Eliminating the profit motive in health care,
October 7, 2017 12:46 PM   Subscribe

Down with Copay. The history of copays in the American health system, and why they shouldn’t be allowed to exist.
posted by blue_beetle (30 comments total) 26 users marked this as a favorite
 
This article is great and highlights an aspect of necessary health care reform in the US that so many seem not to consider; what if insurance just isn’t even the paradigm health care should be addressed with at all?
posted by Jimbob at 12:59 PM on October 7, 2017 [18 favorites]


Working in healthcare I cannot tell you how many people I've met who go without medication for chronic conditions because Medicaid has a 3.00ish copay in IL. (Not all plans).

It is enraging.
posted by AlexiaSky at 1:06 PM on October 7, 2017 [8 favorites]


I grew up a military brat. No copay, no pay at all. Health care for military families was not considered communism by what is typically the most conservative area of the US Government. Yeah. I worked for a hospital system for 17 years, during that time, medical was cheap, just before I went to work for them it was free, and vested retirees had free full medical care, free, for life. No such luck these days, except for me right now.

I live in California, a state, for those of you who do not know, every child in the public school system, gets a free breakfast, no matter how well off, or poor. I am so poor for now, my medical is free, with medicare and medical. All of it is free, except for over the counter medications. Since I don't take any medications my costs are nil. It is the intent of California to take care of its people. There is some opposition to this in conservative camps, but this is how it is for now. If single payer could become a reality, it would be here.

I recently had a run in with "best practices" that I consider a money making plan on the part of a member of the medical establishment. He tried selling me my ruination, and I said, "OK, OK right until fifteen minutes passed and I was well away from his office, then I cancelled. So even with no copays, there are other ways that patients can be victimized for gain.

Every American should be able to get healthcare, no strings attached, excepting for some reasonable efforts on their part to maintain their health, that can be daunting in the reality of homelessness, or societal abuse.
posted by Oyéah at 1:51 PM on October 7, 2017 [26 favorites]


why stop at healthcare?
posted by indubitable at 1:55 PM on October 7, 2017 [8 favorites]


A lot of things are in the line ahead of healthcare. Providing for the common defense, which has become a fund to support theft of others resources, also a multi atrocity mall where the biggest talkers and hawkers, get the bids for things normal people can't even daydream we need.

A lot has been put on a table that no one sees, no one is invited to the banquet where decisions become plans to disenfranchise some, make some wealthy, and plan to create an artificial means to sustain all those who support diversion of critical resources to travel abroad in the galaxy. Or worse still, wring every drop of money from sales of free stuff the extraction industries make a market for, processes which are undermining the planetary biosphere. So health care for all is way back in the line, along with now, the health of our world, and the safety of the lives here. Dr. Frankenstein didn't pay for Igor's medical care, he just made a monster.
posted by Oyéah at 3:40 PM on October 7, 2017 [1 favorite]


It is the intent of California to take care of its people.

As it should be, for all governments, at every level. What else is there? Why is the well-being of the American people not the entire platform of the Democratic Party? Why is said party so willing to compromise the people's welfare in service of various industries?
posted by Kirth Gerson at 4:02 PM on October 7, 2017 [8 favorites]


Because some people matter more than others to political parties.
posted by SpaceWarp13 at 4:42 PM on October 7, 2017 [4 favorites]


I have multiple chronic health conditions. At the insurance I had through my last job, the doctor visit co-pays ranged from $20 to $40, depending on specialty. (I averaged about four visits a month just for regular maintenance) Copays for monthly lab work were $40 minimum, depending on whether I could get the orders synchronized to have all the blood drawn at once, and if anything had to be sent out for a culture. Monthly maintenance prescriptions in the double digits, on a $20-30-40 tier system (or whatever the cost was if less than 20). And that's all just regular maintenance: injuries, complications, or temporary additional illnesses were on top of that. There were some practices who refused to accept the co-payment at the time of service, requiring you to wait until they send you a bill after they bill your insurance company. Of course, this process takes forever, and by the time you ever receive an actual bill they've tacked on exorbitant late fees. Ideally, you could just keep calling and calling the office until they agreed to take your payment, but who has time to even keep all that straight when you're trying to hold down a full-time paying job in addition to your unpaid full-time job as health care case manager?

Of course you're going to be letting some health things slide! Of course there are going to be medical bankruptcies! And in the meantime, you end up with a sick and stressed-out workforce.
posted by The Underpants Monster at 5:36 PM on October 7, 2017 [13 favorites]


...no one is invited to the banquet where decisions become plans to disenfranchise some, make some wealthy,...

I just finished reading Free Lunch, by David Cay Johnston. The subtitle: "How the Wealthiest Americans Enrich Themselves at Government Expense (and Stick You with the Bill)."

On page 212, the author says, "There is another awful cost to a policy of health care as a business. No one in the modern world ever goes bankrupt because of medical bills, except in the United States of America. [There is enormous] medical, economic, and moral harm done by a system in which at least 45 million Americans go without health insurance coverage. The American system is completely at odds with the biblical morality publicly embraced by nearly every elected politician, which imposes a duty to sacrifice for the poor. Yet someone without insurance who gets cancer becomes eligible for government-provided care only at the point where they become permanently and totally disabled. That is to say, when treatment seldom will help and death is virtually inevitable, care begins."
posted by LeLiLo at 6:21 PM on October 7, 2017 [12 favorites]


To be honest, I'm super cranky and bummed out. This is so interesting to me, but I'm so burnt out that I'm happy that I even have a co-pay I can afford. I'm lucky that my co-pay for my therapy appointments is even this low, because my therapist doesn't even take insurance. Anthem Blue Cross just cancelled all of their individual plans for 2018 except for 22 counties in California, due to being unsure about getting their Obamacare subsidies due to Trump's madhouse, and now I'm looking at not being able to receive any of my mental healthcare stuff at all. I'm lucky that I could have been able to afford healthcare for so many years that let me have mental healthcare.

I hate that my chronic condition is not valid. And I live in California. A lot of things are great here, but some of it is just staggering due to privatized healthcare.
posted by yueliang at 8:45 PM on October 7, 2017


"I live in California, a state, for those of you who do not know, every child in the public school system, gets a free breakfast, no matter how well off, or poor."

This is the best fucking thing in the universe and every district should do it. We moved from a Community Eligibility Provision district (the student body is more than 60% Free-or-Reduced-Price lunch, so EVERYONE gets free breakfast and lunch) to a district without CEP, and I MISS CEP EVERY SINGLE DAY. It makes sure every kid gets fed, no matter what is going on at home -- poverty, or absent parents, or abuse, or financial instability, or housing instability -- and it reduces the stigma of eating school lunch, and it ensures that every kid has eaten, so they achieve better and pay more attention, regardless of what their deal is at home (no food? parenting pushing dieting? WHATEV.)

Anyway every child should get free lunch and every citizen should get free healthcare. It makes such a healthier society, with more achievement, better attendance, etc.
posted by Eyebrows McGee at 8:51 PM on October 7, 2017 [12 favorites]


Albany, NY has CEP, and I wouldn't mind another addition. Extend the school day for younger kids to provide de-facto full-day childcare, AND since you have those school kitchen, let's extend CEP to Breakfast, Lunch, and Dinner. FWIW, it might be hard to workout, but why not just make that Dinner public?

Oh, yeah. Socialism is evil. Keep forgetting.
posted by mikelieman at 9:50 PM on October 7, 2017 [1 favorite]


The more I read about free-school-meals-for-everybody programs, the more I love them and want to shout about them from the rooftops. I'm childless and no longer work with K-12 education in any capacity, but just as a citizen I'm excited about the possibilities!
No more kids distracted by hunger!
Lower administrative costs!
No more kids SOL because they forgot their lunch money (or because their parents forgot to load their lunch accounts, as I understand it's done these days).
No more kids getting singled out and picked on.
One less thing for hardworking parents to stress about.
If more kids end up eating school meals, food service depts. can buy more in bulk for better prices.
posted by The Underpants Monster at 12:08 AM on October 8, 2017 [3 favorites]


I'm paying $1700/month (Pre-tax) for employer subsidized health insurance for a family of 4. Not much a subsidy there... But with that exorbitant monthly fee comes the lowest out of pocket maximums we've ever had - just $1500 per person. My wife hit that in March - so she has effectively $0 out-of-pocket health care costs since then this year. It's like a preview of actual socialized healthcare, and I have to say, there hasn't been much to dislike. I wrote a blog post about it.
posted by COD at 5:25 AM on October 8, 2017 [1 favorite]


It's like a preview of actual socialized healthcare, and I have to say, there hasn't been much to dislike.

Literally EVERY provider I speak to LOVES Medicare. And man, I would LOVE to vote with my $ and choose to put what's going to a "non-profit" HMO ( Edna: HA! ) and put that into the Medicare system instead.
posted by mikelieman at 8:00 AM on October 8, 2017 [1 favorite]


Just putting this out there as food for thought... what if the country is just too big?

I mean, can anyone realistically imagine Single Payer in the modern US, with something that doesn't resemble the Underpants Gnomes Business Plan getting us there? I really can't; even if you had a couple of good elections that pushed the pendulum far enough over to get it passed initially, what's to stop it from becoming like any of the other things that the Federal government is supposed to do for the common good, and which people have pointed out above are mostly just ways to upwardly-redistribute wealth to a well-connected few? Given the amount of money that would be involved, is there any doubt -- looking at how politics is functioning right now -- that it wouldn't be the ultimate target for the lobbying class? I have a hard time seeing it, myself.

I have begun to wonder if there is some sort of national-political equivalent to Dunbar's Number, above which the "national interest" becomes so indistinct that people will, given the opportunity which must inevitably present itself when money is being spent, choose to enrich themselves instead of help the community in general. Eliminating every possibility of this just isn't feasible; we've tried! But once a certain number of people are engaged in corruption, suddenly it ceases to be corruption anymore.

The countries that do "common good" well, and that people tend to point to as examples, are mostly much smaller than the US. (They seem to largely be less diverse, too, but I'll be optimistic for a moment and assume that isn't a barrier.) Looking specifically at healthcare, the two countries larger than the US by population (China and India) don't exactly have things worked out. India guarantees healthcare for all in theory (and in its constitution, no less!) but most healthcare services are delivered by a for-profit, private sector system that's punishingly expensive for patients. China has a similarly two-tiered system with an additional significant urban/rural divide; they're working towards 70% public funding of healthcare expenses by 2020, and that's in a system where the government doesn't have to dicker around with democracy or opposing political parties to get shit done.

The biggest country that has a universal healthcare system that I'd say is functional enough to serve as a model* is less than half the size of the US (specifically Japan).

Maybe the California secessionists have a point. More seriously, I just wonder if we aren't barking up the wrong tree in trying to get this done at the Federal level at all. What if there's a scaling-factor problem here, such that the difficulty in doing universal healthcare is not a linear increase that scales with population, but is a higher-order problem? And perhaps as a result, we are attributing too much to cultural differences here in the US compared to other countries that can just be hammered out through argument, and not enough to the idea that gaining widespread political consensus may just be terribly, nonlinearly harder as you involve more people? Maybe achieving consensus on the 300M-person level for a 'big bang' changeover is just too big of a task to reasonably accomplish, and some sort of "domino effect" strategy on the state level is better.

* As of 2009, the countries with functional universal healthcare, defined as a universal mandate (individual or via some other mechanism) plus 90% insurance coverage (via some mechanism), and 90% skilled birth attendance (a sort of measuring stick for actual service-delivery), were: Andorra, Antigua, Argentina, Armenia, Australia, Austria, Azerbaijan, Bahrain, Belarus, Belgium, Bosnia and Herzegovina, Botswana, Brunei Darussalam, Bulgaria, Canada, Chile, Costa Rica, Croatia, Cuba, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Luxembourg, Moldova, Mongolia, Netherlands, New Zealand, Norway, Oman, Panama, Portugal, Romania, Singapore, Slovakia, Slovenia, South Korea, Spain, Sweden, Switzerland, Taiwan, Thailand, Tunisia, UAE, Ukraine, United Kingdom, and Venezuela. Without breaking out Excel, I think the biggest countries on that list, by population, are Japan (127M), Germany (82M), Thailand (68M), the UK (65M), and South Korea (51M). Probably not coincidentally, the Japanese system is frequently cited as an inspiration for some parts of Obamacare.
posted by Kadin2048 at 12:51 AM on October 9, 2017 [1 favorite]


At one point in time in The Land of the Free when your car was not functioning properly you would drive up to a auto shop and were told "it costs what it costs, we can't tell you how much it will cost ahead of time".

And one day, by the power of Congress, quotes needed to be provided before work was done.

Go ahead, wander into a Doctor's office. Ask for a quote on the yearly checkup where you will be weighed, your blood pressure will be taken, perhaps a stethoscope applied to your chest -perhaps not, and blood work reviewed.

I can get a quote for fixing a car - but not for what is an effective bill rate of $956 an hour for someone who's only function in the system of law is to authorize the pharmacy to release drugs 30 pills at a time.

Lobbying got quotes for car repair - why can't something that is a tad more important than the freedom to travel?

(and why a $100 fee for healthcare in prison? )
posted by rough ashlar at 7:19 AM on October 9, 2017 [4 favorites]


What if the country is too big? ... The countries that do "common good" well, and that people tend to point to as examples, are mostly much smaller than the US.

Yet the U.S. does manage near universal care for over 131 million people on Medicare and Medicaid, which is larger than all of the countries you cite. Size is not the issue.
posted by JackFlash at 8:12 AM on October 9, 2017 [5 favorites]


Just putting this out there as food for thought... what if the country is just too big?

When I got my MPH more than a decade ago, the conversation was in part about how bigger is better for massive public health programs. Increasing the number of participants in a healthcare system is a benefit, not a hindrance. It's a ledger, not a machine whose components depend on one another to operate--adding more components doesn't make the system more complex.
posted by late afternoon dreaming hotel at 9:45 AM on October 9, 2017


Just putting this out there as food for thought... what if the country is just too big?

Healthcare scales pretty well. In Britain the NHS is a separate organisation in each constituent country - with the smallest being Northern Ireland at 1.8 million and the largest England at 53 million. I'd be very surprised if there's some arbitrary threshold somewhere between 100 million and 300 million, and bigger tends to be better for public health.
posted by Francis at 5:30 AM on October 10, 2017 [1 favorite]


I'm British, and don't really understand this.

What exactly is a copay, and how much is it? Is it like a prescription charge (we pay £8.60 for each medicine a Dr a prescribes us)?
posted by MattWPBS at 5:53 AM on October 10, 2017


MattWPBS yes, it's exactly like a prescription drug charge, but you pay it for every "thing" that you use. What counts as a "thing" and how much the co-pay for them is varies from insurer to insurer. Some insurers charge a single copay for a doctor's visit, and any tests, scans etc. that the doctor orders are included. Some charge for the visit and also separately for every test and scan. The charge can be as little as $5 or less for low-income plans, up to a percentage of the "cost" of the procedure for big expensive things. (Scare quotes because the "cost" that you or your insurer is billed bears no relation to the cost of the material/labor/capital inputs to the procedure.) Orthogonally to this, some plans have a "deductible" where you pay 100% of costs until you have paid a certain amount (typically $500-1,500, though it can vary by an order of magnitude in either direction depending on insurer etc.) There are also various maxima where if your costs exceed them the insurer will cover everything (no copay). A typical figure might be $1m as a lifetime maximum. (But I don't know anyone who has ever hit that and I imagine it gets complicated when you do.)

I moved from the US to the UK 3 years ago. I would like to think that I can passably imitate native Brits with a good whinge about the shortcomings of the NHS, but for all its warts (both inherent and inflicted by Tory sabotage), it's a veritable paradise compared to the US health system.
posted by dendrochronologizer at 7:16 AM on October 10, 2017 [1 favorite]


The charge can be as little as $5 or less for low-income plans, up to a percentage of the "cost" of the procedure for big expensive things. (Scare quotes because the "cost" that you or your insurer is billed bears no relation to the cost of the material/labor/capital inputs to the procedure.)

The latter (when it's a percentage of the made-up "cost" of the service) is called coinsurance; copays, coinsurance and deductibles are collectively often referred to as "cost-sharing." Sometimes the monthly employee/individual contribution (called a premium under insurance, sometimes just called contribution under a self-insured arrangement) is also considered "cost-sharing." Copays, coinsurance and whatever is paid toward a deductible go toward a plan's "out of pocket maximum" (the amount an individual can be required to pay out of pocket - as regulated by the ACA and Bob forbid you go to an "out of network" provider...), but premium/monthly contributions are not.
posted by Pax at 7:31 AM on October 10, 2017 [1 favorite]


This is pretty damn simple: If you make something cheaper, people will consume more of it. This effect is amplified if you make something free; this is called the zero price effect. In the U.S., we already spend way more on health than in any other country. If you get rid of cost sharing, people will consume more health care. We already are hugely overtreated.

Now, everything I wrote above is completely incontrovertible - except the first line. Because while it's true that cost sharing reduces wasteful consumption of health care, it's also true that it reduces consumption of beneficial care. It's also true that there are many reasons that we spend so much on health care that are unrelated to overtreatment. It's also true that many people forego necessary treatment because of cost.

This is damn complicated. Pretending otherwise and just cheerleading for free stuff isn't helpful.
posted by Mr.Know-it-some at 1:49 PM on October 10, 2017


Hm, I wonder why a profit-oriented health system might overtreat some patients while abandoning others to die in the streets. No clue! Oh, well! Let's just give up, then.
posted by tobascodagama at 2:20 PM on October 10, 2017 [3 favorites]


By placement, tobascodagama's comment seems to be a response to mine, but I honestly do not see any logical connection. Who suggested giving up? Who suggested letting people die in the streets? Achieving a just, universal, and efficient health care system will take constant work, both analytical and political. I share that goal. I just think it's ridiculous to think that charging everybody nothing is the correct path to that goal.
posted by Mr.Know-it-some at 6:03 AM on October 11, 2017


Why though when it comes to healthcare? Because people would use it more? And that would be bad because...overtreatment? You mention all the problems/benefits with charging people. I'm sorry but allowing people to get care who otherwise would not totally outweighs the overusers, in my opinion. As the spouse of someone with a chronic condition (that may have not been so bad if he hadn't been without insurance to fix it for 7 years) and also the spouse of an (undiagnosed) hypochondriac, I see both sides. I don't care how many time my mother goes to the doctor if my spouse could have gotten his back fixed before it was a problem.
posted by LizBoBiz at 6:33 AM on October 11, 2017 [3 favorites]


Who suggested giving up?

Well, the conclusion to your comment was:
This is damn complicated. Pretending otherwise and just cheerleading for free stuff isn't helpful.
Since you didn't actually offer any helpful suggestions, it wasn't much of a stretch to think that's what you meant.

Who suggested letting people die in the streets?

Various hospitals, most insurance companies, and several generations of Republican legislators -- by varying degrees of explicitness or direct action.

I'm not buying the assertion that "we are overtreated." Some of us certainly are, but the poorly-insured certainly are not. I've been having this stupid discussion about how unrestricted access to health care will lead to "excessive use" for over thirty years, and it's still stupid. The overtreatment of the wealthy is a result of the for-profit model of healtcare delivery, not of increased access to it.
posted by Kirth Gerson at 11:22 AM on October 11, 2017 [4 favorites]


Yes, the poorly-insured are more likely to be undertreated than overtreated. They should get better insurance, which would in many cases mean less cost sharing.

But that doesn't mean that cost sharing should be eliminated. For richer people, it might be better to increase the costs.

Yes, there should be less profit motive. Doctors shouldn't get rewarded for referring patients to medical imaging clinics, to mention only one of the most egregious cases.

But just because there are incentive problems on the supply (provider) side doesn't mean we shouldn't address the demand (patient) side.

No matter the system, care has to be rationed in one way or another. Cost sharing should be part of that process.
posted by Mr.Know-it-some at 1:23 PM on October 13, 2017




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