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  #151  
Old 09-22-2019, 09:53 PM
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Originally Posted by survinga View Post
Thank you for your concern about whether we Americans are awake or not. I've had to use the ER a few times, as well as an ambulance once. No big deal from a cost standpoint, as insurance picked up almost all the cost. I also know people who have the same insurance I have, and who've had cancer. They had some out-of-pocket costs, but they were not much.
You, like almost everyone who is happy with their insurance, are not seriously ill. When you question the seriously ill about their insurance, you get a vastly different picture (PDF). In a recent study of those with serious illnesses, and despite 90% being insured, 53% of the respondents experienced "one or more dire financial consequences related to their care." 37% reported using up all or most of their savings for medical issues.
  #152  
Old 09-22-2019, 10:06 PM
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Thank you for this, DMC. I've seen the stat that most Americans are happy with their insurance and have wondered if that stat includes people who have had a serious health issue. This report suggests it does not.
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  #153  
Old 09-23-2019, 04:41 AM
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Something that is quite telling. In these discussions, its always Americans who worry about not having healthcare, not being covered or losing their healthcare.

You never see a European, or Japanese or Canadian worry about not being covered, or losing healthcare. Its medieval, like fear of goblins. I think this is why its easy for those of us not from the USA to assign dishonest motives to Americans who are simply afraid of losing the care they and their families have. Its a very alien mindset, where that is actually a real worry.

Last edited by Grim Render; 09-23-2019 at 04:42 AM.
  #154  
Old 09-23-2019, 05:46 AM
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Originally Posted by survinga View Post
Thank you for your concern about whether we Americans are awake or not. I've had to use the ER a few times, as well as an ambulance once. No big deal from a cost standpoint, as insurance picked up almost all the cost.
what does "almost all" mean? how much did you have to pay out of pocket in that year?

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I also know people who have the same insurance I have, and who've had cancer. They had some out-of-pocket costs, but they were not much.
What were those costs? How much is "not much" how much did they have to pay out of pocket in that year?
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  #155  
Old 09-23-2019, 05:54 AM
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Originally Posted by DMC View Post
You, like almost everyone who is happy with their insurance, are not seriously ill. When you question the seriously ill about their insurance, you get a vastly different picture (PDF). In a recent study of those with serious illnesses, and despite 90% being insured, 53% of the respondents experienced "one or more dire financial consequences related to their care." 37% reported using up all or most of their savings for medical issues.
Really good summary DMC, I'd recommend everyone read it and pay particular attention to the appendices. The two points you highlight above are the ones that jumped out to me as well and strike me as frankly disgraceful in a first-world nation.

Another beauty is that 23% of the seriously ill were

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Unable to pay for basic necessities like food, heat, housing
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  #156  
Old 09-23-2019, 07:19 AM
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Originally Posted by Grim Render View Post
Something that is quite telling. In these discussions, its always Americans who worry about not having healthcare, not being covered or losing their healthcare.

You never see a European, or Japanese or Canadian worry about not being covered, or losing healthcare.
You forgot Australia. I've never seen anything from an Australian worried about losing their healthcare, either.
  #157  
Old 09-23-2019, 08:08 AM
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Anecdote ahead:

I actually do have good insurance. Over the past year (cancer) my credit rating took a hit because, although I could afford my part of the bills, the sheer volume I was receiving per week became difficult to manage. These were all for copays, usually $30 or less, but it was very easy to miss some here or there.

Yes, I was actually charged copays for chemo.
  #158  
Old 09-23-2019, 11:01 AM
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Here's a good example from just this morning of what the OP isn't seeing, and what many of us are talking about, by CBS News.

Man has severe back pain>goes to doctor>doctor says go to hospital immediately> hospital doctors confirm first doctor's diagnosis, say he needs surgery right now or he can end up paralyzed>man has surgery>insurance company says the surgery wasn't medically necessary and they won't cover it>man gets $650,000 in medical bills.
  #159  
Old 09-23-2019, 11:05 AM
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Man has severe back pain>goes to doctor>doctor says go to hospital immediately> hospital doctors confirm first doctor's diagnosis, say he needs surgery right now or he can end up paralyzed>man has surgery>insurance company says the surgery wasn't medically necessary and they won't cover it>man gets $650,000 in medical bills.
Sounds like in that case the insurance company should be forced to cough up and if they feel so badly wronged they should take the two doctors to court. Certainly doesn't seem like the patient is culpable at all.

(ridiculous that it is even a matter of debate of course).
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  #160  
Old 09-23-2019, 01:25 PM
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Here's a good example from just this morning of what the OP isn't seeing, and what many of us are talking about, by CBS News.

Man has severe back pain>goes to doctor>doctor says go to hospital immediately> hospital doctors confirm first doctor's diagnosis, say he needs surgery right now or he can end up paralyzed>man has surgery>insurance company says the surgery wasn't medically necessary and they won't cover it>man gets $650,000 in medical bills.
There's almost certainly a review process for that kind of thing; it's hard to believe that the insurance company is claiming lack of medical necessity/emergency and having it just stick like that. He should be able to request a third party utilization review if one hasn't already been done, and if it was there should be a pretty clear indication of WHY it wasn't medically necessary, complete with the diagnosis and treatment listed, and the guidelines for the typical treatment of that sort of condition. They also should have probably reached out to the original treating provider for their rationale- maybe there was some confounding factor that wasn't entirely clear from the case documentation.

At that point, he needs to go back to the ER doctors and sue them for negligence or malpractice if they diverged from the accepted treatment guidelines. One way or another, either the ER docs or the insurance company reviewer fucked up, and he needs to get that straightened out.
  #161  
Old 09-23-2019, 01:29 PM
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There's almost certainly a review process for that kind of thing; it's hard to believe that the insurance company is claiming lack of medical necessity/emergency and having it just stick like that. He should be able to request a third party utilization review if one hasn't already been done, and if it was there should be a pretty clear indication of WHY it wasn't medically necessary, complete with the diagnosis and treatment listed, and the guidelines for the typical treatment of that sort of condition. They also should have probably reached out to the original treating provider for their rationale- maybe there was some confounding factor that wasn't entirely clear from the case documentation.

At that point, he needs to go back to the ER doctors and sue them for negligence or malpractice if they diverged from the accepted treatment guidelines. One way or another, either the ER docs or the insurance company reviewer fucked up, and he needs to get that straightened out.
I believe there is a formal appeal process. Whoever decided it was not "necessary" will have to prove their medical credentials that proves they know what they are talking about. That's part of the Regulatory dept at the Ins Co. They cannot get out of that one, since the denier is usually some hourly schlub. Anyway, this is how I've seen these stories get worked out. It will likely involve legal action however. He should win.
  #162  
Old 09-23-2019, 01:47 PM
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Originally Posted by Grim Render View Post
You never see a European, or Japanese or Canadian worry about not being covered, or losing healthcare. Its medieval, like fear of goblins. I think this is why its easy for those of us not from the USA to assign dishonest motives to Americans who are simply afraid of losing the care they and their families have. Its a very alien mindset, where that is actually a real worry.
I like your analogy. As someone who lived in the US for several years and had good insurance I felt adequately covered from the goblins but was definitely annoyed that life events (like having children) cost me several thousands. It is quite foreign to have to budget a couple thousand a year for insurance deductibles and co-pays.

What really seemed bizarre was the multitudes working in the insurance industry. I knew someone who worked at a general practitioner / doctors office. They had 3 doctors and about 15 support staff. Why so many staff? Many of the staff, including my friend's only job was to call insurance company's and harass them for the money owed to the doctors.

So it is also worth mentioning that there is a huge industry built up around these goblins and their treasure. Goblin trackers, goblin hunters, goblin trappers etc. The Health Insurance is the medieval Goblin middleman - who is controlling their access to Health Care.
  #163  
Old 09-23-2019, 02:21 PM
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At that point, he needs to go back to the ER doctors and sue them for negligence or malpractice if they diverged from the accepted treatment guidelines. One way or another, either the ER docs or the insurance company reviewer fucked up, and he needs to get that straightened out.


...because the one thing you really need after major surgery is an extremely complicated, probably years-long lawsuit involving multiple possible defendants, and all their lawyers, who are all pointing the blame at the other people.
  #164  
Old 09-23-2019, 03:54 PM
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  #165  
Old 09-23-2019, 04:03 PM
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There's almost certainly a review process for that kind of thing; it's hard to believe that the insurance company is claiming lack of medical necessity/emergency and having it just stick like that. He should be able to request a third party utilization review if one hasn't already been done, and if it was there should be a pretty clear indication of WHY it wasn't medically necessary, complete with the diagnosis and treatment listed, and the guidelines for the typical treatment of that sort of condition. They also should have probably reached out to the original treating provider for their rationale- maybe there was some confounding factor that wasn't entirely clear from the case documentation.
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I believe there is a formal appeal process. Whoever decided it was not "necessary" will have to prove their medical credentials that proves they know what they are talking about.
In other words, it's a feature, not a bug? And what happens while the patient slogs through the appeal process, the doctors and hospital turn the bills over to collection agencies, and the insured patient's credit is ruined.

Last edited by Kent Clark; 09-23-2019 at 04:04 PM.
  #166  
Old 09-23-2019, 04:23 PM
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Yes, basically, that's it - there's always a formal appeals process, but it's lengthy, full of paperwork and red tape, if you don't get ALL the forms and fill them ALL out completely and carefully you can be summarially denied (again), and yes, it's very much a feature and not a bug - the insurance company wants to delay paying as long as possible. Even better if the patient gives up, or is too tired/sick to continue

On top of that, if a patient is unable to do the appeals themself, HIPAA is used to deny access to concerned relatives/friends, sometimes necessitating that one of them go to court to be declared legal guardian and in possession of medical/legal/financial proxy (best to ask for all three at once). Which process may or may not be completed before time runs out for appeals (because of course there are time limits).
  #167  
Old 09-23-2019, 04:47 PM
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I believe there is a formal appeal process. Whoever decided it was not "necessary" will have to prove their medical credentials that proves they know what they are talking about. That's part of the Regulatory dept at the Ins Co. They cannot get out of that one, since the denier is usually some hourly schlub. Anyway, this is how I've seen these stories get worked out. It will likely involve legal action however. He should win.
This sounds like a fantastically efficient system. The free market in action. And great for the patient as well!

I only wish that in my country, we had the opportunity to have a major legal battle between my doctors and insurer after I have undergone a major medical treatment. Sadly, I am denied this freedom.

</sarcasm>
  #168  
Old 09-23-2019, 04:49 PM
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I guess I just know and am a shitty poor person - Almost everyone I know does NOT have insurance.

On one hand, I can count the people in my family, immediate and extended that have employer insurance. I don't think any of my friends or acquaintances have it either.

Is really only 8% uninsured in the US? I would say that from my position (mid 30s in age) only about 8% actually have insurance. Its bizarre to hear people talking about their insurance to us "poor unwashed folks". Part of me wants to slap them up side the head and say, "Bitching about your co-pay to go to the doctor? At least you get to fucking go to the doctor at all, buncha jackasses."

I was reading this thread earlier, and asked everyone around work, "Hey who has insurance?" The CFO of our company and the CEO do. That's it around here of the 40 or so people around this bubble. They are on Medicare.

I went through my cell phone contacts, and of the 180 or so that are real people, about 10 have insurance through their employer. A lot of their kids are on CHIP though.
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  #169  
Old 09-23-2019, 05:44 PM
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On top of that, if a patient is unable to do the appeals themself, HIPAA is used to deny access to concerned relatives/friends [...]
This is absolutely a real thing: HIPAA is used by healthcare bureaucrats as an all-purpose cudgel. I recently had an Kafka-esque appointment at a prominent teaching hospital in Oregonóan Oregon health & science university, if you will.

The hospital administration would not tell me where my appointment was, with which provider or even confirm that I had an appointment at all, citing HIPAA. They caved when I pointed out that I couldnít possibly show up at the right place at the right time if they wouldnít tell me where it was.

That experience can be blamed on an overzealous bureaucrat, but thereís a more serious side: my mom is slipping into dementia and has begun confabulating when asked about meds and appointments. I am her medical executor, but that doesnít kick in until sheís ruled incapacitated. Of course, my momís doctors wonít talk to meólet alone help me help heróuntil my full power of attorney has kicked in.

My mom thinks that she just has to call her doctor and say itís ok if they talk to me. It doesnít work that way. And this is a case where the providers likely want my helpóif my momís doctorsí billing departments were fighting me for fighting a charge, I donít doubt theyíd try to fend me off with HIPAA.

Maybe Iím naive, but I doubt most people who say ďI canít tell you because HIPAAĒ are doing so cynically. But because so many medical bureaucrats see it as a trump card to make the questions stop, it gets abusedóa lot.
  #170  
Old 09-23-2019, 05:52 PM
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Just to be clear, HIPAA unambiguously prevents my mom’s doctors from talking to me under these circumstances. I’m not arguing that they should disregard HIPAA and talk to me anyway. I’m saying that, once I have medical power of attorney, I expect to get stonewalled unless I can wave the relevant documents in the face of the person saying “no.”

If they won’t tell me when/where my own appointments are “because HIPAA,” I expect to get an avalanche of false-positive “no” responses even after I’ve got my mom’s medico-legal ducks in a row.

Many providers’ offices are outright patient-hostile under the best circumstances. It’s unlikely that will change when you’re fighting an erroneous bill.

Last edited by EdelweissPirate; 09-23-2019 at 05:55 PM.
  #171  
Old 09-23-2019, 05:56 PM
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Translucent Daydream, I appreciate your empirical contribution to this thread. Can I ask for a clarification, however? Are you sure your young work force co-workers are on Medicare?

I ask because I keep seeing people in this thread, not just you, mixing up the terms, Medicare and Medicaid. It's confusing, but it's important to understand the difference between these 2 programs.

Medicare is a federally funded program for folks who have attained the age of 65 or who have become permanently disabled and unable to work. They and their employers have paid into the program during their working lifetimes. They are entitled to it.

There are lots of components to Medicare, meaning Parts A, B, C and D, and each covers different things. But the main point to keep in mind about Medicare is that it is for people over age 65 or people who suffer from a permanent disability.

Medicaid is for low income folks and is a safety net program funded with combined state and federal funds. You can apply for Medicaid at any age, but you must have a very low income to qualify. One thing to keep in mind about Medicaid is that there are claw-back provisions -- meaning that if you have tangible assets such as a home, or you receive an inheritance, or if your income at some point exceeds the low income threshold, you can and probably will be made to pay the money back and/or be kicked out of the Medicaid program.

Medicare has no such provision. Once you qualify for Medicare, you qualify. No claw-backs.

When Democratic candidates advocate for a Medicare for all system, they're talking about offering the existing Medicare program, now available mostly to only those over the age of 65, to everyone in some form or another.
  #172  
Old 09-23-2019, 06:18 PM
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Most people are quite healthy most of the time, which is why they can be happy even with shitty insurance coverage. For the most part, they aren't using it, or only a very tiny bit of it.

That's the problem - people don't realize how vulnerable they are until it's too late. And then, well, it's too late.
Exactly. Medical expenses follow a power law distribution.

1% of Americans make up about 25% of medical spending in a given year.
5% make up 60% of spending.
20% make up over 80% of spending.
50% make up 97% of spending

So you flip that around and it means that
50% of Americans make up 3% of spending
80% of Americans make up 20% of spending
95% of Americans make up 40% of spending
99% of Americans make up 75% of spending


Most people are mostly healthy for most of their lives. So they think they have good insurance because the only health care they get is the occasional doctors visit and a few generic medications.

Plus the way our system is set up, people with truly expensive health problems tend to get pushed onto public plans. Medicare covers the elderly. Medicaid covers the destitute elderly and the disabled.

Even with the public sector socializing the risk and taking the highest risk, highest cost patients off of the marketplace, the private insurance marketplace is still garbage.
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  #173  
Old 09-23-2019, 06:22 PM
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Originally Posted by Translucent Daydream View Post
Is really only 8% uninsured in the US? I would say that from my position (mid 30s in age) only about 8% actually have insurance. Its bizarre to hear people talking about their insurance to us "poor unwashed folks". Part of me wants to slap them up side the head and say, "Bitching about your co-pay to go to the doctor? At least you get to fucking go to the doctor at all, buncha jackasses."

I was reading this thread earlier, and asked everyone around work, "Hey who has insurance?" The CFO of our company and the CEO do. That's it around here of the 40 or so people around this bubble. They are on Medicare.
As I noted upthread, I work in the industry, and, yeah, nationally, 8% is accurate. But, it does vary (quite a lot) by state: the Kaiser Family Foundation has a site where you can look at the rates by state -- Texas is at 17% uninsured, Oklahoma and Alaska at 14%, etc.

But, if you limit the data on that KFF site to people age 19-64 (since low-income children may be on CHIP, and the vast majority of those age 65+ are on Medicare), the national uninsured rate is 12%, and in Texas, it's 24%.

One factor in whether or not people have employer-based health insurance or not is the size of the company: if a company has 50 or more full-time employees, they *must* offer health insurance to the full-time employees. If they have under 50, it's optional (and many don't). It sounds like the place you work, with 40 or so employees, doesn't have to offer coverage.

And, the above also alludes to another factor: people who aren't employed full-time at a single job likely won't be offered health insurance coverage by their employer, even if the company is big enough.

And, finally, ACA (Obamacare) policies tend to be expensive. Although the ACA features subsidies for moderate-income people to help them afford coverage, part of the law around the subsidies depended on a plan in which the individual states would raise the income ceiling for qualifying for Medicaid. But, a number of states (particularly "red states") chose not to, leading to a situation in which someone can be making too much money to qualify for Medicaid, but not be making enough money to qualify for a subsidy to buy an ACA policy.

Last edited by kenobi 65; 09-23-2019 at 06:24 PM.
  #174  
Old 09-23-2019, 06:31 PM
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Translucent Daydream, I appreciate your empirical contribution to this thread. Can I ask for a clarification, however? Are you sure your young work force co-workers are on Medicare?
I took what Translucent Daydream was saying was that only two people at their employer -- the CEO and the CFO -- have health insurance, and that the two of them have it because they're on Medicare (and, thus, they're both age 65+). But, I may be mistaken in my interpretation.

Last edited by kenobi 65; 09-23-2019 at 06:31 PM.
  #175  
Old 09-23-2019, 06:44 PM
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Originally Posted by kenobi 65 View Post
I took what Translucent Daydream was saying was that only two people at their employer -- the CEO and the CFO -- have health insurance, and that the two of them have it because they're on Medicare (and, thus, they're both age 65+). But, I may be mistaken in my interpretation.
Oh, I think you are right, and my apologies to Translucent Daydream if I misunderstood. Which it appears I did.

All the same, there does seem to be confusion around the 2 programs and I've been wanting to clarify the differences for awhile now. There's even a thread floating around here touting 'Medicaid for all' -- and no one is pushing for that.

Thanks for the catch!
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Old 09-23-2019, 06:58 PM
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How many American slaves in 1860 were scared and maybe even angry at the prospect of Emancipation? I don’t know how many there were, but undoubtedly there were some who preferred the devil they knew to the uncertainty that was freedom. Sure, with slavery you had to constantly live with the threat of violence hanging over your head like a dangling 500-lb anvil. Sure, you couldn’t become educated, acquire wealth, or have kids without worrying they’d be snatched away from you at any time. And sure, you had to put up with all kinds of indignities like rape, being literally treated like a brute animal, and being worked beyond exhaustion so white folks could have nice big fancy houses and wear the finest clothes. But it was a system you knew. As long as you played by its rules—as oppressive, inhumane, inefficient, and ridiculous as those rules were—you could get by. Maybe even be happy sometimes.

I have to think that people like the OP have fallen prey to the same change phobia these slaves had. Employer-based health insurance is the only system we know. Most of us barely can conceive of anything different. So I’m going to ask the same question that I would ask all those change phobic slaves: what about it is worth defending? Corporate executives see to it that people pay more into the system than they get out of it...tell me, why should the common man fight to see this continue? What exactly as we afraid of? Being able to get the lump in our breasts checked out without worrying about co-pays, deductibles, whether or not our preferred doctor is in the network, and other crap like that? Being able to quit a bad job without instantly jeopardizing everyone in our family’s access to healthcare?
  #177  
Old 09-23-2019, 07:29 PM
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I understand where you're coming from, but I have to quibble with you a bit, in your description of how car insurance works in Sask. Yes, we have government-mandated car insurance from SGI ("Saskatchewan Government Insurance "). Everyone has to get their basic coverage from SGI.

But that's just the basic "plate package", to ensure everyone has the statutory minimum coverage, no funny exclusions or conditions. If you want more coverage than the stat minimum, there's nothing stopping you as consumer from shopping around getting more coverage from a different insurance company. SGI offers extended coverage as well.

And that's just what I did: sat down with my independent broker and reviewed the options available to me for added coverage.
I might be persuaded that government-run car insurance is a good idea, but the point I was making is that since it is, in fact, truly insurance in the correct meaning of the word, there is at least a risk that a public plan might be structured in a way that limits your coverage options. But the OP's concerns are without merit since the kind of single-payer system being proposed isn't insurance at all, but essentially a payment system for all medically necessary health care.
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And that type of model might work for UHC in the US. If I've understood correctly from posters from Australia and New Zealand, i think that sounds sort of like their UHC system.
In a sense it works that way in Canada, too, since one can take out private insurance for drug coverage and for dental. In my view the critically important thing about UHC is that all medically necessary services must be covered, from doctor's visits to the most expensive surgeries.
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There aren't still major diffs between car insurance and health insurance, though. Car insurance is simpler than health insurance. As a consumer, I understand the coverage issues for car insurance better than health insurance. ANd there's rarely that crisis situation that arises with health care. But still, a basic state package with individual private add-ons could offer a way to UHC. Doesn't have to be single payer monopoly, so long as the basic package is truly comprehensive.
I disagree that there aren't major differences, or that car insurance is simpler. My car insurance policy runs to many pages of fine print, with lots of terms that I don't even understand. My health care coverage is basically defined by the fundamental principle that it pays in full for all medically necessary services. That sure seems simple to me.
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General agreement here. I think it's best to consider health care as public service, not an insurance commodity.
Which supports the notion that comprehensive health care coverage such as the single-payer system being proposed or the one we have in Canada isn't "insurance" at all and shouldn't be thought of that way.
  #178  
Old 09-23-2019, 07:37 PM
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what does "almost all" mean? how much did you have to pay out of pocket in that year?

What were those costs? How much is "not much" how much did they have to pay out of pocket in that year?
In the "almost all" reference, I think I had a $35 co-pay.

In your "not much" question (I love how people demand that I have perfect knowledge, but no one else gets these kinds of questions), I don't know exactly what they paid, but it was such that I never heard them utter anything at all about cost. And I know they have the same insurance I have, since we work together, so again "almost all" of their costs were covered, as we don't have high deductible plans and coverage on major illnesses is very good. Maybe over a year or two, they paid out a few hundred bucks....These are anecdotes to answer your questions of course, but many people on this board use anecdotes.

Last edited by survinga; 09-23-2019 at 07:40 PM.
  #179  
Old 09-23-2019, 08:31 PM
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Translucent Daydream, I appreciate your empirical contribution to this thread. Can I ask for a clarification, however? Are you sure your young work force co-workers are on Medicare?

I ask because I keep seeing people in this thread, not just you, mixing up the terms, Medicare and Medicaid. It's confusing, but it's important to understand the difference between these 2 programs.

Medicare is a federally funded program for folks who have attained the age of 65 or who have become permanently disabled and unable to work. They and their employers have paid into the program during their working lifetimes. They are entitled to it.

There are lots of components to Medicare, meaning Parts A, B, C and D, and each covers different things. But the main point to keep in mind about Medicare is that it is for people over age 65 or people who suffer from a permanent disability.

Medicaid is for low income folks and is a safety net program funded with combined state and federal funds. You can apply for Medicaid at any age, but you must have a very low income to qualify. One thing to keep in mind about Medicaid is that there are claw-back provisions -- meaning that if you have tangible assets such as a home, or you receive an inheritance, or if your income at some point exceeds the low income threshold, you can and probably will be made to pay the money back and/or be kicked out of the Medicaid program.

Medicare has no such provision. Once you qualify for Medicare, you qualify. No claw-backs.

When Democratic candidates advocate for a Medicare for all system, they're talking about offering the existing Medicare program, now available mostly to only those over the age of 65, to everyone in some form or another.
My cursor must have jumped. The two people with insurance at my work are on Medicare because they are over 65 years old. Sorry that was jumbled. When I lived in Oregon I was on the state program and that was the only time Iíve been insured in the past 10 years I think. That was the only time my wife has had insurance either.
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  #180  
Old 09-23-2019, 08:53 PM
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I might be persuaded that government-run car insurance is a good idea, but the point I was making is that since it is, in fact, truly insurance in the correct meaning of the word, there is at least a risk that a public plan might be structured in a way that limits your coverage options.
Why on Earth would the government want to limit your coverage options? Because government is inherently eee-vil and wants people to suffer? With all due respect, you're thinking like some Americans who think government can't be trusted to provide basic services, like health-care.

The principle of our mandatory insurance is that everyone has the same basic coverage, thought necessary to address most liability issues. But nothing stops you as a consumer from buying more (e.g. More third party liability coverage) if you want to, and you've got the extra cash to pay for it. And if by chance you're hit by someone who doesn't have insurance (e.g. Driving even though they don't have a permit), the eee-vil government will pay you out from the Uninsured Motorist Fund, so you get compensated and don't have to make an insurance claim and take a hit on premiums. It's almost as if the eee-vil government wants to help its citizens.


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I disagree that there aren't major differences,
That was an auto correct typo - meant to say "there are major diffs between car insurance and health care." Darn technology!

Quote:
or that car insurance is simpler. My car insurance policy runs to many pages of fine print, with lots of terms that I don't even understand. My health care coverage is basically defined by the fundamental principle that it pays in full for all medically necessary services. That sure seems simple to me.
I was referring to US health care policies, which sure seem a lot more complex than auto insurance. What's the premium? What's the co-pays? Who's in network? What medical conditions are covered? (Using the example in this thread, is back surgery to prevent paralysis covered?) I'm not a car guy, but I've got a pretty good idea of what's covered by my car insurance. Does the average US person know what's covered by their health "insurance"? Personally, I would have thought back-surgery-to-prevent-paralysis would be covered by most insurance policies, but if you don't read the fine print carefully ...

Quote:
Which supports the notion that comprehensive health care coverage such as the single-payer system being proposed or the one we have in Canada isn't "insurance" at all and shouldn't be thought of that way.
No dispute here.
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  #181  
Old 09-23-2019, 08:55 PM
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In the "almost all" reference, I think I had a $35 co-pay.

In your "not much" question (I love how people demand that I have perfect knowledge, but no one else gets these kinds of questions), I don't know exactly what they paid, but it was such that I never heard them utter anything at all about cost. And I know they have the same insurance I have, since we work together, so again "almost all" of their costs were covered, as we don't have high deductible plans and coverage on major illnesses is very good. Maybe over a year or two, they paid out a few hundred bucks....These are anecdotes to answer your questions of course, but many people on this board use anecdotes.
FTR, I have never argued that private insurance as implemented in the USA doesn't work most of the time for most people, nor has anyone else AFAIK. But this glosses over the big issues of its systemic deficiencies and the horror stories stemming from the many, many cases where it doesn't work. The three major objections to it are (a) the lack of universality, (b) the enormous and unnecessary costs and complexities inherent in the system, and (c) the bureaucratic interference with medical practice, including claim denials, treatment downgrades, and other forms of meddling.

Your well-meaning proposals could eventually address point (a), and good regulation could make a dent in point (b), but only a dent, but nothing in the private system can address point (c), and that's the most important one of all, because it threatens not only people's financial solvency, but their very lives.

I simply cannot emphasize enough how different it is -- and how important it is -- that when I go to the doctor, or to the ER, or get admitted to a hospital, money is simply not part of the process. Payment in full to the providers is simply taken for granted and never affects the patient or their treatment. I think this is actually a hard concept for Americans to understand because it's so alien to them.
  #182  
Old 09-23-2019, 09:13 PM
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Why on Earth would the government want to limit your coverage options? Because government is inherently eee-vil and wants people to suffer? With all due respect, you're thinking like some Americans who think government can't be trusted to provide basic services, like health-care.
Northern Piper, now that you've clarified your comments, I think we're in agreement on pretty much everything. As to the above, I think it's a misinterpretation of what I meant, which was that if there's only one source of insurance (real insurance, like auto insurance, not health care) then you don't have as many different coverage options and rates to choose from as when you have many different insurance companies.

My point, in the context of this thread, is that any payer for health care coverage has a fundamental moral duty to pay for any health care you need, period, no exceptions, so it's fundamentally different from the conventional idea of insurance. Throw in uniform community-rated premiums where everyone pays exactly the same for the same guaranteed coverage for everything medically necessary (as determined by a doctor, not the insurer) and there is then essentially no difference between different insurers. That's pretty much single-payer.
  #183  
Old 09-23-2019, 09:13 PM
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My cursor must have jumped. The two people with insurance at my work are on Medicare because they are over 65 years old. Sorry that was jumbled. When I lived in Oregon I was on the state program and that was the only time Iíve been insured in the past 10 years I think. That was the only time my wife has had insurance either.
You're kind. I misunderstood you and that was pointed out by kenobi 65. Thanks for being magnanimous.
  #184  
Old 09-23-2019, 10:03 PM
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I've gone throughtbtg thread and it looks like the OP has gone. That's too bad, because I have a genuine question: what is so good about the OP's plan that he doesn't want to give it up? And I mean details, not a vague "choice" issue. And as others have pointed out, I'm curious if it's an employer plan, chosen by the employer?
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  #185  
Old 09-23-2019, 10:14 PM
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And as others have pointed out, I'm curious if it's an employer plan, chosen by the employer?
I'm guessing so, though the OP did also say, "For the record, I support the ACA."

The odds alone are that the OP is getting insurance through their employer. From the Kaiser Family Foundation site that I linked to earlier, here are the proportions for source of health coverage, among all U.S. residents:

- Employer: 49%
- Medicaid: 21%
- Medicare: 14%
- Non-Group (that is, ACA policies and anything else one buys on one's own): 7%
- Other Public (mostly military and VA): 1%
- Not Insured: 9%

Last edited by kenobi 65; 09-23-2019 at 10:14 PM.
  #186  
Old 09-24-2019, 07:50 AM
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In your "not much" question (I love how people demand that I have perfect knowledge, but no one else gets these kinds of questions), I don't know exactly what they paid, but it was such that I never heard them utter anything at all about cost. And I know they have the same insurance I have, since we work together, so again "almost all" of their costs were covered, as we don't have high deductible plans and coverage on major illnesses is very good. Maybe over a year or two, they paid out a few hundred bucks....These are anecdotes to answer your questions of course, but many people on this board use anecdotes.
Anecdotes are fine and thanks for that, I guess the bit that is important is

Quote:
we don't have high deductible plans and coverage on major illnesses is very good
which leaves open the possibility that others do not have that level of coverage.
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  #187  
Old 09-24-2019, 10:12 AM
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I don't understand some of the problems people have with governmental health care. The best health care I ever had when when I lived in Oregon, and that was Medicaid (the poor people stuff.) When we had to go to the doctor, it was just "go to the doctor" it wasn't "do I have the $40 dollar co-pay today" or "whats my deductible at right now" or anything like that. The paperwork to get it started was pretty ominous, but it seemed like the paperwork was more to do with the private company that was administering it. It was first Moda health out of the Portland area then it was something else when we had to move to Salem.

The wife and I used to have Blue Cross PPO about ten years ago though an employer in Texas. It was $625 a month for both of us with a $8000 out of pocket and $40 co-pay. When my wife had medical problems, we had to go to the doctor 17 times (yes, for real 17 times, twice a week) before he would order a test to determine she had cancerous legions growing throughout the inside of her abdomen. The test was a "cut you open and find out whats cookin' in the oven" type of surgery. The day before the surgery, we found out that the hospital doing the surgery would only admit her the following morning if we paid them $1,200 dollars up front, so we were going to have to cancel the surgery. My next door neighbor was a nurse over taking care of my wife while I was at work and over heard the wife telling me she was going to have to cancel the procedure, so she whipped out her credit card and paid the "pre-op fee". I took a loan out from my work to cover her credit card charge, which is a whole other story that involved me throwing my boss's computer monitor across the room and throwing a huge fit, but that's another story of one of my bad moments. It took me 2 years to pay it off.

Anyway the next day she is under the knife for what they told me was going to be a 20 - 30 minute deal. 4 hours later, Doctor Dickhead comes into the room as white as his lab coat, and tells me that he is glad that the surgery happened, because they found all of these masses pulling on her insides and they had to remove them. He didn't know how she was able to walk or anything like that. They were going to have to send off stuff for biopsies, but they were definitely malignant.

So we get her home and try to get her to heal up from this rush job procedure, and then the bills started. Turns out the doctor switched anesthesiologists an hour before the surgery to some guy that wasn't covered by our insurance. So this guy sent us this $1,700 dollar bill with FedEx in an envelope. Then we found out that the doctor also switched the surgery from the hospital to a day surgery center attached to the hospital, so the insurance wouldn't cover that either. And since the surgery went from "exploratory" to "oh shit you are loaded with weird tumors" the surgery wasn't covered at all either.

So lets recap what we have spent so far (I sold almost all of the stuff I inherited from my grandfather to pay for this as we went):

17 doctor's office visits at the $40 dollar co-pay over the course of about two 2 months = $680
Two months worth of insurance premiums = $1250
"Pre-op fee" whatever the hell that was = $1200
Doctor switcharoo not in my right flavor of Blue Cross/Blue Shield = $1700
The surgery center not in the hospital even though it was attached to it = $3250
The surgery itself (not sure still if it was the doctor or the hospital billing) = $6000

So we are up to a total of $14,080 and that isn't all of the bills either that we got. This includes none of the copays for the medication that Dr. Dickhead kept throwing at my wife to see if it would "help her feel better." I spent about 6 months on the phone with BC/BS trying to figure out how I was getting charged so much when I thought my limit of out of pocket was $8000 a year. Turns out, what I paid only had a portion applied to the deductible in some sort of Darth Vader percentage math that nobody was aware about.

We are still paying off the first surgery to this day. When she had the growths return, we were in Oregon on that evil government insurance. Her new doctor helped us look at the bills we were still paying for the first surgery. Besides a bunch of cussing, she had no idea why we got stuck with it. But the new surgery wouldn't cost us a dime, and we didn't have to pay any copays or pre-op fees or anything like that. It was covered by the evil no good insurance.

Why is the employer insurance better in this situation? Even though we technically had a "choice" with Dr. Dickhead, he was the only one in the network in our area so it really didn't feel like a choice.

Why was the co-pay necessary?
Is that a deterrence to keep you from going to the doctor? It made most of my prized family possessions evaporate, thats for sure.
Why can the doctor change locations on the surgery and his buddies in the room and have my bill change? I never authorized any of those changes.

I mean, help me understand why that is the better system. I'm not the smartest guy around so I don't try to have lofty opinions on things, but the only thing that was different to me in both versions of health care is that BC/BS made a shit ton on money from me and didn't do their damn job. The evil government stuff just paid for the health care.
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  #188  
Old 09-24-2019, 10:43 AM
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I believe there is a formal appeal process. Whoever decided it was not "necessary" will have to prove their medical credentials that proves they know what they are talking about. That's part of the Regulatory dept at the Ins Co. They cannot get out of that one, since the denier is usually some hourly schlub. Anyway, this is how I've seen these stories get worked out. It will likely involve legal action however. He should win.
I know in the workers comp world, the initial triage person for this sort of utilization review(UR) is usually a RN. They basically sort them into two piles- clearly medically necessary (i.e. a cast for a broken leg, stitches for a cut, etc...) or ones that have questionable stuff.

The questionable ones go out to a third party UR provider for review for medical necessity. Who it goes to is subject to a whole host of state/federal rules as to specialty, licensure, etc...

Anyway, this third party provider reviews the case documentation against the relevant treatment guidelines, tries to contact the original provider to discuss their rationale for that particular treatment, and makes their determination based on all that.

Now in this case, assuming the UR process for a regular insurance claim is similar, I'd guess that one of four things happened:
  • the triage nurse messed up
  • the reviewing physician messed up (didn't contact the original surgeons for background)
  • the original surgeons flubbed their documentation
  • the original surgeons didn't follow the proper treatment guidelines (i.e. freestyled it without regard to the accepted treatment for the condition).

Any of those could cause a review to fail when it shouldn't. If I had to guess, I'd bet it was the original surgeons botching the documentation or not following the treatment guidelines (doctors in general have a ornery streak and are know-it-alls and don't like being told what to do).


** used to be the IT product manager/business relationship manager for my old employer's worker's comp UR review business unit, so I'm pretty familiar with the worker's comp side of that business.

Last edited by bump; 09-24-2019 at 10:45 AM.
  #189  
Old 09-24-2019, 10:50 AM
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I know in the workers comp world, the initial triage person for this sort of utilization review(UR) is usually a RN. They basically sort them into two piles- clearly medically necessary (i.e. a cast for a broken leg, stitches for a cut, etc...) or ones that have questionable stuff.

The questionable ones go out to a third party UR provider for review for medical necessity. Who it goes to is subject to a whole host of state/federal rules as to specialty, licensure, etc...

Anyway, this third party provider reviews the case documentation against the relevant treatment guidelines, tries to contact the original provider to discuss their rationale for that particular treatment, and makes their determination based on all that.

Now in this case, assuming the UR process for a regular insurance claim is similar, I'd guess that one of four things happened:
  • the triage nurse messed up
  • the reviewing physician messed up (didn't contact the original surgeons for background)
  • the original surgeons flubbed their documentation
  • the original surgeons didn't follow the proper treatment guidelines (i.e. freestyled it without regard to the accepted treatment for the condition).

Any of those could cause a review to fail when it shouldn't. If I had to guess, I'd bet it was the original surgeons botching the documentation or not following the treatment guidelines (doctors in general have a ornery streak and are know-it-alls and don't like being told what to do).


** used to be the IT product manager/business relationship manager for my old employer's worker's comp UR review business unit, so I'm pretty familiar with the worker's comp side of that business.
Can you help me understand this in a little bit of an easier way? They way I took it is that its "your doctor vs. the doctor that the insurance company has"?

It would seem to me that there is one of these doctors in this scenario that would have your medical interests in mind, because, um, he is your doctor and is looking at you in person? The other doctor is the "doctor of your insurance company's money"?
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  #190  
Old 09-24-2019, 10:53 AM
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Yes, basically, that's it - there's always a formal appeals process, but it's lengthy, full of paperwork and red tape, if you don't get ALL the forms and fill them ALL out completely and carefully you can be summarially denied (again), and yes, it's very much a feature and not a bug - the insurance company wants to delay paying as long as possible. Even better if the patient gives up, or is too tired/sick to continue
Let's not get too pissy about it; under a universal health care system, it's likely that the doctors will have less discretion about how they can treat a patient- if they want to get paid, they'll have to adhere to specific treatment guidelines, even when they don't necessarily agree with them.

Or go through the same sort of review process to see why they didn't follow the procedures; the only difference is that it won't involve the patient's pocketbook, but it may well involve the way they're treated and their outcome.

In practical terms, this'll mean that a doctor who's practiced for decades and knows what condition X looks like and that medication Z is most effective for patients of a specific type, will now have to go through the medical theater of trying other medications first, instead of just cutting to the chase and prescribing treatment Z right off the bat. Or they'll make you go through physical therapy and various conservative (and cheap) treatments before finally resorting to surgery, even if they knew it was the right treatment all along.

The good news is that it won't cost the patient anything.
  #191  
Old 09-24-2019, 11:15 AM
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Let's not get too pissy about it; under a universal health care system, it's likely that the doctors will have less discretion about how they can treat a patient- if they want to get paid, they'll have to adhere to specific treatment guidelines, even when they don't necessarily agree with them.

Or go through the same sort of review process to see why they didn't follow the procedures; the only difference is that it won't involve the patient's pocketbook, but it may well involve the way they're treated and their outcome.

In practical terms, this'll mean that a doctor who's practiced for decades and knows what condition X looks like and that medication Z is most effective for patients of a specific type, will now have to go through the medical theater of trying other medications first, instead of just cutting to the chase and prescribing treatment Z right off the bat. Or they'll make you go through physical therapy and various conservative (and cheap) treatments before finally resorting to surgery, even if they knew it was the right treatment all along.

The good news is that it won't cost the patient anything.
Stupid people like me would find that this type of rationing doesn't have the same angering effect of an insurance company that is taking 35% of my monthly pay - pretax - and then not paying my claims.

I feel like if there is some sort of system in play that isn't there to ensure the profits of some rich board of assholes, but to make sure that unnecessary triple tests that the doctor can bill for and make more money aren't the norm.

As it is now, unnecessary tests are a profit center of doctors and hospitals. And our medical spending per citizen is way out of whack with what other countries are spending on their citizens, and they have better out comes.

One of these systems has protections for profits cooked into them, and one does not. I'm just saying it seems like you are missing a bigger picture here.

Also, since when has anyone I know gone to a doctor and the doctor isn't actively googling your symptoms anyway? The last time I went to a doctor, I got to see what they were typing away at on their little computer tablet because the doctor stood in front of a mirror. That bastard was googling "sinus drainage and fever".
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Last edited by Translucent Daydream; 09-24-2019 at 11:16 AM. Reason: weird cursor jumpin
  #192  
Old 09-24-2019, 11:32 AM
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In practical terms, this'll mean that a doctor who's practiced for decades and knows what condition X looks like and that medication Z is most effective for patients of a specific type, will now have to go through the medical theater of trying other medications first, instead of just cutting to the chase and prescribing treatment Z right off the bat. Or they'll make you go through physical therapy and various conservative (and cheap) treatments before finally resorting to surgery, even if they knew it was the right treatment all along.

The good news is that it won't cost the patient anything.
That's already what happens now, and it costs me plenty.

I've got good employer-provided insurance with a prescription plan administered by CVS/Caremark. There's a formulary (they call it the "Preferred Drug List") of approved medications, and RIGHT NOW this means that a doctor who's practiced for decades and knows what condition X looks like and that medication Z is most effective for patients of a specific type, will now have to go through the medical theater of trying other medications first, instead of just cutting to the chase and prescribing treatment Z right off the bat, because medication Z either costs a whole lot more or simply isn't covered at all for patients who don't have prior approval from the prescription drug manager (and you don't get that prior approval unless your doctor can document why the preferred drug is contraindicated ["it's not the best choice for this patient" is NOT an acceptable reason] or was tried and didn't work).

There's a whole list, regularly updated, of "Medications Requiring Prior Approval for Medical Necessity"; if you are taking a medication that is on the preferred list and it gets moved to the prior approval list, then the insurance company requires you to stop taking it and try one of the currently-preferred drugs before they will continue paying for your medications (that happened to a friend on asthma meds; it took MULTIPLE trips to the ER before the insurance company relented and decided that maybe the doctor really did know what she was doing).

Since that is the current system, why is a government system that does something similar such a bogeyman? At least with a government system, there is likely a legislator whose constituent services staff can intervene; who can intervene when the corporate bureaucrat decides you really don't need that expensive anti-psychotic anymore?
  #193  
Old 09-24-2019, 12:02 PM
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At least with a government system, there is likely a legislator whose constituent services staff can intervene; who can intervene when the corporate bureaucrat decides you really don't need that expensive anti-psychotic anymore?
I hear a familiar refrain a lot from better off people that is something like "thats what lawyers are for" or "man just get a lawyer."

I am not sure these same people have been poor and sitting in the legal aid office begging someone not to look at them like a piece of sub human garbage, but a decent person needing help fighting the wealthy in a system skewed for the wealthy.

Those same "why don't you get a lawyer" people are never going to see the pitch forks and torches coming for them either.
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  #194  
Old 09-24-2019, 12:28 PM
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Let's not get too pissy about it; under a universal health care system, it's likely that the doctors will have less discretion about how they can treat a patient- if they want to get paid, they'll have to adhere to specific treatment guidelines, even when they don't necessarily agree with them
Doctors (in the UK at least) have a wide discretion about how they treat a patient and they don't "paid" in the way you seem to suggest above. There is also an independent body that assesses treatments for effectiveness against cost.

In the USA do the doctors have the latitude to prescribe any threatment they like and the insurance companies will definitely cough-up?
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  #195  
Old 09-24-2019, 12:38 PM
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I don't understand some of the problems people have with governmental health care. ...<payment horror story follows>



I mean, help me understand why that is the better system. I'm not the smartest guy around so I don't try to have lofty opinions on things, but the only thing that was different to me in both versions of health care is that BC/BS made a shit ton on money from me and didn't do their damn job. The evil government stuff just paid for the health care.
As I understand it, if you had Universal Health care, and a single government insurer, you would not have FREEDOM, and would be in the grip of SOCIALISM. So this would be terrible.

That's really all I've ever gotten from supporters of the status quo.
  #196  
Old 09-24-2019, 12:42 PM
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Let's not get too pissy about it; under a universal health care system, it's likely that the doctors will have less discretion about how they can treat a patient- if they want to get paid, they'll have to adhere to specific treatment guidelines, even when they don't necessarily agree with them.
Yeaaaaa.... you might want to check into what ACTUALLY happens in a UHC country, and just how treatment guidelines are arrived at (hint; it involves actual physicians who are experts in their field, not insurance company middlemen)
  #197  
Old 09-24-2019, 01:20 PM
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Yeaaaaa.... you might want to check into what ACTUALLY happens in a UHC country, and just how treatment guidelines are arrived at (hint; it involves actual physicians who are experts in their field, not insurance company middlemen)
For those interested, in the UK this is handled by this organisation, NICE
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  #198  
Old 09-24-2019, 01:47 PM
PatrickLondon is online now
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Wandering off-topic a little, but NICE provides clinical guidelines for doctors on the effectiveness of particular treatments and protocols for how to use them, and rulings on the cost-effectiveness of different treatments that don't prevent doctors from using them, but rather require local NHS organisations to provide them if the doctor prescribes them within the guidelines and protocols.

True, local NHS organisations have some flexibility in determining the thresholds at which they will allow for some treatments, which in recent times of financial stringency have led to some reductions in free services, e.g.,
https://www.bionews.org.uk/page_144287
https://www.southportvisiter.co.uk/n...ments-13771922

but (a) there is strong representation from local GP practices in the local CCGs that manage NHS funds and (b) they have to go out to public consultation on priorities before coming to such decisions

But of course any country can set up its public services how it wishes - there is no one and only model for UHC.

Last edited by PatrickLondon; 09-24-2019 at 01:49 PM.
  #199  
Old 09-24-2019, 01:54 PM
Translucent Daydream is offline
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Quote:
Originally Posted by Euphonious Polemic View Post
As I understand it, if you had Universal Health care, and a single government insurer, you would not have FREEDOM, and would be in the grip of SOCIALISM. So this would be terrible.

That's really all I've ever gotten from supporters of the status quo.
There has to be some sort of fear of it that they have of something besides that.

Are they afraid that too many people will actually be getting health care that they won't be able to go to the doctor? Are they afraid that there will be some sort of shortage? If it is truly only 8% of people that are going without insurance that will get it and then have access, I don't think that would be the problem.

Are they afraid that people will immigrate to the country just to get the sweet medical benefits? I don't know if that is a problem or not, thats for people above my pay grade to decide.

Are they afraid that it will somehow cost them more? I had no idea how expensive and bullshit my insurance was until I had to use ours.



RANT It seems like from the middle sometimes seems like one side sees the other as either rednecks or hippies. I don't see a whole lot of either in the real world. END RANT
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  #200  
Old 09-24-2019, 02:39 PM
Euphonious Polemic is offline
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For some, it may be that they don't want to pay for something that the UNDESERVING will benefit from. There are various definitions of "undeserving" out there, depending on one's point of view.
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