Socialism: Converting Hysterical Misery into Ordinary Unhappiness
December 18, 2013 8:26 PM Subscribe

In real (or at least our preferred) life, we do have other, better things to do. We have books to read, children to raise, friends to meet, loved ones to care for, amusements to enjoy, drinks to drink, walks to take, webs to surf, couches to lie on, games to play, movies to see, protests to make, movements to build, marches to march, and more. Most days, we don’t have time to do any of that. We’re working way too many hours for too little pay, and in the remaining few hours (minutes) we have, after the kids are asleep, the dishes are washed, and the laundry is done, we have to haggle with insurance companies about doctor’s bills, deal with school officials needing forms signed, and more.
posted by latkes (126 comments total) 35 users marked this as a favorite

All I have to say to anyone who thinks these deductibles are too high is that they probably never had to shop for individual health insurance on the insurance market before Obamacare. Because the $5000 deductible, with all the exlusions that are now illegal, was about the best they ever did for a lower- to middle-income person.

As the linked Times piece says, "These plans are more generous than what’s prevalent in the current individual insurance market, but significantly less generous than most employer-sponsored insurance.”

Comparing it to the employer-subsidized plans is apples to oranges - individual plans were always double, triple employer plans. The point is, now you can have them, and at a price you can afford.

Still absolutely worth it. As someone who's spent a lot of time on a tight income, a sudden and unexpected accident costing $2500 you don't have is bad. But a sudden and unexpected accident costing $25,000 you don't have is a massive life-derailer. And it's not hard to run up a bill like with hospitalization. My dad once had an emergency involving surgery and his bills ultimately totalled a million. That's why some of us bought that high-deductible insurance, and why it's still better than none at all.

As to the larger point of the article, yes. That's it in a nutshell, though pretty elementary. We have the resources we need to end the extreme miseries of poverty in our society. "Ordinary unhappiness" would be a dream come true for millions. I agree with the offer that neoliberal, free-marketeer thinking often assumes an Ideal Consumer/Citizen - someone with wits, time, good connections, great reading and language ability, minimal physical challenges, who had many protective factors in their upbringing and have the skills for self-care, and so on. Anyone who has worked with the public knows that Ideal Consumer/Citizens are pretty rare, already quite privileged, and probably not the best profile of person to write the rules for.
posted by Miko at 8:38 PM on December 18, 2013 [57 favorites]

Yes, yes, yes, this. The morass of bureaucratic details an average citizen is expected to stay on top of is just impossible combined with the hustle most of us are trying to perform every day just to keep our heads above water. Add in any complicating factor-- a learning disability, low English literacy, whatever-- and you're on real thin ice. And the stakes are so high; missing some fine print or being misinformed on some procedure can lead to ruin for your family.
posted by threeants at 8:49 PM on December 18, 2013 [9 favorites]

In the neoliberal utopia, all of us are forced to spend an inordinate amount of time keeping track of each and every facet of our economic lives. That, in fact, is the openly declared goal: once we are made more cognizant of our money, where it comes from and where it goes, neoliberals believe we’ll be more responsible in spending and investing it.

This is so true, and such a source of anxiety (among other, much worse effects). I usually feel like I shouldn't contribute to discussions of the financial impact of insurance, because I'm financially ok (at the moment) and have ok insurance through my job. But the fact that so much that should be part of a social safety net has been turned in to a family-level responsibility - things like retirement savings, college expenses, finding a non-fraudulent bank to get a mortgage, fighting with the insurance company when they lie to us for the fourth time in a row about not receiving our claim - this takes so much time and effort and worry. I'm one of the lucky ones, and I'm literally sleepless worrying about what happens to our family if I make a bad choice. What a waste.
posted by medusa at 8:54 PM on December 18, 2013 [25 favorites]

But a sudden and unexpected accident costing $25,000 you don't have is a massive life-derailer.

It's hard to argue that a $10k deductible and a $12k out of pocket maximum on top of several thousand dollars a year in premiums is that much better. At least you can negotiate with the hospital to bring down that $25k. (Of course, some emergencies cost a lot more than $25k, which is a separate issue)
posted by RobotVoodooPower at 9:18 PM on December 18, 2013 [2 favorites]

I completely agree with this piece. It's absurd that we Americans have to use insurance for health care. Everyone gets sick. Just use our taxes & be done with it, like every other developed nation. Thanks Republicans!
posted by wmoskowi at 9:34 PM on December 18, 2013 [37 favorites]

The biggest advantage to insurance in the US, is the power of their price books. We, as individual consumers, cannot negotiate the same 60-80% write-off that insurance companies demand.

That said; I've purchased insurance on the open market as a freelance contractor, and I would have killed for a 5k deductible with a premium under $500 for two people.
posted by dejah420 at 9:41 PM on December 18, 2013 [2 favorites]

We, as individual consumers, cannot negotiate the same 60-80% write-off that insurance companies demand.

If insurance companies couldn't demand that, how much would the procedures and treaments cost?
posted by Pope Guilty at 9:43 PM on December 18, 2013 [3 favorites]

Cribbing from Freud, and drawing from my own anti-utopian utopianism, I think the point of socialism is to convert hysterical misery into ordinary unhappiness. God, that would be so great.

Please, oh please, let people learn what "socialism" actually means. There is nothing socialist about the Patient Protection and Affordable Care Act. The entire thing, with limited caveats, is basically a hand-out to private, capitalist enterprise known as medical insurance. The auto industry bailout also was not socialism. It was government stock purchases of a capitalist enterprise.

Actual socialism in the auto industry would be if the government had taken over the auto makers and then started giving out cars to people needing transportation to and from work. Actual socialism in the health insurance field would have been if for-profit medicine had found itself outlawed and health care were being provided for citizens of the country based on what they needed to remain productive for the common good.

None of this is present in the linked article. It's a victory for the right wing that "socialism" is equated with anything resembling Obamacare, let alone the kind of fighting for deserved paid-for benefits which overextend low wage earning honest people in our current social structure.

Rolling back the tide of redefinition on the real meanings of words which are used for propaganda purposes in order to make the concepts they contain into boogeymen is something which those who seek to introduce actual, beneficial change into the dominant culture is something which is sorely lacking, and which should be fought for by any who have an actual interest in seeing real change being made.
posted by hippybear at 9:43 PM on December 18, 2013 [55 favorites]

Sorry, but anyone who labels a program "socialist" which is designed to continue enriching a few at the cost of the many is either guilty of stupid or misuse of irony.

The USSR was not "communist" either. The US is not the "land of the free". And plastic is not cash. In 1984 the government imposed Newspeak, are we really doing it to ourselves?
posted by Twang at 9:51 PM on December 18, 2013 [5 favorites]

Pfff. We just got our new insurance under the ACA. We're saving $48/month and have gone from a $3000 deductible EACH to a $2000 deductible COMBINED, and have gone from 80/20 coverage to 85/15. A total win. And it wasn't very complicated and took all of 20 minutes. Not that I wouldn't prefer a single payer system but my experience with the ACA does not match up with all the whinging I hear in the media.
posted by HotToddy at 9:54 PM on December 18, 2013 [17 favorites]

One more account to keep track of, one more bell to answer. Why would anyone want to live like that? I sure as hell don’t know, but I think that’s the goal of the neoliberals: not just so that we’re more responsible with our money, but also so that we’re more consumed by it: so that we don’t have time for anything else. Especially anything, like politics, that would upset the social order as it is.

"Somebody" wants us to live like that, because they know individuals with limited free time and better things to do are easy to fleece. Take a look at retirement funds. Who is easier to scam into paying a nice fat expense ratio on a mutual fund, dumb old me, or a well-managed group of accountants running a state pension fund?

This is why the bastards who run our financial system keep drooling over "unfixable" Social Security. It's not Randian purism, they just want to privatize it, increase inefficiencies, and harvest their cut, with society at large footing the bill.
posted by benzenedream at 9:58 PM on December 18, 2013 [30 favorites]

Please, oh please, let people learn what "socialism" actually means. [...] None of this is present in the linked article. It's a victory for the right wing that "socialism" is equated with anything resembling Obamacare, let alone the kind of fighting for deserved paid-for benefits which overextend low wage earning honest people in our current social structure.

I don't think you understood the article.
posted by threeants at 9:58 PM on December 18, 2013 [7 favorites]

Well, what does it mean that America's social democrats, the Democrats brought us the ACA? The Republicans had nothing to do with it--they voted against it. So how on earth can you blame them? Please tell me how.

The Repubican/conservative ideas were, and continue to be paying for "maintenance" out-of-pocket, with subsidies and tax breaks to make that possible. That's probably going to happen when the ACA is trashed some time in the next two years.

Obamacare is moronic. "Insurance" for health maintenance is moronic. Insurance is for big, unpredictable medical disasters. Everything else should be just paid for out of your pocket, with some government help if you need it. Government paying for everything means huge amounts of waste, fraud and really, national bankruptcy and/or rationing.
posted by NiceParisParamus at 10:06 PM on December 18, 2013

America's social democrats, the Democrats

The Democratic party is not nearly a party of social democrats.
posted by immlass at 10:10 PM on December 18, 2013 [14 favorites]

Rationing happens now, it's called "being poor". The US is already the most inefficient and wasteful medical system among developed countries.
posted by benzenedream at 10:13 PM on December 18, 2013 [25 favorites]

As a freelancer, it's been interesting to watch the fallout from Obamacare. From my perspective it is an absolutely massive improvement. Of course the bar wasn't exactly high - our healthcare system went from total shit to merely awful. I was paying close to $300/mo for a plan with a $15k deductible, and I'm young and healthy. Obamacare plan for me is $120 with a $4500 deductible and they will actually pay for shit when I go to the doctor.

Oh and shopping for plans? If you think the ACA websites are bad, previously you had to give a detailed medical and life history, answering dozens of questions on every cold you've ever had on every single different insurers website, before they would word vomit dozens of pages of legalese bullshit at you (or more likely, deny you). Kafkaesque is an understatement.

Really the best part about Obamacare is now everyone knows just how fucking stupid this whole system is. Unfortunately, I doubt the next step will be single payer.
posted by bradbane at 10:15 PM on December 18, 2013 [22 favorites]

All the articles I read complaining about the cost of insurance under the ACA seem to have been written by people who have never had to worry about health insurance. I spent 10 years doing seasonal work and the ACA is a huge, huge fucking improvement. Huge.
posted by fshgrl at 10:18 PM on December 18, 2013 [12 favorites]

And, benzenedream, many countries' citizens have a longer life expectancy than U.S. citizens with less than half the health care costs per capita.
posted by citizenoftheworld at 10:19 PM on December 18, 2013 [7 favorites]

The only good part of Obamacare is that it puts the lie to the claim that Evil Insurance Company Profits were making insurance expensive. That was never true. The American system is very messed up, but it was never because of gauging by insurance companies.
posted by NiceParisParamus at 10:19 PM on December 18, 2013

Government paying for everything means huge amounts of waste, fraud and really, national bankruptcy and/or rationing.

Then how come every other country who's done single payer provides better care for cheaper?
posted by bradbane at 10:20 PM on December 18, 2013 [15 favorites]

citizenoftheworld, that's actually not true. If you tease-out accidents and violent deaths from the stats, Americans have the longest life spans.
posted by NiceParisParamus at 10:21 PM on December 18, 2013 [2 favorites]

" "Insurance" for health maintenance is moronic. Insurance is for big, unpredictable medical disasters. Everything else should be just paid for out of your pocket, with some government help if you need it. Government paying for everything means huge amounts of waste, fraud and really, national bankruptcy and/or rationing."

Are you seriously back? Cuz, um... oooo-kay.

Right. Have you priced medical costs WITHOUT insurance that offers copays? Feel free to go ahead and schedule that endoscopy. That's maintenance, right? You aren't sick. No symptoms. Just need to take a look to make sure you don't have any polyps or odd blockages.

Oh, you have asthma? Yeah, that's something that you need to maintain to keep from it becoming a crisis (disclosure; I spent 10 years with unmanaged asthma, because I could not afford to take time off to go to a doctor, and did not have insurance. This cost me 2 comas due to respiratory failure at age 30). Those meds are $240/inhaler, or $475/script for Advair or other patented medicines. Or you could just spend $12 for an epinephrine inhaler that will "rescue" you from a sudden asthma attack, but also completely fucks your endocrine system because you have to process massive adrenaline spikes every time someone wears too much cologne.

Yeah, no.

Universal healthcare. Healthcare as a not-for-profit industry. Go ahead and put your optional, non-health based medicine as for profit. Plastic surgery or other non-life essential procedures should be for profit.

But you want to charge me $200 just so you can say "yep, you've got asthma, no go spend 50% of your paycheck on meds to maintain it."

/end rant

And just to be a little less vitriolic. At least put some thought into this.
posted by daq at 10:26 PM on December 18, 2013 [19 favorites]

Bradbane, here is a list of why I think that might be less true than the stats you hear indicate:
--see above article;

--especially in the realm of infant mortality, American medicine "counts" births in a way that skews the data in favor of other nations;

--in a number of ways, American medicine subsidizes the rest of the world (MDs we train; R&D we do);

--I think we have people who are culturally pre-disposed to having less healthy people (poor, immigrants, etc.)

--there's rationing (or at least much more rationing) elsewhere; less efforts to keep people alive at the very end.

--we have a vibrant legal system to police crappy medicine and practices, and that costs money.
posted by NiceParisParamus at 10:28 PM on December 18, 2013 [1 favorite]

Does anyone else recall how we had to fill out our own insurance claim papers and send them in years ago? When your claim was denied because you missed a checkmark somewhere or signed on the wrong line, you could start over. When a claim was paid, it usually took months to get the check from the insurance company, but the doctor's office or hospital didn't wait - you had to pay up and settle with your insurance company yourself.

Yes, it was worse in the old days. When the doctor's office started doing all the claim filing and paperwork, oh my - it seemed wonderful. What we didn't know was that the door had just been opened to total loss of accountability and corruption on both sides - the insurance companies, who used the opportunity to raise everything they could, and the doctor's offices, who jumped at the idea of billing for stuff they never did and products they never used.

If your insurance was through your company, which it usually was, that added a third party to the merry-go-round - and more opportunity for mistakes. The company needed to keep its claims down in order to keep its premiums down, so it pretty much came down to you fighting the battle alone. I firmly believe that once the paperwork was taken over by everyone else, leaving the patient out, it was like a match to dry kindling - the price of everything skyrocketed, the accountability disappeared, and before you know it, no one knows nothin'.

The Affordable Care Act is just the beginning - we need universal health care and we will have it. The word "socialism" is just a keyword to trigger knee-jerk hate - hate without any understanding - just a Pavlovian exercise engineered by the right wing.
posted by aryma at 10:29 PM on December 18, 2013 [15 favorites]

Daq, yes endoscopy is expensive. It will likely never be cheap. But, as I suggested, I favor help for those who genuinely can't afford it. But also, the right policies would lead to lowering the cost of procedures. And if it didn't? Then I would favor even more government help. But the more the government interferes in the market with regulation, the more expensive things get.
posted by NiceParisParamus at 10:32 PM on December 18, 2013

We have a vibrant legal system to police crappy medicine and practices, and that costs money.

The costing money part is right.
posted by ducky l'orange at 10:32 PM on December 18, 2013 [1 favorite]

When I was laid off this month and received my final paycheck of the year, I was horrified to discover that I had earned slightly more than 133% of the Federal Poverty level, I think I got up to somewhere around 139%. This kicks me up into the income bracket where I have to pay income tax, and I am ineligible for state Medicaid. I probably should not have done that last ~$200 of overtime, because that's going to cost me like $500 in taxes.

It appears that my state has accepted the Federal money to extend Medicaid to a higher income bracket, but nobody knows what that level is. I have heard 133%, 150%, and 166% of the poverty line, but certainly I'd be eligible for heavily subsidized State insurance. My current State health insurance has been extended to January 31, 2014, just to make sure they keep everyone covered until they work out this transition.

My state's Republican Governor accepted the Federal subsidies to extend Medicaid, but it asked for (and was granted) a waiver to make some subsidies dependent on joining stop smoking or weight loss programs. So now I suppose I have to worry whether I have a BMI greater than 133% of the standard.
posted by charlie don't surf at 10:36 PM on December 18, 2013 [2 favorites]

Heh. Oh, come on, bring you A game. Stop being cheap. (I'm sorry, I must jovially tease).

From your link: (and I'm going to shine a laser on this one)
"...gross domestic product per capita... that correlates most strongly to life expectancy."

Ok. This is just fucking silly. I mean, really just kindergarden levels of fucking stupid to put right at the beginning. What's the line kids? We all know it by now, we repeat it every day.

CORRELATION DOES NOT IMPLY CAUSATION

Yeah. Next?
posted by daq at 10:36 PM on December 18, 2013 [1 favorite]

. But the more the government interferes in the market, the more expensive things get.

Well, unless they set fixed prices for all medical procedures like they do in Canada. Then things get cheaper and you get in line for them. There is some disagreement on whether that's better or worse. I think it's better on the whole, but far from perfect.
posted by GuyZero at 10:37 PM on December 18, 2013 [1 favorite]

Then how come every other country who's done single payer provides better care for cheaper?

C'mon. Stop comparing apples and oranges. What other country with a population of over 300m has successfully implemented a single payer system? Only China and India have larger populations than the US and neither country has "better care for cheaper." The infant mortality rate (a common metric for comparison of outcome) is five times higher in China than in the US. In India it is almost nine times higher.

Single payer is not scaleable. Bureaucracy and inefficiency is non-linear.

The single payer system in the US, the VA is a typical example of government efficiency. Only 6.2% reported receiving all of their health care at the VA, 6.9% reported receiving some of their health care at the VA, and 86.9% did not use VA health care. The fact that 90% of vets avoid it like the plague is a strong indication that it is something to be avoided.
posted by three blind mice at 10:38 PM on December 18, 2013 [3 favorites]

If you tease-out accidents and violent deaths from the stats, Americans have the longest life spans.

Care to speculate on why the US's life expectancy goes up while everyone else's goes down?
posted by klanawa at 10:39 PM on December 18, 2013 [6 favorites]

That's very interesting NiceParisParamus - I hadn't even considered such confounding factors. I will certainly stop quoting and linking to that page.

Thanks for the heads up.
posted by citizenoftheworld at 10:39 PM on December 18, 2013

--in a number of ways, American medicine subsidizes the rest of the world (MDs we train; R&D we do);

There's a net influx of MDs into the US from other countries.

I mean, what incentive does a US-trained doctor have to go practice anywhere else?
posted by GuyZero at 10:39 PM on December 18, 2013 [6 favorites]

Fixed price for medical procedures would lead to MORE businesses going into the medical procedure business, because it is a safe and guaranteed revenue stream. See every defense contractor with offices near Washington, D.C.

heh. Maybe. But reality says otherwise. Google up canadian medical wait times. There's also a fixed amount of money spent, unlike in defence.
posted by GuyZero at 10:40 PM on December 18, 2013 [1 favorite]

Also interesting from that article, which begins with the premise that wealth=health: Americans have better outcomes for cancer treatment at the point of intervention. No comment on outcomes for those without the benefit of intervention.
posted by klanawa at 10:42 PM on December 18, 2013 [8 favorites]

It's not a perfect indicator, but economists often point to the evolution of prices for procedures that are not covered by insurance to suggest what might happen to other procedures if they were more subject to market forces; things like Lasik and plastic surgery. Those procedures have gone down in price because there's a monetary incentive on the part of MDs and researchers to figure out how to do things cheaper. Actually that's true across medicine, as anyone who know anyone who has had prostate therapy might know. If you regulate prices to much, the incentive to improve things diminishes too.
posted by NiceParisParamus at 10:43 PM on December 18, 2013 [1 favorite]

[To respond to my own comment above, there's an update in the article]
posted by klanawa at 10:44 PM on December 18, 2013

GuyZero, I think "Canadian wait times" are distorted by the fact that those with money can jump the line by easily heading south. And if that option disappears or contracts with single payer here?
posted by NiceParisParamus at 10:45 PM on December 18, 2013

No comment on outcomes for those without the benefit of intervention.

Are you suggesting that US stats are made to look better by a set of people not getting treated at all, and thus not being in the "denominator" of the stats? I hope that's not true.
posted by NiceParisParamus at 10:47 PM on December 18, 2013

GuyZero, I think "Canadian wait times" are distorted by the fact that those with money can jump the line by easily heading south.

This is not a statistically significant portion of the population. I don't have numbers at all, but based on my anecdotal middle-class experience, it never happens. I'm sure it actually does happen, but not to the point where it really impacts wait times in a material way.

That point is always brought up but unless you have hard data to say it happens, it's irrelevant for the vast majority of non-rich Canadians who don't have US medical insurance.
posted by GuyZero at 10:47 PM on December 18, 2013 [2 favorites]

charlie don't surf, that's not how tax brackets work. You don't pay tax on your whole income because it's too high. (Not that there might not be other things that could cause your tax to go up sharply, but it's not what bracket you're in.) Also, Medicaid eligibility is generally determined monthly, not annually, so if you've lost income then you should still be able to get it. Minor quibbles, but I figure especially worth pointing out if you were just going to skip applying! (I'm stuck in the just-above level, but my silver ACA plan is freaking amazing, even if it's going to cost me a little.)
posted by Sequence at 10:50 PM on December 18, 2013 [2 favorites]

"Are you suggesting that US stats are made to look better by a set of people not getting treated at all, and thus not being in the "denominator" of the stats? I hope that's not true."

Um, yeah, we are.
posted by daq at 10:53 PM on December 18, 2013 [4 favorites]

Daq, those articles don't support my fear. Yes, poor people are in poorer health. That wasn't my question.
posted by NiceParisParamus at 10:56 PM on December 18, 2013

Off to bed. Goodnight.
posted by NiceParisParamus at 10:57 PM on December 18, 2013

Well other than arguing with NiceParisParamus I do agree with the article that while it's a good idea to analyze how you're using your money, you simply can't spend all your time doing it and the effort is often redundant. Most people don't have very unusual requirements for health insurance or retirement savings, etc. Regulation ends up being a net gain as it prevents scams and people messing up through standardization.

Neoliberals would have us all wiring our own homes and deciding what voltage to use to suit our individual requirements. While we monitor our own power generation facilities.
posted by GuyZero at 11:02 PM on December 18, 2013 [3 favorites]

Heh. Oh, come on, bring you A game. Stop being cheap. (I'm sorry, I must jovially tease).
From your link: (and I'm going to shine a laser on this one)
"...gross domestic product per capita... that correlates most strongly to life expectancy."
Ok. This is just fucking silly. I mean, really just kindergarden levels of fucking stupid to put right at the beginning. What's the line kids? We all know it by now, we repeat it every day.
CORRELATION DOES NOT IMPLY CAUSATION
Yeah. Next?

daq, I think you're actually agreeing with that article. Some other quotes from the article:

Benjamin Disraeli, British Prime Minister under Queen Victoria, once said, “There are three kinds of lies: lies, damned lies, and statistics.” Nowhere is this more true than in the debates about health-care policy.

Life expectancy is an appealingly simplistic, but deeply flawed, way to think about the quality of a country’s health-care system.

One is wealth. It’s gross domestic product per capita, and not health-care policy, that correlates most strongly to life expectancy.

(Note that the article isn't saying that correlation implies causation. It's actively arguing that using these statistics is a bad idea.)

If you really want to measure health outcomes, the best way to do it is at the point of medical intervention. If you have a heart attack, how long do you live in the U.S. vs. another country? If you’re diagnosed with breast cancer?

Another point worth making is that people die for other reasons than health. For example, people die because of car accidents and violent crime.

What do you say, daq, not so bad after all?
posted by citizenoftheworld at 11:11 PM on December 18, 2013 [1 favorite]

The biggest advantage to insurance in the US, is the power of their price books. We, as individual consumers, cannot negotiate the same 60-80% write-off that insurance companies demand.

This isn't always the case. My insurer, Aetna, managed to negotiate an amazingly shitty ~10% discount with local hospitals for my high-deductible plan. That means I got to pay 90% of the list price out-of-pocket for an ER visit this year. I basically don't have health insurance until I hit my (high) deductible, but I still have a large monthly bill.

Now that high-deductible plans are becoming the norm, insurers don't have the same incentive to negotiate those big discounts with hospitals anymore*. The discounts in those price books are treated like state secrets by the healthcare industry, so you can't even pick an insurer with a good one. The end result is still unaffordable healthcare, and Obamacare really dropped the ball by not fixing that.

* At least for procedures that are less than the plan's deductible, since the consumer is likely to pay for those. They'll probably still negotiate hard on very expensive things like cancer treatments that they'll likely still pay for.
posted by cosmic.osmo at 11:32 PM on December 18, 2013 [1 favorite]

citizenoftheworld,
I'd argue that I am interpreting that sole statement correctly (though I am willing to be wrong, however).

The other part to argue (and especially since you really wanted to get into the medical intervention point which I was kind of letting go, because, well) is this fun phrase "point of medical intervention." Please feel free to google that phrase. I did. It's curious that there are no measurements or studies on what the breakdown is on medical interventions. I mean, it would be a useful data point as to just how or when people are getting medical intervention for their health conditions. Is this point of medical intervention early? What other correlations are there to this early intervention? Does that mean that, maybe, being able to see a doctor on a regular basis (and I don't care if it's paid for through insurance, single payer, or out of pocket) improve the likelyhood of detecting health issues and thus, treating health issues with greater success? Does it meant that when people have access to healthcare, they are more likely to have better health outcomes?

So why the bloody fuck are people arguing on creating barriers (monetary, primarily) for people to get healthcare? Are we really trying to say "oh, if you are poor, you don't deserve to find out if you have a life threatening disease. Medical care for diseases are only for rich people who can afford it?"
posted by daq at 11:41 PM on December 18, 2013 [1 favorite]

Interesting how a post that was primarily about the cost to normal people's quality of life of having to deal constantly with paperwork and statistic overload due to them being expected to be the perfectly informed capitalist about every facet of just surviving, became instead the usual dick waving contest over how great American healthcare is vs the world.

Wonder how that happened.

Anecdata: I had to take an ambulance to hospital to have emergency surgery to remove my (as it turned out) necrotic gallbladder. I filled out one short form. When I left. I paid nothing. I've had asthma treatment, and lots of help with clinical depression, for nothing more than £7 a prescription (which also would have been free if I was poor). Of course, I do pay generally out of my taxes, as we all do proportional to income.

The British NHS serves some 70 million people, and while it may have its flaws around non essential care, it's fucking awesome for when things go sideways. You guys should try it; your system sounds horribly stressful and complicated.
posted by ArkhanJG at 11:46 PM on December 18, 2013 [29 favorites]

Really weird article. First, it puts Socialism in the title, then talks about Obamacare. But it is not what you think. He's saying Obamacare is an anti-socialist plot by neoliberals!

That’s what the neoliberal view reduces us to: men and women so confronted by the hassle of everyday life that we’re either forced to master it, like the wunderkinder of the blogosphere, or become its slaves.

His solution? A welfare state.

That’s what a good welfare state, real social democracy, does: rather than being consumed by life, it allows you to make your life. Freely. One less bell to answer, not one more.
posted by eye of newt at 12:29 AM on December 19, 2013 [1 favorite]

The phrase "welfare state" is intersting, though.

Welfare. It's in the United States Constitution, right there in the preamble (which, yes, does count as part of the Constitution). It is also in the Taxing and Spending Clause. Mentioned twice. That's 2 times. Two.

The modern interpretation of welfare seems like such a strange new speak to the definition of the word by itself. Welfare: definition - the health, happiness, and fortunes of a person or group.

Welfare. The health, happiness, and fortunes of a person or group.

Why is this a bad thing? WHY THE FUCK ARE WE LETTING THIS MEAN SOMETHING ELSE?

Should any of us fall upon hardship that takes away ANY of those three things, we would cry and plead and beg for anything or anyone to alleviate this. Yet every person who denies this to others is simply denying their own vulnerability to all of those things being taken away. This belief that what they have is immutable and permanent. How childish must you be to believe this? How coddled and utterly bereft of imagination or even general empathy do you have to be to say that you are somehow different, or so far removed from this fate?

I hate the world some days. Sadly, today is one of those days.
posted by daq at 12:41 AM on December 19, 2013 [24 favorites]

"Well, what does it mean that America's social democrats, the Democrats brought us the ACA? The Republicans had nothing to do with it--they voted against it. So how on earth can you blame them? Please tell me how. "

Uh, NicePP, since you're from the goatee universe, did the Dems there have a fillibuster-proof majority, large enough that they didn't have to rely on the Yellow Dogs? Because over here, the idea that the flaws in a marginal improvement have nothing to do with the negotiation with the free market nihilists is pretty ahistorical.

"citizenoftheworld, that's actually not true. If you tease-out accidents and violent deaths from the stats, Americans have the longest life spans."

Two points: First off, that doesn't address the broader claim that we have worse life expectancy per dollar than the other countries cited; second, accidents and violent deaths still often include health care.

"--I think we have people who are culturally pre-disposed to having less healthy people (poor, immigrants, etc.)"

Wait, immigrants are culturally predisposed to being less healthy here than they are in their home countries? That just seems like confused xenophobia.

"But the more the government interferes in the market with regulation, the more expensive things get."

This is nonsense and ignores one of the bigger points of the linked essay: That expecting individuals to navigate complex systems with tremendous information asymmetry and incredibly distorting proximate incentives is begging for a market failure; regulation is necessary to overcome those. And "expensive" is misleading there; the Pure Food and Drug Act increased regulation and arguably increased consumer prices, but in doing so, it decreased the external costs of poisoning and quack medicine.

"his kicks me up into the income bracket where I have to pay income tax, and I am ineligible for state Medicaid. I probably should not have done that last ~$200 of overtime, because that's going to cost me like $500 in taxes."

That's mathematically unpossible in a progressive tax system.

"hat other country with a population of over 300m has successfully implemented a single payer system? Only China and India have larger populations than the US and neither country has "better care for cheaper." The infant mortality rate (a common metric for comparison of outcome) is five times higher in China than in the US. In India it is almost nine times higher. "

Wait, you want to complain about apples and oranges and you're making bare-faced claims without controlling for per capita income's effect on health outcomes?

"Single payer is not scaleable. Bureaucracy and inefficiency is non-linear. "

This is a theological claim, not a rational one. It requires belief in a magic exemption to economies of scale while pretending that private insurance is free of bureaucracy and inefficiency.

"The single payer system in the US, the VA is a typical example of government efficiency. Only 6.2% reported receiving all of their health care at the VA, 6.9% reported receiving some of their health care at the VA, and 86.9% did not use VA health care. The fact that 90% of vets avoid it like the plague is a strong indication that it is something to be avoided."

Uh, the idea that vets are avoiding the VA "like the plague" is more an indication of your editorializing. 83 percent of the vets had other private insurance, and 67 percent of vets who received some care at the VA had other insurance. Given that the vast majority of people — even vets — have employer-based health care, that most of them would use that isn't a surprise. And even beyond that, your stat is for all vets surveyed in the last year — 26 percent of them didn't go to any doctor at all. So, we're back down to just over 60 percent of the sample who got health care someplace other than the VA, which is lower than the proportion of the population covered by employer health insurance.

"Those procedures have gone down in price because there's a monetary incentive on the part of MDs and researchers to figure out how to do things cheaper. Actually that's true across medicine, as anyone who know anyone who has had prostate therapy might know. If you regulate prices to much, the incentive to improve things diminishes too."

Two objections. First off, elective surgeries don't have concrete patient outcomes to measure, so price to value is not a good metric for comparing to broader medical care. Second, if you base payments on outcomes, as the new Obamacare billing starts to, then the incentive is to improve efficiency and outcomes to maximize the reward. There's not less incentive there to innovate; there's more.
posted by klangklangston at 12:49 AM on December 19, 2013 [17 favorites]

Just use our taxes & be done with it, like every other developed nation.

Actually, the core idea behind ACA/Obamacare, a system of obligatory health care insurance for everyone, for which you cannot be refused access but which is still provided by private, commercial insurers, is roughly the same as the health insurance system here in the Netherlands.

The major difference seems to be that over here the government hasn't just proscribed health care insurance for all, but also what said health care entails. Your basic, government proscribed health care package is the same no matter which insurance company you go with and companies largely compete on price. It's not perfect (little to no dental care in the standard package) but it does mean that for roughly 100-150 euros a month you're covered for everything that would bankrupt you if you had to pay for it yourself. (As I keep saying, the largest bills we had for the two years my wife spent in hospital were the television bills...)
posted by MartinWisse at 1:29 AM on December 19, 2013 [5 favorites]

Following on MartinWisse's comment wrt France, "a system of obligatory health care insurance for everyone, for which you cannot be refused access but which is still provided by private, commercial insurers" is also what's found here, on top of the core (base) sécurité sociale which is indeed funded by taxes, as well as by base contributions on non-urgent things such as GP visits, for which you end up paying one euro, for instance. The private ones aren't quite "commercial", however, as they're required to be not-for-profit. Mutuelle de santé en France, in French (the English wiki link does not actually have anything about France, weird...).

As for it not scaling to a country of 300 million, this rings very hollow to my American ears. We do happen to have these smaller governmental entities called "states", some of which have implemented their own health coverage programs.
posted by fraula at 1:40 AM on December 19, 2013 [5 favorites]

Big hee hee on the post title.
posted by Wolof at 4:16 AM on December 19, 2013

C'mon. Stop comparing apples and oranges. What other country with a population of over 300m has successfully implemented a single payer system? Only China and India have larger populations than the US and neither country has "better care for cheaper." The infant mortality rate (a common metric for comparison of outcome) is five times higher in China than in the US. In India it is almost nine times higher.

Single payer is not scaleable. Bureaucracy and inefficiency is non-linear.

India doesn't have universal single-payer health care, and the vast majority of their health care is provided by private doctors and hospitals. Plus, both India and China have pretty low levels of spending on healthcare relative to other nations. Neither of these prove that single-payer is not scaleable.

But, hey, you want apples and apples? Let's use Medicare and Medicaid, which each serve populations of about 50m people, equivalent to a large European country such as the UK (which has single-payer) or Germany (which has a universal system quite similar to Obamacare). In 2010, Medicare and Medicaid had a payout error of about 9%, in relation to the total budget. During that same time period the improper payment rate for private insurers was more than double that, at 20%. And in almost every single objective comparison of Medicare and Medicaid effectiveness, they have beat out most or all private insurer, often quite decisively. Medicare's efficiency ratings outstrip those of most private insurers, usually by a good margin (PDF), and it does it consistently from year to year, too (PDF). Meanwhile, Medicaid cost constraints compared to private insurers (and, for that matter, Medicare and FEHP) have been proven to be almost universally superior, because "no payer has been as motivated to undertake cost containment as state governments."

The single payer system in the US, the VA is a typical example of government efficiency. Only 6.2% reported receiving all of their health care at the VA, 6.9% reported receiving some of their health care at the VA, and 86.9% did not use VA health care. The fact that 90% of vets avoid it like the plague is a strong indication that it is something to be avoided.

Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample

Overall, VHA patients were more likely than patients in the national sample to receive the care specified by the indicators (67% vs. 51%; difference, 16 percentage points [CI, 14 to 18 percentage points]). Performance in the VHA outpaced that of the national sample for both chronic care (72% vs. 59%; difference, 13 percentage points [CI, 10 to 17 percentage points]) and preventive care (64% vs. 44%; difference, 20 percentage points [CI, 12 to 28 percentage points]), but not for acute care (53% vs. 55%; difference, −2 percentage points [CI, −9 to −4 percentage points]). In particular, the VHA sample received significantly better care for depression, diabetes, hyperlipidemia, and hypertension. The VHA also performed consistently better across the entire spectrum of care, including screening, diagnosis, treatment, and follow-up. These differences in quality of care held true when we considered only those indicators (n = 72) supported by randomized, controlled trials (57% vs. 45%; difference, 12 percentage points [CI, 3 to 20 percentage points]).

Vets Loving Socialized Medicine Show Government Offers Savings

Patients routinely rank the veterans system above the alternatives, according to the American Customer Satisfaction Index. Last year, the government program got a satisfaction rating of 85 for inpatient treatment, compared with 77 for private hospitals. The index, a University of Michigan project, found that veterans’ outpatient care scored 3 points higher.

Proponents say the agency also offers a model for restraining health-care costs. While an August report from the nonpartisan Congressional Budget Office found a “substantial degree of cost control,” it also said the comparison with private care is difficult because of the changing mix of enrollees in the veterans system and differing benefits.

posted by zombieflanders at 4:22 AM on December 19, 2013 [15 favorites]

HotToddy: And it wasn't very complicated and took all of 20 minutes. Not that I wouldn't prefer a single payer system but my experience with the ACA does not match up with all the whinging I hear in the media.

My whine about the sign-up for the ACA is that getting information about the calculated income and IRS end of it is challenging for someone like me who has an income that isn’t predicable for the next year. I started in early October trying to get it all settled. I even went to an independent insurance agent and gathered all of their suggestions and hints, but could not get comfortable with the possible penalties for wrongly estimating income.

Of course, my state has not accepted the Federal money to extend Medicaid. And I may or may not fall below the poverty line because I’m self-employed thus my income varies greatly from year to year. So, here’s what I’m left with: I either don’t qualify for a subsidy under ACA, or I guestimate my income for 2014. Fine and dandy, but if my income is drastically different than anticipated, then my subsidy is recalculated at the end of the year and I have to pay back the difference in premium.

I don’t have the tolerance for that kind of swing in payments, which could add up to thousands, so I gave up on the ACA and just kept my crappy $5000 deductible (100% co-pay) plan. And that premium went up by $35 per month.

I too would prefer a single payer system that wasn't penalty based.
posted by mightshould at 4:32 AM on December 19, 2013 [1 favorite]

Just paying with taxes is a TERRIBLE idea--it minimizes the possibility that things can be done for less (aka better, a la every other realm of life), and assures that as much wasteful, useless care will be sought and rendered.

And if you say, "well, it works elsewhere, e.g., in places in Europe, I say, yes it does, as does rationing, higher mortality rates (once other factors are considered); and WE in the USA subsidize those other systems in myriad ways, so of course they pay less.
posted by NiceParisParamus at 5:28 AM on December 19, 2013

My wife an I are struggling with what to do about our insurance. Up til now, we've been buying our own on the "open" market, to the tune of about $1100/month. For that sum, we are saddled with a $5000 individual/$10,000 family deductible schedule. Plus, damned near everything is an out-of-pocket expense, applied to deductible.

Of course, we were informed that our policy was being cancelled. Though, somehow, we are able to extend it through next November.

So, we took a look at the Marketplace. This is, though, Indiana. A state which shouted a defiant "fuck you" to Obama and did not accept the Medicaid expansion. Our choices on the Marketplace are abysmal. We had a total of two options, and both were limited to a single particular health network. One was with a network that has a single doc-in-the-box in my county. The other, while it was in the biggest network in our county (including the hospital) was limited to a smaller sub-network of doctors, and had a whole raft of other limitations. Since we don't qualify for any subsidy, both policies weren't appreciably lower in cost than the one we currently have.

Then, my wife's employer threw a monkey wrench in the mix by deciding to offer a business plan (they're a very small business and wasn't required to do so). That policy would cost $1200/month, more than our current policy. Of course, her employer would pay part of the cost, but only for her coverage, not mine. Because her income can be highly variable month-to-month, the part she would have to pay out of her salary would, in some months, take most of her check. And we'd still have to cover me somehow.

My wife has been up over the past two nights literally crying her eyes out going over the details of all these plans, trying to determine the best move for us. There are so many variables, and apples-to-oranges moments that it's simply impossible to figure. The only point that does become clear is that none of this is going to save us any appreciable money over our current policy. We're probably going to hold on to our current policy for now and hope things improve by next November.

At least for this consumer stuck in Indiana, the ACA hasn't improved anything for me. I envy people living in states that took the Medicaid expansion. I hear a lot of good stories. But, it's not happening here in Indiana. Thank you, Gov. Pence.
posted by Thorzdad at 5:31 AM on December 19, 2013 [8 favorites]

Medical bills underlie 60 percent of U.S. bankrupts: study.
posted by lucien_reeve at 5:38 AM on December 19, 2013

Also, my point is actually that Canadian wait times are pretty mediocre. A simple varicose vein removal which took a month to schedule here in the US took my wife about a year in Toronto, ignoring any other differences.

Did you mean mediocre as in not that good, or not that bad?

My experience - which includes working with people who study health care access and wait times in Canada for a living - is that wait times are for non-critical procedures. No one is missing out on life-saving procedures. We do have issues around procedures like orthopedic surgery, which are quality-of-life enhancing - and we're actively dealing with them (thus government grant money to study wait times, etc).

That said, I have experienced health care in the USA (private, excellent insurance), in Canada (private, single payer provincial insurance) and the UK (public health care). For everyday and mental health care, the place where I received the speediest care was the UK (had crisis, needed help), followed by Canada and then the US. The most integrated care (people treating you like a whole person) was in the UK. The best reproductive care was in the UK.

Meanwhile, my friend in the US on a good university-based insurance was left with an infected foot and blood poisoning for weeks due to a wait for treatment ...

And as someone in Canada with a low income, I pay maybe a couple hundred dollars per year in income tax, for which I receive excellent healthcare with NO deductible.
posted by jb at 5:44 AM on December 19, 2013 [7 favorites]

if public healthcare is socialism, then raise the red flag high.
posted by jb at 5:44 AM on December 19, 2013 [7 favorites]

Uh, the idea that vets are avoiding the VA "like the plague" is more an indication of your editorializing.

data point, my Vietnam vet dad went to the VA system after a private insurer struggle over something or other. He loves the VA and has received far better care with them than he has with other providers. He has been really pleased and surprised to find that the experience is far better than the general rhetoric would have you believe and enjoys letting people know about this. The only downside is that the centers are located in out of the way places, a hardship for some. The solution to that is not "end the VA" but "invest in the VA."
posted by Miko at 5:46 AM on December 19, 2013 [3 favorites]

Just paying with taxes is a TERRIBLE idea--it minimizes the possibility that things can be done for less (aka better, a la every other realm of life), and assures that as much wasteful, useless care will be sought and rendered.

The problem with this being, that we're already doing it the market-based way, and it has proven to be more wasteful and useless than single-payer both here and abroad. So, it's only a terrible idea in a hypothetical world you've cooked up For Reasons, but quite the opposite here in the real world.

And if you say, "well, it works elsewhere, e.g., in places in Europe, I say, yes it does, as does rationing, higher mortality rates (once other factors are considered); and WE in the USA subsidize those other systems in myriad ways, so of course they pay less.

We have rationing here, too, or at least we did before Obamacare. It's just called "pre-existing conditions" (one of which can be "female"), pricing, and bankruptcy. So, really, it's cutting down on the rationing that already existed. And as for mortality rates, your comments on this subject have repeatedly failed to take into account the amount of health care spending in this country. For instance, the Forbes link you provided noted that America seems to have the best life expectancy once fatal injuries are removed. What it doesn't note is that the health care expenditures in every single one of those countries are far lower than those in the US. Americans have a whole 0.3 years on the Swiss, and yet we spend almost twice as much (17.9 vs 10.9) as a percentage of GDP on health care. The rest of the list reads similarly or even better: Norway is 9.1%, Canada is 11.2%, Iceland is 9.1%, Sweden is 9.4%, Germany is 11.1%...you get the picture? What's more, every one of those countries is also raising their life expectancy at rates far exceeding that of the US. And that doesn't even take into account the multiple non-mortality metrics at which the US is barely ahead or even well behind.

Americans are spending vastly more amounts of money, and much higher percentages of their incomes, for infintesimal gains or poorer outcomes than those in universal and/or single-payer health care countries. Pointing this out as the glory of market solutions, or a hypothetical American Way, or a shining example of the average American's "economic freedom" is ridiculous.
posted by zombieflanders at 6:13 AM on December 19, 2013 [11 favorites]

Agreeing with Bradbane's comment. I recently went through the process via the NYS website/marketplace. I procrastinated because of the dread of having to find all the info for all the forms and the endless back and forth from some rep or another because they couldn't verify one thing or another.

After shopping through the plans offered on the website, I chose one that seemed a good fit (gold plan, $600 deductible, $440 a month), clicked the confirm button, and waited to get directed to endless forms to fill out. Nope. Instead I had the confirmation number of my insurance coverage with the insurer/policy type that I had chosen and was told that the insurer would contact me about premium payments.

10 minutes. I couldn't (and still don't) believe it.

Interesting side note; because I had been forced to switch to government backed insurance a few years back (the only private insurance I could find was about $2000 a month and they would NOT cover my pre-existing condition the first year), I had to switch doctors from one I liked very much and trusted to one that I was just okay with, my doctor didn't take the state backed (though still private) insurance that I had. My new policy that I just chose is the same one that the doctor previously didn't take, but because the hospital that she is affiliated with is mandating that they accept at least one ACA policy, she now accepts this insurance. All around win for me.
posted by newpotato at 6:37 AM on December 19, 2013 [1 favorite]

We have rationing here, too, or at least we did before Obamacare...

I agree with this. In fact I've called BS on my center-right buddies who don't point it out. But the Phase II question you should be asking is who is in a better position to do the "rationing"/death paneling, etc., A federal or state bureaucracy, or an insurance company? I'd chose the insurance company any day. The Obamacare fiasco unfolding before our eyes proves that. And yes, it is a fiasco on every level (even if a small number of people under 30yo aren't having their rates raised enormously or policies canceled).
posted by NiceParisParamus at 7:05 AM on December 19, 2013

who is in a better position to do the "rationing"/death paneling, etc., A federal or state bureaucracy, or an insurance company? I'd chose the insurance company any day.

Why? Have they done a great job of it so far? Rationing doesn't have a point unless it controls costs, and it's obvious the insurance companies haven't done a good job of that.
posted by mittens at 7:08 AM on December 19, 2013 [5 favorites]

NiceParisParamus, this thread is not your soapbox.
posted by jessamyn (staff) at 7:15 AM on December 19, 2013 [6 favorites]

We're in New York. Our employer-provided health insurance has been growing crappier and more expensive by the year, copays increasingly higher. A zero-deductible plan, but hospital procedures like a colonoscopy were going to cost us $750 where once it had been covered, etc., etc. And we were already paying $850/month for family coverage, not including the employer contribution.

That plan has been canceled. In its place we're signing up for an excellent new plan that evens covers things like mental health services (Hey! Maybe I should give therapy a shot!) and we'll be paying $100/month more than before. Sigh.

it stings and I'd much rather the amount we pay be going DOWN, but I'm more glad that more people are going to have access to health care now than I am resentful that our costs are higher. I'm all for a fair and just society, and if it means things have to get a little harder for me so that people much worse off can have it a little easier, so be it.
posted by Andrhia at 7:19 AM on December 19, 2013 [3 favorites]

Because of Socialism I don't have to bother spending time...

Evaluating which local toughs provide the most comprehensive protection of my home and valuables.
Choosing the right fire rescue plan that includes a cost-effective response time and complimentary oxygen in case of smoke inhalation
Switching my subscription to a different highway system if I change jobs to one that's located outside of my road network.
Renewing my parks membership and upgrading it to include unlimited walking trails and picnics.

posted by RonButNotStupid at 7:28 AM on December 19, 2013 [25 favorites]

My deductible with my employer provided $600+/mo plan is $5k for each family member. Awesomely shitty. Was this shitty years before Obamacare.
posted by lordaych at 7:31 AM on December 19, 2013

"I'd chose the insurance company any day."

I used to work in a field ancillary to the health insurance
industry and I have to ask: have you MET us?? At least a government bureaucracy
has to pay some lip service to transparency and answer-ability, for starters.

Also, sorry, mittens, but they HAVE done a good job of controlling costs - THEIR
costs. Costs to the rest of us, not so much.
posted by Chitownfats at 7:32 AM on December 19, 2013 [11 favorites]

I'm honestly not trying to start an argument, but I am really interested to know:

"and WE in the USA subsidize those other systems in myriad ways, so of course they pay less."

How does the US subsidise other countries healthcare?
posted by Just this guy, y'know at 7:32 AM on December 19, 2013

What is needed is some deregulation, not still more.

That's pretty much the last thing we need.

The health insurance industry has a pretty set outlook. They figure that customers will be off of their books within 2 years. During those 2 years, their goal is to spend as little as possible on those customers while charging them as much as possible. That's the basic idea of insurance - you pay out less than you take in, or you go bust.

A health care model that would work (in terms of providing a healthy population) involves extensive preventative care. A good deal of serious illness is avoidable, if sufficient care is taken. Insurance companies do not want this. From their perspective, a customer is a hot potato - you do exactly as much as necessary to not be the one carrying them when they get seriously ill. Preventative care, from this perspective, is more likely to help a company 2 or 3 carriers down the road, not the insurance company providing it now. They're competitors, why would insurance carriers eat into their profits to help their competitors? No; insurance is the business of denying health care. Deregulation is going to make this worse, not better.

The insurance model doesn't work because it doesn't create incentives for preventative care. You need to socialize the whole thing (like Britain, not Canada) and treat wellness as a social goal. On the whole, this model would be cheaper - not because government is more efficient, but because the need is to increase front-end expenditure to decrease catastrophic illness which is a large expenditure. The ACA doesn't fix it - it amounts to forcing everyone to buy insurance so the carriers will have the young/poor/healthy customers they don't currently have, while forcing them to carry the catastrophically sick. It will numerically get more people covered in the broken insurance model without actually increasing wellness.
posted by graymouser at 7:36 AM on December 19, 2013 [5 favorites]

I think the healthcare/ACA discussion is important, but it's also a bit of a derail from the article's point that by reducing everyone to consumers of everything, individuals are buried under a mountain of time-consuming responsibilities and tasks that could be much more efficiently handled by a communal resource.

For instance, I don't have the time to inspect the food I buy for containments, nor do I even have the time to research the information necessary to select a good testing firm, and even if I did, I certainly don't have the time to continually re-evaluate their work on an annual basis. Good thing there's a government agency which staffs highly specialized people to do all that for me!
posted by RonButNotStupid at 7:47 AM on December 19, 2013 [7 favorites]

"A federal or state bureaucracy, or an insurance company? I'd chose the insurance company any day."

Despite a greater incidence of payer error and lower quality than Medicare, Medicaid and VA care as rated by patients? That's ideology trumping common sense.
posted by klangklangston at 7:57 AM on December 19, 2013 [7 favorites]

Bradbane: Oh and shopping for plans? If you think the ACA websites are bad, previously you had to give a detailed medical and life history, answering dozens of questions on every cold you've ever had on every single different insurers website, before they would word vomit dozens of pages of legalese bullshit at you (or more likely, deny you). Kafkaesque is an understatement.

Right, pages and pages, including every medication you've been prescribed in the last five years (call around to pharmacies, get them to fax your records, etc), every doctor you've seen, every condition you've had. If you forget something, then later that could be grounds to deny coverage.
This last time I applied I was denied coverage due to a previous back surgery in 2001 from which I've completely recovered. Had to contact the doctor and get him to write a letter, go through an appeals procedure. THAT was time consuming.

For the ACA I told them my age and whether I smoke. That's it (besides my identifying information of course).
posted by HotToddy at 8:01 AM on December 19, 2013 [6 favorites]

RonButNotStupid: That point is undermined somewhat by the fact that the FDA is subject to regulatory capture. This is not to say that regulation is a bad idea, but when you have modern capitalist industries regulation itself can be problematic.

This is not to say I'm against socialism, mind; in point of fact I'm a socialist, but in the social-ownership Marxist sense rather than the regulated-welfare-state social democratic sense. I think that regulations are well-meaning but ultimately will fail in their stated aim. This is because corporations have the ability to influence policy decisions and undermine those regulations.

(I'm hoping this isn't too much of a derail considering "socialism" is in the title of this post. It can lead very easily into a looooooong reform vs revolution debate that has been going on for over a hundred years among socialists.)
posted by graymouser at 8:07 AM on December 19, 2013 [1 favorite]

Just paying with taxes is a TERRIBLE idea--it minimizes the possibility that things can be done for less (aka better, a la every other realm of life), and assures that as much wasteful, useless care will be sought and rendered.

And if you say, "well, it works elsewhere, e.g., in places in Europe, I say, yes it does, as does rationing, higher mortality rates (once other factors are considered); and WE in the USA subsidize those other systems in myriad ways, so of course they pay less.

Do you have anything but faith-based statements to offer?
posted by Steely-eyed Missile Man at 8:15 AM on December 19, 2013 [5 favorites]

That point is undermined somewhat by the fact that the FDA is subject to regulatory capture. This is not to say that regulation is a bad idea, but when you have modern capitalist industries regulation itself can be problematic.

No, it isn't. My point is that individually there's no way we can all be perfect consumers and in the interests of efficiency at some point certain tasks need to be delegated to a collective organization working as a public service everyone's best interest. Are such organizations subject to corruption? Yes. Is having a single FDA more efficient and better than expecting everyone to make an informed decision about which private "food safety certifier" they trust? Absolutely.
posted by RonButNotStupid at 8:19 AM on December 19, 2013 [2 favorites]

My wife and I finally enrolled on Healthcare.gov last night. Thanks to the subsidy, we were able to afford a plan with a $zero deductible and reasonable dental coverage for our kids.

The website was kind of slow, it took about two hours to get enrolled. At one point, I had a question and I clicked on the "Live Chat" thingy and waited fifteen minutes before someone could answer. The answer to my question was: call the toll-free number and ask them. I called the toll-free number and waited twenty minutes before I could speak to someone that could answer my question. So it was kind of a minor pain in the ass.

But, as has been pointed out above, all they ask you is some identification stuff, and do you smoke. Compared to the complete medical history bullshit that insurance companies have been fucking with us with for years, it's a breeze. And we didn't get turned down because my wife had cancer two years ago.

So I'm not sure what the author of TFA means by: "It requires inordinate time, doggedness, savvy, intelligence, and manipulative charm (lest you find yourself on the wrong end of a disgruntled telephone operator). Obamacare fits right in with that world and multiplies it."

Obamacare was the second easiest health insurance enrollment experience I ever had. (The first was when I worked for a Canadian company that fully covered all their USA employees.) As far as dealing with a government program goes, it was slightly more of a pain in the ass than getting my passport.
posted by Cookiebastard at 8:32 AM on December 19, 2013

Neoliberals would have us all wiring our own homes and deciding what voltage to use to suit our individual requirements. While we monitor our own power generation facilities.
posted by GuyZero at 11:02 PM on December 18

Yes, this. If you're focused just on health care, you're missing the point of the article.
posted by medusa at 9:35 AM on December 19, 2013 [5 favorites]

Just paying with taxes is a TERRIBLE idea--it minimizes the possibility that things can be done for less (aka better, a la every other realm of life), and assures that as much wasteful, useless care will be sought and rendered.

And if you say, "well, it works elsewhere, e.g., in places in Europe, I say, yes it does, as does rationing, higher mortality rates (once other factors are considered); and WE in the USA subsidize those other systems in myriad ways, so of course they pay less.

The universe said the dark canvas in the past. Gothe and spanking didn't reconsider the close reply of the underwhelmed Christians. Boxes because 66 token desk forsaken cloud masters.

Evidently I can't do nonsense as well as it's being done in this thread.

I think we have people who are culturally pre-disposed to having less healthy people (poor, immigrants, etc.)

I think this is absolute bullshit.
posted by juiceCake at 9:51 AM on December 19, 2013 [3 favorites]

Uh, the idea that vets are avoiding the VA "like the plague" is more an indication of your editorializing.

Klangklangston, I heart you and all, so this isn't meant badly, but I really wish people who are not actually vets or integrated well with the veteran community would stop talking about the VA, and about what vets feel about the VA. It's really complicated, and I understand the impulse to defend it, because it always comes up in these conversations, but vets avoiding the VA like the plague is not necessarily an incorrect assumption.

Veterans have different opinions of the VA, often depending on what services they qualify, whether or not they are rated service-connected for a disability, and what time period they served in. Some of those opinions are justified for only their particular segment, but that doesn't mean they're not justified.

VA is really bad at initial qualification in the first place. It really enjoys, or seems to enjoy, shutting people out or denying their injuries or need for healthcare in the first place. There's an enormous backlog on claims, and C&P investigators are pretty universally acknowledged to be a worse experience than combat itself. They often start on a presumption the veteran is lying and go from there.

Once you actually get through the gate, the healthcare is a mixed bag, often depending on the facility, how many people are there, and a host of other factors. You almost always have to wait a significant amount of time. It can take an hour and a half just to fill your prescription. You can wait weeks to schedule a medical appointment, even if it's imperative you be seen quickly. However, some of the doctors are highly skilled, and the equipment is occasionally phenomenal. VA offers more additional programs than many healthcare providers, and it's usually free, or very low cost. The hospital costs are often stunningly low.

These things aren't really unique to VA, though. They're similar to other programs, like the NHS, and so there are similarities that can be extrapolated to this kind of relatively socialized healthcare. First and foremost, you don't get luxury goods. You don't get a lot of specialized care, nor do you get referrals for those types of care - even if that is care you would like and care that would benefit your life. Also, attempts are made to ration that care - which is happening here. Whether it's high deductibles or high copays, or long wait times, the government-as-provider has a vested interest in lowering their costs, which means lowering your access to medical care. And that is the problem being complained about above.
posted by corb at 10:25 AM on December 19, 2013

the government-as-provider has a vested interest in lowering their costs

As opposed to who...?
posted by Steely-eyed Missile Man at 10:54 AM on December 19, 2013

I really wish people who are not actually vets or integrated well with the veteran community would stop talking about the VA, and about what vets feel about the VA

These things aren't really unique to VA, though. They're similar to other programs, like the NHS, and so there are similarities that can be extrapolated to this kind of relatively socialized healthcare. First and foremost, you don't get luxury goods. You don't get a lot of specialized care, nor do you get referrals for those types of care - even if that is care you would like and care that would benefit your life.

Maybe we should also leave criticisms/compliments of NHS to people who live under NHS?
posted by RonButNotStupid at 10:57 AM on December 19, 2013 [2 favorites]

I really wish people who are not actually vets or integrated well with the veteran community would stop talking about the VA, and about what vets feel about the VA. It's really complicated, and I understand the impulse to defend it, because it always comes up in these conversations, but vets avoiding the VA like the plague is not necessarily an incorrect assumption.

I posted a couple links regarding the quality of care and perception of patients in regards to the VA above that largely address this.

These things aren't really unique to VA, though. They're similar to other programs, like the NHS, and so there are similarities that can be extrapolated to this kind of relatively socialized healthcare. First and foremost, you don't get luxury goods. You don't get a lot of specialized care, nor do you get referrals for those types of care - even if that is care you would like and care that would benefit your life.

This isn't really true. There is an option for private health care in the UK, for one, if that's what you mean by "luxury goods," although the primary job of health care is to heal, not comfort. I mean, sure, perhaps that's one metric at which the US excels, but it is neither a preferred outcome financially speaking, nor is it one available to most Americans. Also, doctors in the NHS will provide specialized care and referrals, but there are higher barriers to get it. Of course, elective and/or unnecessary medical procedures are one of the big reasons why health care is expensive in the US, so I'm not sure how you think that reducing that is a bad thing.

Also, attempts are made to ration that care - which is happening here. Whether it's high deductibles or high copays, or long wait times, the government-as-provider has a vested interest in lowering their costs, which means lowering your access to medical care. And that is the problem being complained about above.

Well, no, the problem being complained about above was this:

The single payer system in the US, the VA is a typical example of government efficiency. Only 6.2% reported receiving all of their health care at the VA, 6.9% reported receiving some of their health care at the VA, and 86.9% did not use VA health care. The fact that 90% of vets avoid it like the plague is a strong indication that it is something to be avoided.

But as I pointed out, the VHA is one of the most efficient health care systems in the country, easily beating out the private insurance industry and edging out similar (but not identical) programs like Medicare and Medicaid, which are themselves almost always more efficient and effective than private insurance. And since government-provided health care nearly always provides better cost constraints than private health care, if you're someone who is serious interested in lowering costs across the board while maintaining superior levels of service, you should be cheering VHA/Medicare/Medicaid/etc, not denigrating it. Besides, "lowering costs" is something everybody involved in healthcare wants, with the exception of people looking to profit off of it. If government-provided health care was actually the wasteland that conservatives always portrayed it as, every single health metric in the US would be be miles ahead of the rest of the world. The fact that it isn't, and is often just the opposite, should be a clue as to where the real problems are.
posted by zombieflanders at 11:02 AM on December 19, 2013 [5 favorites]

If you tease-out accidents and violent deaths from the stats, Americans have the longest life spans.

NiceParisParamus, I followed that link and then the one given there to this presentation, where we get the table with no information on precisely how it is obtained. The authors (Ohsfeldt and Schneider) have a book, which I haven't checked. Their results seem a little strange, with expectancy decreasing for many countries when you take *away* violent/accidental deaths, and the update at the end of the Forbes article does not clear things up for me. It's hard to say more without details on their method, but searching around I found links like this one or this one. I'm not saying there is no effect from correcting life expectancy tables to take away the influence of violent or accidental deaths, but at this point it does not seem possible to just use the link you provided as giving a definitive answer at all. In particular, the first link I give looks at life expectancy for 65 year olds, as a measure suggested by Ohsfeldt and Schneider themselves, and still finds the US in a mediocre position.
posted by anzen-dai-ichi at 11:14 AM on December 19, 2013 [2 favorites]

the government-as-provider has a vested interest in lowering their costs

Say what?
posted by IndigoJones at 11:25 AM on December 19, 2013

They're similar to other programs, like the NHS

Or a private HMO.
posted by Miko at 12:04 PM on December 19, 2013

the primary job of health care is to heal, not comfort...that's one metric at which the US excels, but it is neither a preferred outcome financially speaking, nor is it one available to most Americans. Also, doctors in the NHS will provide specialized care and referrals, but there are higher barriers to get it. Of course, elective and/or unnecessary medical procedures are one of the big reasons why health care is expensive in the US, so I'm not sure how you think that reducing that is a bad thing....If government-provided health care was actually the wasteland that conservatives always portrayed it as, every single health metric in the US would be be miles ahead of the rest of the world. The fact that it isn't, and is often just the opposite, should be a clue as to where the real problems are.

Zombieflanders, I actually do want to thank you for that comment, because it helped illuminate a perspective divide - possibly between just you and me, but I think more likely, between conservatives and liberals on health care.

When I think of what I'd like from doctors/medical professionals, I think less of rationed care, and more of directed care, to include directed care that relates to self-esteem and emotional wellbeing, rather than directed care that just focuses on physical health.

So I'd like to go to doctors that have cheery, clean waiting rooms with not too many people, where the doctor has time not just for a checkup but also to ask about any things that are concerning me, and give full time to those concerns. I want them to listen to what I want. If I am concerned about even stupid shit, like acne or excess body hair, I want them to refer to a dermatologist or someone who does laser hair removal. If I am concerned because my foot hurts me, even if it doesn't actually cause any major problems in mobility but is just irritating, I want to be referred to a specialist who can deal with and remove the source of pain. If I have a wart on my knee, even if it hurts nothing at all, I want to be able to get it removed just because it shouldn't be there and it bothers me. When I give birth, I want to have a private room where I don't have to deal with other people, and a room to recuperate in until I feel up to going home.

So for me, comfort and "elective procedures" are the things that drive my health care choices, and I bitterly resent the idea that these things that I want are terrible things that need to be done away with. That was the experience I had as a kid, and that's the experience I'd like for my kids. I don't want the doctor to be the gatekeeper that says what I want is wrong.

Now, you're totally right that there have always been barriers to that - you need to have pretty good health insurance, or a lot of money, to access that level of kind of casual, thoughtless care. But it seems like a lot of people want to do away with it entirely - to view it as a totally expendable situation in the pursuit of everyone having kind of mediocre care - which is better for a lot of people, but shittier than some. And I think - though of course, I can't speak for all conservatives - the divide may be about this - whether or not it's a good idea to give up those comfort outcomes at which America is best at, in exchange for everyone having uncomfortable but competent outcomes.
posted by corb at 12:07 PM on December 19, 2013

you need to have pretty good health insurance

I am sure this is a YMMV situation because when I was on Vermont's state insurance (basically Medicaid) when I was low income, I had all the things you describe. This may be a rural/urban divide as well, possibly.
posted by jessamyn at 12:11 PM on December 19, 2013 [1 favorite]

corb: "Now, you're totally right that there have always been barriers to that - you need to have pretty good health insurance, or a lot of money, to access that level of kind of casual, thoughtless care. But it seems like a lot of people want to do away with it entirely - to view it as a totally expendable situation in the pursuit of everyone having kind of mediocre care - which is better for a lot of people, but shittier than some."

No matter how many times you say this, across however many threads, it's still bullshit. No system does away with the ability of people with sufficient means to buy themselves whatever level of care they'd like. There is no ceiling, only a floor. You don't want the floor, and we get that already, but you keep trying to scare people with the prospect of a ceiling that simply doesn't exist in any of the more socialized systems in the world.
posted by tonycpsu at 12:12 PM on December 19, 2013 [12 favorites]

So for me, comfort and "elective procedures" are the things that drive my health care choices, and I bitterly resent the idea that these things that I want are terrible things that need to be done away with. That was the experience I had as a kid, and that's the experience I'd like for my kids. I don't want the doctor to be the gatekeeper that says what I want is wrong.

Now, you're totally right that there have always been barriers to that - you need to have pretty good health insurance, or a lot of money, to access that level of kind of casual, thoughtless care. But it seems like a lot of people want to do away with it entirely - to view it as a totally expendable situation in the pursuit of everyone having kind of mediocre care - which is better for a lot of people, but shittier than some. And I think - though of course, I can't speak for all conservatives - the divide may be about this - whether or not it's a good idea to give up those comfort outcomes at which America is best at, in exchange for everyone having uncomfortable but competent outcomes.

I kinda-sorta understand this perspective, but it's just not something that exists in places like the UK or Canada, and has no chance of happening in the US in the foreseeable future. It's certainly not included in Obamacare, let alone proposed as a next step, but rather a boogeyman based on incorrect or incomplete understandings of healthcare systems both here and abroad. If you want comfort and elective procedures and a chatty doctor, there's nothing to stop you from getting that, provided you want to pay for it. And perhaps this is another divide in the debate, since it appears that most Americans would rather have better overall healthcare (or hell, access to healthcare period) with an option for the finer things, rather than it being a requirement outright.
posted by zombieflanders at 12:21 PM on December 19, 2013 [1 favorite]

The degree to which virtually everything that comes out of the mouths of defenders of the US's current (or former!) system is essentially a lie designed to discourage people from supporting an actually functional system is both gross and telling.
posted by Pope Guilty at 12:30 PM on December 19, 2013 [4 favorites]

I kinda-sorta understand this perspective, but it's just not something that exists in places like the UK or Canada, and has no chance of happening in the US in the foreseeable future. It's certainly not included in Obamacare, let alone proposed as a next step, but rather a boogeyman based on incorrect or incomplete understandings of healthcare systems both here and abroad. If you want comfort and elective procedures and a chatty doctor, there's nothing to stop you from getting that, provided you want to pay for it. And perhaps this is another divide in the debate, since it appears that most Americans would rather have better overall healthcare (or hell, access to healthcare period) with an option for the finer things, rather than it being a requirement outright.

So again, I'm not trying for any kind of gotcha, and am totally open to having my mind changed on things. But it's my understanding that the broad and nationwide lowering of reimbursement costs for medical care, while still demanding that patients actually be seen, is having a downward push on the profitability of such medical care, thus essentially pricing providers out of business. (I think I've posted some articles from doctors about their take on this in the past, I can probably dig them up if needed.) Thus, if the government takes on the healthcare for a broad segment of the population (say, the low-income variant), then it gets to decree that the doctor accepts, say, $100 for what he would ordinarily charge $200 for. (I'm going with random simplistic numbers for effect) And sure, on the one hand, some of those are probably people who would not have been able to afford the services previously, but some of them are also maybe people who would have paid over some months, but eventually paid.

So if the doctor really needs to make about 150 per visit, say, in order to maintain his status quo, then (again, as I understand it) he has two options: he can either raise the costs of all of the non-government-fixed patients, which is going to have patients grumbling that other people are getting the service for less while they have to pay more, or he can increase the amount of clients he sees, which means that there is less time for being chatty and involved in the patients and remembering little details of their lives, and more like a machine, trying to get the bare essentials done and no more.

I do think some of this is probably rural/urban divide - in a more rural area, you don't have as much of the demands of rent, and honestly the prices of the government payouts, because they're averaged, may even come close to what you actually charge normally. But these things don't seem to be the case in places like New York.
posted by corb at 12:50 PM on December 19, 2013

corb: "he has two options: he can either raise the costs of all of the non-government-fixed patients, which is going to have patients grumbling that other people are getting the service for less while they have to pay more, or he can increase the amount of clients he sees, which means that there is less time for being chatty and involved in the patients and remembering little details of their lives, and more like a machine, trying to get the bare essentials done and no more."

Why are you artificially holding the number of doctors constant in this scenario? When demand for a service increases, as it will when you have millions of new people showing up, more suppliers will arrive to meet those needs.
posted by tonycpsu at 12:54 PM on December 19, 2013 [3 favorites]

> I think we have people who are culturally pre-disposed to having less healthy people (poor, immigrants, etc.)

> I think this is absolute bullshit.

Pretty much, yeah.

> Thus, if the government takes on the healthcare for a broad segment of the population (say, the low-income variant), then it gets to decree that the doctor accepts, say, $100 for what he would ordinarily charge $200 for.

Where do you get this idea that the doctor who gets $100 for Procedure X from Insurance Deal A isn't free to charge more for the same procedure when a patient doesn't have Insurance Deal A and can and will just pay out of pocket? Nothing in the ACA or before it ever told doctors "You must only charge $X for Thing, ever."?
posted by rtha at 12:58 PM on December 19, 2013 [2 favorites]

If we could keep this thread from turning into ACA 101 and keep it more or less on topic, that would be wonderful.
posted by jessamyn (staff) at 1:13 PM on December 19, 2013

"Klangklangston, I heart you and all, so this isn't meant badly, but I really wish people who are not actually vets or integrated well with the veteran community would stop talking about the VA, and about what vets feel about the VA. It's really complicated, and I understand the impulse to defend it, because it always comes up in these conversations, but vets avoiding the VA like the plague is not necessarily an incorrect assumption."

Well, see, my counterpoint is that when you're dealing with an assertion like vets avoiding the VA like the plague, the purported evidence did not demonstrate that, and the data on patient satisfaction, outcomes and cost strongly implies that many vets prefer the VA, for any number of reasons.

Are you confused by the idea that if people are not "avoiding the VA like the plague" that doesn't mean that the VA is perfect or doesn't have problems that need to be fixed? That's a problem with inferences; the VA has plenty of problems that should be fixed, the top being the insanely long wait times for eligibility and determinations. But given that the VA is being used as a boogie man, it's worth pointing out that for all its flaws, vets are preferring to go there and it has a lower incidence of payer error.

I think this is something that people miss when discussing universal/socialized/subsidized/government-run health care: It's not going to be perfect, it's probably not even going to be great — it's going to, as the very title of the FPP alludes, convert hysterical misery of our current system into ordinary unhappiness.

"Veterans have different opinions of the VA, often depending on what services they qualify, whether or not they are rated service-connected for a disability, and what time period they served in. Some of those opinions are justified for only their particular segment, but that doesn't mean they're not justified."

Sure, but what we see from surveys is that veterans who have gotten VA care tend to prefer it. So, that's not an argument against VA care, as it was posited, it's pointing out flaws in the eligibility process.

It's also worth noting that a good portion of that is due to the VA being underfunded, which was primarily a GOP legislative action.

"Once you actually get through the gate, the healthcare is a mixed bag, often depending on the facility, how many people are there, and a host of other factors. You almost always have to wait a significant amount of time. It can take an hour and a half just to fill your prescription. You can wait weeks to schedule a medical appointment, even if it's imperative you be seen quickly. However, some of the doctors are highly skilled, and the equipment is occasionally phenomenal. VA offers more additional programs than many healthcare providers, and it's usually free, or very low cost. The hospital costs are often stunningly low."

Yes, and again, that still rates as BETTER than the alternative of private insurance on quality and cost metrics.

"These things aren't really unique to VA, though. They're similar to other programs, like the NHS, and so there are similarities that can be extrapolated to this kind of relatively socialized healthcare. First and foremost, you don't get luxury goods. You don't get a lot of specialized care, nor do you get referrals for those types of care - even if that is care you would like and care that would benefit your life. Also, attempts are made to ration that care - which is happening here. Whether it's high deductibles or high copays, or long wait times, the government-as-provider has a vested interest in lowering their costs, which means lowering your access to medical care. And that is the problem being complained about above."

But none of those things are unique to socialized health care. Especially when controlled for cost — that you don't get luxury coverage is meaningless when compared with someone who can't afford luxury private coverage. And that the VA doesn't cover these things doesn't mean that they aren't available, it means that they're extra costs, just like every private plan. It's like complaining that the vending machines at the VA don't have caviar — there's no caviar in the vending machines at Kaiser either.

Further, one of the best reasons to rely on broad studies is because people rarely understand the forgone alternative or the opportunity costs. Vets with VA care still complain about VA care, but they don't necessarily know what non-VA care is like, which is why it's worth noting that vets who have had both generally prefer VA care.
posted by klangklangston at 1:19 PM on December 19, 2013 [4 favorites]

"I don't want the doctor to be the gatekeeper that says what I want is wrong."

They're not saying it's wrong; they're saying that we won't pay for it and you're welcome to pay for it on your own. Which I'd think you'd support, honestly.

"Thus, if the government takes on the healthcare for a broad segment of the population (say, the low-income variant), then it gets to decree that the doctor accepts, say, $100 for what he would ordinarily charge $200 for. (I'm going with random simplistic numbers for effect) And sure, on the one hand, some of those are probably people who would not have been able to afford the services previously, but some of them are also maybe people who would have paid over some months, but eventually paid."

This is both a weird misunderstanding of reimbursement procedures (rtha can tell you more) and one of those inconsistencies worth highlighting: If it's private insurers cutting reimbursements and payments based on their costs, well, then that's pressure on doctors to innovate and cut costs themselves! But if it's the state, that's strangling free enterprise!
posted by klangklangston at 1:25 PM on December 19, 2013 [4 favorites]

you need to have pretty good health insurance, or a lot of money, to access that level of kind of casual, thoughtless care.

The only time I've ever had insurance good enough for "casual, thoughtless care"--i.e., the kind Robin describes in the posted essay--is when I had Medicaid. I could go to the doctor anytime I needed to, be referred to whatever specialist I needed to see, and not have to worry about saving up to pay the copay or deductible, and not have to worry about getting a bill for thousands sprung on me a few months later when insurance decided not to pay.

That is so, so different than any insurance experience I've had since then.
posted by mittens at 1:26 PM on December 19, 2013 [2 favorites]

which means that there is less time for being chatty and involved in the patients and remembering little details of their lives, and more like a machine, trying to get the bare essentials done and no more.

This is also a great incentive for targeting the use of doctors' time better and employing more holistic models of care. Doctors, really, are 90% technician, and I don't need them to be chatty and talk about details of my life. In a real holistic health-care model, I'd have a service coordinator/case manager who got to know me and did the chatting, and set me up with opportunities to speak to providers who have specialties consistent with my needs. Sometimes that's a doctor, if I need a diagnosis or prescription, but it could be a PA or NP, or a nurse, or a therapist, or a physical therapist, etc. etc. I agree that the end goal of health care in the ideal world is total well-being; I don't agree that expecting doctors alone to supply that makes financial sense. In fact, as long as we're imagining doctors as the be-all and end-all of the health care system, the people we design the whole thing for, we're keeping ourselves pretty far away from that ideal of comprehensive, holistic care.
posted by Miko at 1:31 PM on December 19, 2013 [4 favorites]

Zombieflanders, I actually do want to thank you for that comment, because it helped illuminate a perspective divide - possibly between just you and me, but I think more likely, between conservatives and liberals on health care.

When I think of what I'd like from doctors/medical professionals, I think less of rationed care, and more of directed care, to include directed care that relates to self-esteem and emotional wellbeing, rather than directed care that just focuses on physical health.

[...]

So for me, comfort and "elective procedures" are the things that drive my health care choices, and I bitterly resent the idea that these things that I want are terrible things that need to be done away with. That was the experience I had as a kid, and that's the experience I'd like for my kids. I don't want the doctor to be the gatekeeper that says what I want is wrong.

I understand your position, and I can sympathize with it to a degree. But you also said:

So again, I'm not trying for any kind of gotcha, and am totally open to having my mind changed on things.

I try to have the same attitude - truth over ideology. In this spirit, see what you think of this - an FPP I made some time ago:

A landmark study has established that patient satisfaction is correlated with mortality - in the wrong way. The more satisfied, the greater mortality. What accounts for this dynamic? And what are the implications for healthcare costs and available political options? 'One of the primary findings itself raises concern—a 26% mortality excess among the most satisfied patients, an effect size that far exceeds that for all other, more immediate, study outcomes (eg, a 12% excess in hospitalizations).'

The Cost of Satisfaction
A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality

Consider why patients express satisfaction - one of the reasons is that the doctor may cooperate in ordering tests and procedures and often specific medication merely because the patient requests it, even if it is highly inadvisable medically. The doctor makes $, the patient is satisfied - win/win on one level. Only it ends up badly for the patient. Look at that study, and look at what makes you demand elective procedures and your resistance to having the doctor be the gatekeeper of what is a good procedure and what is not. I have a friend who dropped his doctor because the doctor would not prescribe some antibiotic my friend read about (and which was ineffective against his condition, and had horrible side effects). He went to a different doctor, who obliged - worse health outcome (he refuses to admit that his peripheral nerve pain is associated with that antibiotic), but a more satisfied patient.

Consider what else happens when you admit the profit motive (which you apparently favor?) into your healthcare providers calculations - millions of unnecessary procedures which leave broken human beings in bad health and early death.

Those unnecessary procedures are often in a setting of surgery mills where the treatments prescribed by the doctors are performed in their privately owned facilities, all designed for huge profits with zero concern for the disastrous results on patient health and longevity (see my FPP). And you know the irony of it all? Patients love it! Take just one example - prostate cancers which would have either disappeared or not become a problem within a lifespan of the patient, are operated upon, for high profit, the patient is crippled with bad quality of life, excess morbidity and early mortality. But what does the patient say? The doc saved my life - I had cancer! This was such a problem for so many millions that finally a Task Force was commissioned which recommended not having the PSA test done at all, given its inability to distinguish between cancers that need to be treated, the uncertain advantage of any treatment, and the outrageous overtreatment health epidemic. I have no doubt many considered the recommendations something akin to a death panel rationing care... even though American Urologist associations in private practice eventually agreed about the science and recommendations.

But the patient believes the heart operation he had saved his life. The cancer treatment saved his life. They express high satisfaction. Except that high satisfaction comes with the high price of 26% excess mortality.

Think long and hard, whether you want the profit motive in the healthcare industry. Think long and hard about what you look for in a physician. Think long and hard about putting the feeling of satisfaction and physician compliance with your elective procedures demands at the top of the list of your health care concerns.

I hope I have made my argument, backed by facts and evidence, one which you're willing to entertain in the spirit of open inquiry.
posted by VikingSword at 2:14 PM on December 19, 2013 [10 favorites]

Is government or a private insurance company more likely to keep this kind of abuse under control?

I suspect the government. The reason is because in general any procedure that is done that the government pays for, has to pass Evidence Based Medicine standards. The reason for the "panels" and Task Forces, is to establish which procedures are actually beneficial. They have the kind of regulatory power, wide access to expertise and nation-wide reach which any one insurance company is not going to have. The insurance company cares only about one thing - making a profit. If there is an accommodation, such as for example the physician being willing to be in-network for the insurance company in exchange for the insurance company allowing the patient to be stuck with a larger bill for an unnecessary procedure, then that's a fine little quid pro quo, because the bottom line shows $ benefits for both the insurance company and the unscrupulous physician. The government doesn't need that, as it doesn't need to make a profit - they can afford to focus on Evidence Based Medicine first and foremost.

I would sooner trust the government that doesn't need to make a profit off my health, to adjudicate my health needs, just as I would trust government judiciary system that doesn't need to make a profit rather than a private one which has to make a profit.
posted by VikingSword at 2:45 PM on December 19, 2013 [2 favorites]

We don't have to talk about this using hypotheticals.
posted by tonycpsu at 3:01 PM on December 19, 2013 [4 favorites]

I think insurance companies, who have a profit motive (albeit a regulated, limited one), are infinitely more interested in controlling costs and efficiency and minimizing corruption.

And every single piece of data proves you completely wrong. Seriously, read upthread where myself and others have noted that the fraud, waste, and abuse of the private insurance industry was double that of the government-provided options the year Obamacare was passed; or where the VHA, Medicare, and Medicaid beat out private insurance in efficiency and effectiveness by nearly every available metric; or where Americans with government-provided health care were both getting better care and were happier with the outcomes.

The government can just ask for more tax dollars. Which is what they do. All. The. Time.

Because. It. Works.
posted by zombieflanders at 3:03 PM on December 19, 2013 [5 favorites]

I think insurance companies, who have a profit motive (albeit a regulated, limited one),

Yes.

are infinitely more interested in controlling costs and efficiency and minimizing corruption.

No.

Being interested in profit, does not imply controlling costs and efficiency and minimizing corruption. If more can be made through corruption, or inefficiency, or not controlling costs, that's what they will do.

A mini example from my life. I was producing an American movie in Eastern Europe. We had to hire a local production company, by law. Their service fee was 10% of the cost of production. Guess what happened to the cost of production. Yes, it went up. The more it went up, the more that 10% got them. Inefficiency? Bring it on! They hired people who were just sitting around, to make the cost higher, and I swear the sound person was hired to slow down the production. They did not control costs, they didn't make it more efficient, they didn't make it less corrupt. Instead: they made it more expensive, they made it more inefficient, they made it more corrupt.

This is not an isolated example. Tons of businesses exist only to profit from inefficiencies and who thrive on those and are opposed to any regulation that limits corruption and inefficiencies.

To bring it to our subject: look at my first response to you and the example of how this would work with the profit driven surgeon and the profit driven insurance company. Exactly the same.
posted by VikingSword at 3:19 PM on December 19, 2013 [1 favorite]

I think insurance companies, who have a profit motive (albeit a regulated, limited one), are infinitely more interested in controlling costs and efficiency and minimizing corruption. The government can just ask for more tax dollars. Which is what they do. All. The. Time.

Saturday, February 6, 2010
Anthem Blue Cross customers got a shock this week when the health insurer informed thousands of individual policyholders that their premium rates will jump as much as 39 percent on March 1.
[snip]
The company, based in Woodland Hills (Los Angles County), declined to say how many customers received the increase or what the average premium hike was, but the insurer has the largest number of individual customers in the state. Last year, when Anthem Blue Cross raised rates by as much as 68 percent for some customers, the company said it had about 800,000 members. (emph. mine)

Thursday, March 22, 2012
Responding to pressure from state officials, Anthem Blue Cross has agreed to lower planned premium rate increases for almost 600,000 policyholders in California, the Los Angeles Times reports.
[snip]
Anthem has agreed to lower its rate increases from an average of 10.4% to 8.2%.

According to the California Department of Insurance, the maximum rate hike will be 20% instead of 30%, as Anthem originally proposed.

February 15, 2013
In response to pressure from California regulators, Anthem Blue Cross agreed to a slightly lower rate increase for about 630,000 individual policyholders that will save consumers an estimated $54 million.

Anthem, a unit of Indianapolis insurance giant WellPoint Inc., had sought to raise rates an average of 18% beginning Feb. 1. California Insurance Commissioner Dave Jones said Thursday that the company had agreed to reduce the average increase to 14% after regulators reviewed Anthem's rate filing.

Some Anthem customers will still see their premiums rise as much as 25% under this agreement with the state.

April 2, 2013
Insurance Commissioner Dave Jones announced today the Department of Insurance has found the latest rate increase by Anthem Blue Cross Life and Health Insurance Company is excessive and unreasonable. Anthem Blue Cross is increasing rates on its small group health insurance policyholders, while posting a return on equity of 25.2 percent as noted in the company's 2012 financial statements. For some Anthem small business customers, this translates to an alarming 12-month increase of 22.9 percent. The average 12-month increase for the policyholders impacted by this rate filing is 10.5 percent. Anthem's April 1st small group rate increases ultimately impact more than a quarter of a million healthcare consumers.

---

Anthem is not unusual in how it operates. It is not an outlier. I find it hard to believe that an organization motivated by efficiency and controlling costs would - surprise! - have to propose raising its rates by so much every year; to me, that says someone ain't doing their job. Unless their job is actually to make a profit. And the government in this country on this planet cannot just "ask for more tax dollars." Well, they can ask, but they might not get. Anthem et al. can and do ask, frequently, and frequently also get.
posted by rtha at 3:38 PM on December 19, 2013 [5 favorites]

I think money attracts the smartest MDs, motivates researchers.

Bell Labs says hi.
posted by asterix at 3:47 PM on December 19, 2013 [2 favorites]

Don't forget, that one way in which insurance companies contain costs, is by denying treatment to their policyholders, and throwing them off as soon as they make a claim, under the flimsiest of pretexts.

Profit motivated doctors don't have your best health interests at heart in almost any scenario. They might prescribe a suboptimal drug, because they make more money from the pharma company for the prescription numbers. Or they might please the insurance company by prescribing a less expensive - and less efficient drug "to control costs". This is of course also true for tests and procedures and so forth.

I just cannot see how "controlling costs" and "profit seeking" by health providers or middlemen such as insurance companies is something you want to invite into the healthcare system.
posted by VikingSword at 3:47 PM on December 19, 2013 [3 favorites]

So for me, comfort and "elective procedures" are the things that drive my health care choices, and I bitterly resent the idea that these things that I want are terrible things that need to be done away with.

I don't really know that anyone's saying comfort needs to be done away with. I get plenty of treatment on the NHS because chronic illness, and it's in a pleasant enough environment. The real teller that it's comfortable, though, is that my heart rate never reads much above 60 bpm. I mean, I've got good cardiovascular health, but I've taken my pulse sitting at my desk at work, and it's 70. I just know that everyone around me's got my best interests at heart when I'm in hospital, because actually, money's not the best overall motivator for people, helping people is. That's what motivates nearly everyone clinical I've met in the NHS (5 years an employee) and it makes it a very productive organisation.
posted by ambrosen at 4:10 PM on December 19, 2013 [5 favorites]

I think insurance companies, who have a profit motive (albeit a regulated, limited one), are infinitely more interested in controlling costs and efficiency and minimizing corruption.

That is either the single-most naive or willfully blindered statement I have ever read. Seriously. That is blind dogma totally unfettered by reality.

The government can just ask for more tax dollars. Which is what they do. All. The. Time.

And just as regularly don't get. Unlike insurance companies who get rate increases like clockwork.
posted by Thorzdad at 4:13 PM on December 19, 2013 [2 favorites]

The USA has fewer immigrants per capita than Canada.

It helps when your policy is based on facts, rather than stereotypes.
posted by jb at 4:29 PM on December 19, 2013

Vets with VA care still complain about VA care, but they don't necessarily know what non-VA care is like, which is why it's worth noting that vets who have had both generally prefer VA care.

I think this is sort of true-and-not true at the same time: most vets who have experienced VA care and non-VA, non-active-duty care may in fact prefer VA care, because most veterans come from low socioeconomic brackets, and the insurance that they can afford that is not the VA is pretty crummy. I would be keenly interested in seeing how those satisfaction surveys stack up when you adjust for paygrade and secondary income level.

"I don't want the doctor to be the gatekeeper that says what I want is wrong."

They're not saying it's wrong; they're saying that we won't pay for it and you're welcome to pay for it on your own. Which I'd think you'd support, honestly.

Am I misreading the NHS thing quoted above? It seemed to say that a specialist would not see you without a recommendation from the GP, which he was free to withhold. As I've understood it, every doctor in England is a part of the NHS. I may be wildly inaccurate because I'm gleaning this about a country I don't actually live in, though, but would certainly appreciate more (calm) information about it.

Consider why patients express satisfaction - one of the reasons is that the doctor may cooperate in ordering tests and procedures and often specific medication merely because the patient requests it, even if it is highly inadvisable medically.

You are most likely correct - I do know that often people get medical procedures done on them that are completely inadvisable, and you are probably right that they often lead to worse outcomes. I think, personally, though, the principle of self-determination and consent means that people should be allowed to do these things, even if they are injurious for them - but at the same time, I definitely say that as someone who is competent to do research and knows where to go for the answers if I don't know where to find them already. I think my problem is more with the paternalism being expressed than with the overall arc of outcomes, necessarily. Its kind of like doctors who refuse to show people their own medical charts - really, it may be for the best as people horribly misinterpret them, but at the same time, it's their own medical information and who are they to deny it?
posted by corb at 5:05 PM on December 19, 2013

corb: "I would be keenly interested in seeing how those satisfaction surveys stack up when you adjust for paygrade and secondary income level. "

What would such a comparison even prove? People who can afford to spend more are obviously going to be able to seek out care they're happier with, regardless of whether it improves their healthcare in any measurable way. So what? At the end of the day, what we're talking about is trying to improve healthcare outcomes for the largest number of people at the lowest possible cost. Anything people want to spend on extra care they can do in the presence of or absence of a single payer option.
posted by tonycpsu at 5:22 PM on December 19, 2013 [1 favorite]

https://www.google.com/search?q=nhs+specialists&oq=nhs+specialists: If you wish to see a private specialist, you are still advised to get a referral letter from your GP. However, if you see a private specialist without a GP referral, your GP is not obliged to accept the specialist's recommendations.
posted by klangklangston at 5:22 PM on December 19, 2013

corb, to clarify your understanding of the NHS, yes you do need a GP (or other professional) referral for nearly all specialist care, but in no way is a GP free to withhold a referral that is clinically appropriate. And you are always free to get a second opinion on the NHS.

The NHS don't hold a monopoly on doctors in the UK either. If you want to go and pay for treatment you can, and the hospital has a nicer garden and your bedside TV's better, but that's about it. The doctor will probably be the same person who works at the local NHS hospital for the other 4 days of the week, though. And if there are complications, I'd much rather be in the NHS bed in the same building as intensive care than the other side of town.
posted by ambrosen at 5:46 PM on December 19, 2013 [2 favorites]

Jesus.

Look, before the ACA, your doctor was under no obligation to give whatever treatment just because you wanted it. You were free to go look for a doctor who would, and who would accept your money. That is still the case. You are not legally required to only go to doctors covered by your insurance plan. You can still go out of network, just like before, and pay for it yourself, just like before.
posted by rtha at 5:50 PM on December 19, 2013 [7 favorites]

It's so tiring responding to these bad faith arguments multiple times per thread. Repeating the same falsehood after people have debunked it makes one look really desperate.
posted by tonycpsu at 6:02 PM on December 19, 2013 [6 favorites]

daq,

The other part to argue (and especially since you really wanted to get into the medical intervention point which I was kind of letting go, because, well) is this fun phrase "point of medical intervention." Please feel free to google that phrase. I did. It's curious that there are no measurements or studies on what the breakdown is on medical interventions. I mean, it would be a useful data point as to just how or when people are getting medical intervention for their health conditions. Is this point of medical intervention early? What other correlations are there to this early intervention? Does that mean that, maybe, being able to see a doctor on a regular basis (and I don't care if it's paid for through insurance, single payer, or out of pocket) improve the likelyhood of detecting health issues and thus, treating health issues with greater success? Does it meant that when people have access to healthcare, they are more likely to have better health outcomes?

I had the same thought when I was reading that article. I live in Australia where we have very good access to healthcare of this sort. Two examples:

Anyone visiting a doctor will be reimbursed by the government up to a certain amount (the amount varies depending on the type of consultation). Plenty of doctors here go out of their way to charge the patient exactly that amount and then go one step further and process the claim on behalf of the patient so that the patient is never out of pocket. They pay nothing. This allows people who are concerned about something to talk to a doctor about it regardless of their financial situation.

(It's not a perfect system - I've heard stories of false claims, etc but I think overall it works very well.)

Once every few months, a large portable clinic parks on my street and gives free mammograms. Talk about your early intervention - women can walk to a free mammogram.

So why the bloody fuck are people arguing on creating barriers (monetary, primarily) for people to get healthcare? Are we really trying to say "oh, if you are poor, you don't deserve to find out if you have a life threatening disease. Medical care for diseases are only for rich people who can afford it?"

I'm certainly not arguing for anything of the sort. I voted for the Labor Party in the recent federal election.
posted by citizenoftheworld at 9:10 PM on December 19, 2013

most vets who have experienced VA care and non-VA, non-active-duty care may in fact prefer VA care, because most veterans come from low socioeconomic brackets

That's a pretty fantasy story. My dad? From the anecdote above? Came from a middle-class background. and for decades had white-glove health insurance as a VP electronics engineer in a specialty technical field throughout his career. Still happier with the VA though, even though he is fully employed and has an (inferior) employer-based option.

But the free-floating elitism is charming; keep it coming! Obviously, if your ideology is correct, only the plebes could possibly value their government-run healthcare. In spite of any facts or anything.
posted by Miko at 10:44 PM on December 19, 2013 [3 favorites]

yes you do need a GP (or other professional) referral for nearly all specialist care

Who else has a private, employer-sponsored HMO? Because you need this for a private, employer-sponsored HMO as well. Just had a serious eye problem for which I first went to my GP; GP wanted me to see an opthalmologist. And she had to have her staff call in a referral to my private, very good, low-copay, employer-sponsored HMO before I could go. You think this is some insane obstacle? This is standard practice. It is what prevents hypochondriacs from flooding specialists' offices - have the GP evaluate and refer, and have the GP sign off, so the GP is fully informed about your course of treatment - which is exactly the thing you seemed to be wishing for in your ideal picture of kindly, patient-centered holistic care managed by the GP, above.
posted by Miko at 10:51 PM on December 19, 2013 [3 favorites]

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