a month supply of prozac, for a dog, for $5? These are the kinds of costs we should have for human medical care, and they are the costs that result when there is a true competition for consumers. It used to be that a simple procedure such as an appendectomy would be affordable without insurance. Not any more.

I don't want "Universal health care with single payer" which is only going to happen in the US if the insurance companies get their profit guaranteed in such a plan. Fuck them.


Our best bet is to eliminate insurance.

here's a good piece that explores some of what I have said, above, but doesn't advocate elimination of insurance
posted by yesster at 6:15 AM on December 9, 2003


gd770 - 'Eurpopean nations...very opposed to immigration in large part because of the drain that an immigrant population puts on a heavily socialist state.'

From whence do you get your information? I can only comment on the situation in the UK, where immigrants contribute £3 billion/year to the national economy after factoring our any benefits and health-care costs associated.
I would imagine that this were the case for all European countries, although this information is not publicised as polititians capitalise on this disenfranchised and easily scapegoated group for political gain.
AFAIK the economy of California relies on cheap immigrant labour, slavery-lite.
Good health care, in fact the best available is a right for every person on the planet, IMHO. We have the technology, the knowhow and the ability, only greed stops this becoming reality.
posted by asok at 6:22 AM on December 9, 2003


Yesster - excellent points.

Prozac for a dog?
posted by swerdloff at 7:28 AM on December 9, 2003


Thinking about HMOs and insurance and the rising costs of health care, I briefly thought, "At least health insurance isn't mandatory like car insurance." God forbid we should be forced to line the pockets of those greedy bastards. Then I thought of a proposed universal health care plan that would have mandated insurance... Please chime in with the details, but I think it was a democratic plan. You can't trust either side.
posted by PigAlien at 7:46 AM on December 9, 2003


My parents' dog had a problem with chewing on her own limb. The vet said it was obsessive compulsive disorder or boredom, but whatever the problem, they gave the dog prozac and she stopped chewing on her paw. It works!
posted by PigAlien at 7:48 AM on December 9, 2003


I think this is one of those instances that show the differnces between USians and citizens of other first world countries.

USians (in the main) think that a National Health Service is evil, and to be avoided at all costs.

Everywhere else, people (in the main) think that private health care without a State-provided backup is evil and should be avoided at all costs.

Speaking as someone who had to go to the hospital last week, and paid in total £6 for a course of antibiotics, I'm in the latter category.
posted by salmacis at 7:51 AM on December 9, 2003


I work in healthcare management, and it is much messier on the inside than it even appears on the outside, which is already deplorable.

Insurance companies are the BANE of medical care in this country. Period.

If we did not have to deal with insurance, we could drop our prices over 40% instantly.

And the above poster was right. Your $100 office visit? Insurance might pay $60. Maybe.

But see, we can't CHARGE $60, or else insurance would only pay us $35.

And it gets worse. The insurance doesn't give the $60 over gladly. Oh no. They deny the claim multiple times for sometimes nit picking but often NO REASON AT ALL requiring multiple followup from Accounts Receivable staff. Why? They get to hold the money another billing cycle or two. Holding 100's of millions of dollars worth of claims for an extra month or so would contribute greatly to their bottom line.

The insurance claims adjustors are required to deny a certain % of claims to keep their jobs. Just like quotas for traffic cops.

So, it costs us maybe $10 in manpower, postage, long distance calls, and transaction costs to collect the $60 that the insurance won't voluntarily hand over. So now we are at $50, and the doc, nurse, front desk, manager, electric bill, medical supplies, and what not have still not been paid.

Would have been a hell of a lot better to just charge the $50 and get paid $50 wouldn't it?

So guess who suffers under the current pricing scheme. The uninsured, who pay the full $100. That's right, the people least able to pay, pay the most. Consistantly. And we can do nothing about it without jeopardizing our already paltry insurance payments.

It's absolute lunacy. And I mean that in all sincerity without a modicum of exaggeration.

By 2015, the US will either have some sort of single payer insurance, or else the medical industry will collapse.

Single payer is far from perfect. At least with single payer, you have ONE entity to file claims to with ONE set of requirements. If nothing else that would reduce the cost to collect the money we are rightfully due to maybe $5 or less. There would be large efficiency gains if nothing else.

The insurance companies are the ones who benefit under the current situation. Not consumers, not medical providers.

The malpractice is another whole discussion for another day.
posted by Ynoxas at 7:53 AM on December 9, 2003 [1 favorite]


I can only comment on the situation in the UK, where immigrants contribute £3 billion/year to the national economy after factoring our any benefits and health-care costs associated.

The UK is different from the rest of Europe. It's much less socialistic. And to answer your previous question, some of my friends in Europe have told me about their immigration debates. Like I said, it's apparently a big deal there.
posted by gd779 at 8:01 AM on December 9, 2003


the problem is when will congress recognize it as one and when will the media and our national will demand a working universal healthcare solution

Come on skallas. You know the answer: "When it starts significantly affecting the middle class!" (Which it already is, and it's getting worse every year.) (Some interesting Census tables.)

Ynoxas: Very well put. Administrative waste is a huge part of it--not just in HMOs, who spend on average, about 15 cents of every dollar on administrative costs (Medicare is around 3 percent)--but in doctors offices, hospitals, clinics, etc.

On malpractice: Canadian malpractice is much cheaper, for a number of reasons (different laws, culture, etc.) but also the fact that everyone's covered. If there's been malpractice by a doctor, but you know that you'll be guaranteed health care for the rest of your life if there are later complications, you're much less likely to sue your doctor. Add to that the fact that you get to truly choose your doctor in Canada, compared to the preset list you get from your HMO--patients are also much less likely to sue their physicians if they know the physician, and feel like the physician is trustworthy, has good communication with them, and feels that he or she is acting in the patient's best interest.

You've gotta think something's up when the president of Ford AND the UAW start mentioning single-payer publicly.
posted by gramcracker at 8:30 AM on December 9, 2003


Come on skallas. You know the answer: "When it starts significantly affecting the middle class!"

Sadly, that may not be true either. Americans tend to vote their aspirations rather than their reality or reasonable expectations -- in other words, there's a strong part of the electorate that tends to be warmly disposed towards the haves and dismissive of the have-nots, irrespective of, and often in stark contrast to, their own position on that scale. It has something to do with the cherished concept of upward mobility on the part of many "mainstream" Americans. Even though statistically speaking few of them are likely to rise significantly above their current economic class in any given generation, they're still not about to bestow any gifts upon a class they're loath to acknowledge as their own and which they hope to leave behind.
posted by George_Spiggott at 8:50 AM on December 9, 2003


Thanks to insurance, we have ridiculously inflated prices for prescription drugs, hospital stays, and all medical procedures.

Well, doesn't the for-profit nature of the medical industry share some of the responsibility for high prices? It's basically profit at the point of a gun (metaphorically speaking). Buy this medicine, or die. Get this surgery, or suffer for the rest of your life.

No other industry has the ability to cause death or extreme suffering when someone can't afford their product.

One thing we do seem to care about in this country though is mental health. Thanks to the county mental health system, I got psych visits and drugs basically free of charge during my long spell of unemployment. Without it, I'd likely be dead.
posted by beth at 8:55 AM on December 9, 2003


The UK is different from the rest of Europe. It's much less socialistic.

So Canada and the UK both show that you can have a national health care system -and- relatively high levels of immigration. Glad that argument is out of the way.
posted by Armitage Shanks at 10:01 AM on December 9, 2003


"Which of course means that the money has to be made up somewhere thus higher insurance bills."

When people can't pay for health care and are not insured it doesn't really effect the insurance company, it effects the hospital or doctor treating the patient.

Health care should be interesting in the next couple of decades. I work in pediatrics and we're beginning to see how it might be. With fertility treatment all the rage, multiple births, to older parents is higher than it was in 1978 when Louise Brown, the first "test tube baby" was born. Many of these pregnancies, especially the triplets + group, are born at low or extremely low birth weights. We can save a lot of the babies, but of those saved, there is a group of them that will have life-long medical conditions. Who's going to pay for this when they become adults?

Remember the McCaughey septuplets? Don't get me started about those people who decide to carry 6 and 7 fetuses at a time. (Remember the McCaughey's already had a child under 2 years old so where was the infertility?) I work at a major medical center with a large and well respected neonatal intensive care unit. We will not deliver more than 3 babies per pregnancy.

"No other industry has the ability to cause death or extreme suffering when someone can't afford their product."

No other industry is required to provide their product knowing that they may never see a dime for it. No other industry has to negotiate the price after the service is delivered. Is there another industry that has to charge 3 times the rate for their product because their primary customers will never pay full price?

A friend of mine had just started a new job and didn't have insurance coverage yet. He wound up with a bizarre infection (MRSA) in his hand. The bill wound up being around $16,000 US dollars. I told him that he could negotiate that down. After negotiating the price the bill wound up being around $4000. Can you name another industry that works like this?
posted by whatever at 10:16 AM on December 9, 2003


I work at a major medical center with a large and well respected neonatal intensive care unit. We will not deliver more than 3 babies per pregnancy.

whatever, I found this sentence alarming. What do you do when you have a patient in your waiting room who is pregnant with 4 or more babies? Do you direct her to another hospital or....?
posted by orange swan at 10:39 AM on December 9, 2003


When people can't pay for health care and are not insured it doesn't really effect the insurance company, it effects the hospital or doctor treating the patient.

It's all linked together. The hospital's provision of uncompensated care to the indigent (which is legal required in many states) raises their costs, and thus the market price for their services. Although HMOs have significant leverage over reimbursement to the hospitals and doctors, it is not absolute leverage. Eventually the hospital will tell the HMO to go to hell if they squeeze them too much.

The arguments about eliminating insurance are interesting. I would argue though that one of the biggest factors that distorts the health insurance "market" (if you can call it that) is the widespread use of employer-provided coverage. Every increase in premiums by HMOs is a raise that workers aren't getting. Of course, workers aren't aware of those costs to nearly the same extent that they would be if they were paying for the insurance themselves. A lot of workers would probably choose leaner coverage and bigger raises over comprehensive coverage and no raises if they had the choice.

The basic problem with private insurance is not that its inherently inefficient but that it seeks to profit by covering the healthy and not the sick. And since the healthy/sick dichotomy is closely correlated to socioeconomic status of patients, it's ultimately a force for increasing social inequality. Interestingly, one simple solution to this problem would be making insurance coverage mandatory, along with community rating and guaranteed issue laws (laws that require insurance companies to provide insurance to anyone that wants it, and at the same price for everyone). This would prevent insurers from cherry-picking, and would greatly lower premiums by forcing young healthy people to enter the risk-pool. Then you provide subsidies to lower-income people to make insurance affordable for them.

So, there you go: universal health care that is not run directly by the government. Just get rid of employer insurance (which would be easy to do by eliminating the tax advantage that employers get by offering it), require everybody to buy insurance, and then force the insurance companies to issue coverage to anyone that applies and at the same price. Then watch prices fall as insurance companies are forced to compete on price rather than on underwriting.

I'm not saying that this is necessarily a better solution than single-payer or fully nationalized health care, but it does allow for the market to set prices, which many economists would argue is preferable to the government setting prices, (assuming that you have a functioning market of course)
posted by boltman at 10:48 AM on December 9, 2003


A patient with 4 or more babies is not in anyone's waiting room. That is a high risk pregnancy and they are in an outlying hospital. We don't accept the transport. There was one case where we delivered 4 babies. The woman had been pregnant a couple of times before with more than three and every time they tried to "reduce" her she lost all the babies. She finally became pregnant with just 4 and they made an exception for her.
posted by whatever at 10:51 AM on December 9, 2003


Let me rephrase the above. A patient with 4 or more viable babies (greater than 24 weeks gestation) is not in anyone's waiting room.
posted by whatever at 10:54 AM on December 9, 2003


Is there another industry that has to charge 3 times the rate for their product because their primary customers will never pay full price? posted by whatever

Well that helps prove my point. The medical co's bill a higher rate than what they need, in hopes of at least collecting something. So those who aren't in a bargaining position, those who have no insurance, really get screwed. They get a bad debt 3x what the medical co actually wants. Plus finance charges on top of that.

boltman suggest requiring everybody to buy insurance - sorry, you lose. Everybody loses with insurance. If you don't need medical care, you lose because you've paid in premiums more than you receive in benefit. If you receive more benefit than you pay in premium, you apparently win, but think about this:
(a) the insurance company will try to find a way to screw you out of your benefit
(b) don't change jobs - you'll be denied coverage for those conditions that caused you to use your insurance before
(c) on the surface, you're essentially counting on the good health of others to subsidize your medical care - yay for you I guess, but you should feel some measure of guilt about that
(d) in reality, you still lose -- so you have a $10,000 medical bill, you pay a deductible plus a percentage, so let's say that's a total of $3600 (same example I used in my last post). The insurance company pays whatever percentage of their billed portion. But the actual cost of that medical care should have and would have been less than that $3600 you're paying. In other words, your "benefit" screwed you.

With insurance, nobody wins but the insurance companies.

Besides that, the notion of requiring everybody to buy insurance really can't fly. In no circumstance can a forced purchase be considered morally right. Forced car insurace - yes, well, that's what you have to do to drive. But forced to pay health insurance just because you're alive - fuck that. It strips all notion of consumer freedom. It only serves to support insurance providers (basically, it's a welfare program for insurors).

I strongly advocate no insurance, and consumers directly pay for their own medical care. Everything contained in my last post.

Of course, the medical care industry doesn't make it easy. In every other consumer experience, you can find out how much something will cost before you buy. Need car repairs? They'll give you a window of cost, and ask your permission before exceeding that cost window. Same for veterinary care. But try to do that for health care, and you're S.O.L.

If we're going to treat medical care as a consumer item, then we need to make it possible for consumers to make informed choices.

A consequence of this, of course, is that if you can't pay for medical care, then you don't get it. I'm willing to live with that. If I were in a situation in which I had a choice of paying $500 for a limb amputation or $150,000 for neurosurgery, vascular surgery, rehabilitative care, etc., for recovering the same damaged limb, then as a rational consumer, I would have to make the $500 choice. So it sounds harsh. Big deal. People live without limbs. I'd rather live without a limb than with a lifelong debt I can never repay.

And if the insurance industry hadn't ruined the medical industry already, I could get that amputation for $500. As it is, the bill would be significantly higher.

Fuck the insurance industry. It is an unnecessary layer of beurocracy feeding of the consumer dollar.
posted by yesster at 11:22 AM on December 9, 2003


The number of sextuplets being born should decrease in the near future with the advent of zygote intrafallopian tube (ZIFT) implantation and blastocyst transfer. I'm not sure people should be allowed to implant 10 zygotes, in hopes that at least 1 will survive--it endangers the health of the mother and the others, if more than one survives.

boltman said:
require everybody to buy insurance, and then force the insurance companies to issue coverage to anyone that applies and at the same price. Then watch prices fall as insurance companies are forced to compete on price rather than on underwriting.

That won't work. That's techinically how the (new) Medicare system is supposed to work. Here's the secret: HMOs advertise to healthy markets, end up getting all the healthy people, and finding perfect reasons to deny care for the sick--"preexisting conditions" or inundate them with so many forms and questions that they just give up.
posted by gramcracker at 12:56 PM on December 9, 2003


Okay, yesster, let's take your arguments one at a time:

If you don't need medical care, you lose because you've paid in premiums more than you receive in benefit.

yes, but that's the whole point of insurance---spreading of risk. When you have a gigantic risk pool, everyone pays the exact health care costs of the average person, which is statistically likely to be pretty close to what you would actually have to pay out of pocket without insurance. But you don't have to worry about going bankrupt due to medical bills or dying in a ditch. This is a real benefit that you gain from insurance which compensates for any overpayment. Plus, society as a whole is benefited when more people are healthy and they have the mental assurance that they are going to be able to afford their medical bills if they get catastrophically ill.

(a) the insurance company will try to find a way to screw you out of your benefit

Any system of health care is going to ration care. There are definitely many HMOs that do a lousy job of it---and this needs to be fixed. However, it's not clear that the government would do a better job of it than the HMOs. At least the HMOs have competition to worry about (competition that would be far more ferocious if individuals paid for health insurance themselves, see, e.g. the cell phone market). And, the idea that the only fair way to ration health care is through ability to pay is morally indefensible, IMO. We're the richest nation on earth. We don't let people die in ditches because they can't afford to go to the hospital.

(b) don't change jobs - you'll be denied coverage for those conditions that caused you to use your insurance before

The purpose of pre-existing condition restrictions in the insurance market is to prevent people from going without insurance by choice and then buying health coverage only once they've gotten sick. Insurance would be economically unsustainable if people could do this. This is a classic moral hazard problem, and one that would be eliminated if coverage was mandatory. You could ban these restrictions with no adverse effects.

(c) on the surface, you're essentially counting on the good health of others to subsidize your medical care - yay for you I guess, but you should feel some measure of guilt about that

Why? Its a mutually beneficial arrangement. You subsidize others when they get sick and they subsidize you. Risk of death or incapacity is reduced for all and all (or at least the vast majority) are happier and better off.

(d) in reality, you still lose -- so you have a $10,000 medical bill, you pay a deductible plus a percentage, so let's say that's a total of $3600 (same example I used in my last post). The insurance company pays whatever percentage of their billed portion. But the actual cost of that medical care should have and would have been less than that $3600 you're paying. In other words, your "benefit" screwed you.

This would only be true if you believe that HMOs are a big cartel and that they are essentially fixing prices. This is a questionable assumption even now (except perhaps in very small markets) By banning underwriting, banning employer-based insurance, and making coverage mandatory for all, you set the stage for a more transparent market in which this kind of anticompetitive behavior would be extremely difficult. For your argument to work, you have to explain why HMOs wouldn't naturally compete for subscribers by offering the best benefits possible for the lowest price.
posted by boltman at 1:02 PM on December 9, 2003


An interesting difference between Canada and the US with respect to malpractice insurance: Canadians don't litigate as much as our southern neighbours. Not because of virtue, but because the stakes are higher. In Canada (except for Quebec), the loser of a civil case generally pays for everything, for both parties. Makes the stakes higher and lowers the chance of speculative legal-lawsuitery.
posted by bonehead at 1:04 PM on December 9, 2003


gramcracker: although you probably couldn't control the more clever cherry-picking that HMOs engage in (advertising, offering free gym memberships, etc), you could certainly deal with the blatant forms--charging higher premiums to the sick, denying coverage for preexisting conditions--through regulation. In addition, the government could act as an infomration clearinghouse about HMOs, publishing information about premiums and benefit packages in order to minimize any informational assymetry that might herd sick people into different HMOs than healthy people.
posted by boltman at 1:07 PM on December 9, 2003


If I were in a situation in which I had a choice of paying $500 for a limb amputation or $150,000 for neurosurgery, ...then as a rational consumer, I would have to make the $500 choice...I'd rather live without a limb than with a lifelong debt I can never repay.

I was cheering for you all the way through your post until you showed you were crazy.
posted by Ynoxas at 2:18 PM on December 9, 2003


(b) don't change jobs - you'll be denied coverage for those conditions that caused you to use your insurance before

Does this still happen? I have a 'pre-existing condition' and I changed jobs this year ... all I had to provide to my new insurance company was a certificate from my old company that I had been insured within the past six months. Presto! Insurance.......
posted by anastasiav at 3:09 PM on December 9, 2003


anastasiav: It's better now than it used to be, thanks to a federal law called HIPAA which regulates most of this stuff. But insurers can still exclude pre-existing conditions for up to a year if they want and they can deny coverage to people in the individual market if they have been uninsured for more than two months.
posted by boltman at 5:53 PM on December 9, 2003


Sensible health care has three requirements:

1) It must be universal. A civilized society simply can not deny adequate health care to its citizens, no matter their socio-economic status.

2) It can not be profit-oriented. When health care is profit-oriented, costs must necessarily escalate in order to support and grow those profits. This has a snowball effect that ultimately can not support universal coverage.

3) Cost risks must be spread throughout the society. This means, yes, health care funding through taxation. When everyone must kick into the kitty, then no one pays excessively.

(At least, not until we start getting stupid with our definition of "adequate." The extreme measures we take to save premature babies and end-of-life seniors are rapidly becoming daft. Just because we have the means to save a life does not necessarily mean we must save a life: there is a quality-of-life quotient that must be taken into account, and in all too many cases of extreme life-saving we only end up giving the victim a horrible life.)

(Also, it would really help America if the government were to put even 1% of the massive amounts of money it puts into the war machine into health care instead. In fact, I'll wager that the US government could provide universal Canadian-style health care without raising taxes at all, simply by reducing the money it wastes on war and corporate subsidization.)
posted by five fresh fish at 10:46 PM on December 9, 2003


Also, it would really help America if the government were to put even 1% of the massive amounts of money it puts into the war machine into health care instead.

You want the US to reduce health-care spending to about $5billion?
posted by ROU_Xenophobe at 11:33 PM on December 9, 2003


Yeah, its a little known fact that roughly 55 percent of total health care spending in the US comes from the government. I'm not sure what the exact figure is, but I'd wager it's substantially higher than the defense budget.

We already have near-universal coverage for the elderly and disabled---the two most expensive groups to cover. It would not be that difficult to cover the rest.
posted by boltman at 1:36 AM on December 10, 2003


ROU, no: it needs to add another $5B.
posted by five fresh fish at 8:51 AM on December 10, 2003


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