The medical director of a major insurance company performed an experiment one year; for that year, all asthma medications had zero co-pay.
At the end of the year, there had been huge savings in ER visits and inpatient stays for asthmatics. Which demonstrates that paying for medication can keep people out of the hospital setting (which is ridiculously expensive).
Unfortunately, this is still not the norm, and people have to argue to get their medications for heart conditions, asthma, stroke, high blood pressure, and diabetes.
Even more so now that insurance companies have the new trick of making only one of a class of medications “formulary”, and have made the others non-covered. (So, for example, if you have depression, asthma, you can have one kind of preventative inhaler. Even if you’ve been treated for years with a different kind. If your doctor fights for you to get the medication you’ve been stable on for years, then you pay top-tier prices for it, even if it’s generic.)
Yes, it covers too much. Insurance exists only to pool money against unforeseen risks that one cannot normally afford out of pocket. For example, if my house burns down, I can’t afford to rebuild it. Most people can’t.
But, a house burning down is a relatively rare event. So how do we handle it? We all pitch in a little bit of money on the off chance our house burns down each month and when someone in the group suffers the misfortune of having his house burn down, we take that pool of money and pay to rebuild the person’s house. That is the base logic of insurance. We do it for cars, houses, our lives, and pretty much anything that has value.
However none of that insurance covers known and predictable risks. Car insurance doesn’t pay for gasoline, tires, and oil changes. Home owners insurance doesn’t pay for light bulbs and toilet paper. Commercial business insurance doesn’t pay for coffee filters.
So turning to health insurance, it should represent that basic model. Cancer, heart disease, and other serious illnesses that many will unfortunately suffer, but most won’t, should be pooled against in the same manner as above. But doctor’s visits, contraception, and immunizations are things which are regular, expected, and recurring expenses which don’t lend themselves to be paid for through a pooled risk model. We all have those “risks.” To pool those costs through an insurance company who will tack on an administrative fee and take profits on top of it doesn’t make good financial sense.
But then again there is the argument that these measures will save future costs (e.g. paying for contraception will decrease the costs of paying for a future pregnancy that would occur but for the contraception benefit). I laugh at this. I know that the free market isn’t perfect. I am also no fan of insurance companies. Those money grubbing bastards would do anything to make a dime. If the data showed that providing preventative care would save the insurance companies a nickel, then they would have been paying for preventative care ten minutes ago.
The practice of insuring against known risks related to health has caused the prices of basic services to skyrocket because consumers do not see the actual cost and therefore do not engage in basic market action of going to cheaper providers or demanding value for services. If I have a $10 copay for a doctor’s visit, I don’t care if he has charged my insurance $200. If I actually pay $200, then I and everyone else in the country are storming the castle with pitchforks. Costs would come down.
Actually, insurance companies that expect to have their customers for awhile do already pay a bunch for preventative care and other measures to get their customers into the doctor. (It may not make as much sense for groups in which there is a lot of churn and employee turnover.) For example, when I worked in a civil service plan (not federal), the coverage was pretty good for the basic preventative measures, AND the employer and the plan worked together to provide insurance discounts if you utilized those services. The premiums employees paid for single-only coverage for non-tobacco users who received an annual physical and standard blood tests such as cholesterol were substantially cheaper than premiums even for non-tobacco-users who skipped the physical.
Health care is such a different market that I don’t think basic market actions really work well. As already noted, nobody with an emergency is in a position to shop around. Further, there is a perception generally that cheap = low quality. You may not mind buying cheap clothes that don’t last very long, but who wants low quality health care? Doctors may be more related to luxury goods: customers are willing to pay more because of the belief that they’re getting something better.
The market itself is oddly-shaped and tends towards natural monopolies. In many smaller cities, there is one hospital, take it or leave it. Even leaving aside matters of convenience, the one in the next town may well be owned by the same company or non-profit, or is under the same contract with your insurer, so there are no money savings to be had by going somewhere else. The growth of “super-practices” (many many doctors in all different specialties working under common management) and insurance preferred-provider lists further limits your ability to shop around.
Finally, how many people are good at determining “value for services” for most of the services sold on the health care market? Are you, personally, able to judge the relative professional merits of two different MRI technicians or clinics, or which oncologist delivers the best value?
That would depend on the value of the doctor visit. I agree with you that emergency services aren’t a good example of the free market. They should be covered under insurance because, again, going to the hospital in an ambulance is not a normal and expected part of life.
Doctor visits come in different forms. Yes, if I am feeling near death and I see a doctor who recognizes my condition and prescribes a medication and/or other treatment that brings me back to good health, then his professional expertise is probably worth a $200 fee (or more).
If I go and see a guy who has got me lined up with others who are there for “follow up” visits because the law doesn’t allow prescriptions to be written for more than six months at a time, and I’m part of the cattle herd that gets the renewal of said prescriptions, then his service just ain’t worth $200.
Under the insurance model, nobody complains about the cost of the latter visit because the patient isn’t paying. It’s a code in the billing system. The code looks just the same as the saving of my life in the first instance and the re-prescribing cattle call in the second. There is no market cost control.
I’m always amused (and amazed) that right-wingers react to the failure of their private-insurance health care system by trying to screw the average citizen even more than he’s already being screwed. One can only conclude that conservatives just don’t want people to have health care at all. Unless, that is, they’re rich enough to pay for it themselves. That ought to fix the problem once and for all!
Health care is a basic human right. Period. Every civilized country on earth provides all medically necessary health care for their citizens regardless of ability to pay.
This business of fiddling with premiums and coverages to try to rescue an inherently failed system – a system in which the free market intrinsically has absolutely no place or function – has all the absurd futility of Don Quixote attacking ferocious windmills, and has about as much chance of success.
I’m not sure what you are going on about. If a person is unable to pay for medical care (or food, or housing) then we have a social welfare system to provide for those needs. Nobody (at least not me) is saying that sick people should die from lack of medical care. The only debate in this thread is the procedural vehicle to get people care.
And I think that a system which pools “risk” for the overwhelming majority who can afford the basics “risks” of life, is simply flawed. Under the ACA, Bill Gates’ wife must be covered at zero copay for contraception. Do you think that your premium dollars should cover that? How does it relate to your rant that I don’t want anyone to have medical care?
Around 45,000 Americans die every year from lack of medical care because they don’t have insurance. To say that the “social welfare system” is sadly inadequate is a gross understatement, somewhat like the guy who once informed me that the US actually has “universal health care” because “anyone can go into an ER and get treated”. And even among those who do have insurance, health care costs are the #1 leading cause of personal bankruptcies.
One wonders why anyone even bothers paying for health insurance in such a wonderful nirvana of free health care! :rolleyes:
Right. And my view is that as long as the procedural vehicle is private health insurance and the US continues to reject true universal coverage under a common risk pool and community-rated common premium model, irresolvable systemic problems will persist and costs will continue to rise much faster than the cost of living and faster than in nations that have adopted such policies.
Yes. Because taken to its logical conclusion, such a system lowers costs for everyone while promoting a healthier population. If one can get one’s head out of worrying about either subsidizing the rich or subsidizing the allegedly undeserving lazy poor and just worry about what is operationally most cost-effective, great progress can be made.
Your observation seems to be that we should enact a social national health care system. That is outside the scope of what is being debated here.
You also assume without evidence that preventative care in the form of insurance provided contraception to Bill Gates’ wife would somehow lower overall costs. It doesn’t and will not. Increased premiums to pay for contraception care for those who can afford these regular and customary expenses only tax the system when the insurance companies take their costs and profits out. Even in a government run system, there is a bureaucracy that must pay their staffers and processing fees so that Mrs. Gates can get her birth control free of charge.
That is absurd and wasteful.
I would be happy to entertain reforms to the social welfare system so that people do not refrain from going to the doctor because of an inability to pay. I am happy to pay tax dollars for that system provided that checks are in place to make sure that people are being helped, when possible, to get out of that system.
To address your larger point, people are not entitled to monetary assistance from society just for breathing. I have no duty to help my neighbor except by morality. To enact that morality into positive law so that I must provide my neighbor full health care benefits presents problems of moral hazard Moral hazard - Wikipedia and frankly a theft of my property to the benefit of another who may or may not deserve or need such a benefit.
My blood pressure meds are the cheapest drugs around - there are many, many OTC pills which cost much more.
Diet is cheap, but not fun.
Routine blood work is cheap.
What is NOT cheap is Stage 5 - kidney replacement.
This is so expensive that the US decided to use Medicare to pay for ‘End Stage CKD’.
For an concrete example of why it’s cheaper to go to the doc and drugstore BEFORE the disease presents in all its glory, this is it.
I just now have developed the first CKD-specific symptom. Had I not been on blood pressure meds, this would have come years ago, and I’d be well into Stage 4 before I’d break down and pay for a doc out of my own pocket.
The great discussion of ACA covered the ER crisis pretty well - poor people who can’t afford doctors - show up here, but only after the disease has progressed well past routine treatment.
I had a run-in with the ER many years ago (mid-90’s). I got the “Is there anyone you wish to have present?” question in the ICU with 3 tubes and too many wires to count attached.
I left approx. 14 hours after arriving. The bill for those 14 hours came to $54,000.
My health insurance had been taken out (self-employed) only 3 months before this entertaining night.
Blue Shield hates me.
the most obscenely expensive place to treat a patient
In the first place, what’s the difference between the two appointments? In both cases, you got the prescription that you think brought you back to good health. (It is a rare prescription that can be given out for a lifetime without followup visits even if regulations permitted, because of side effects, dose tolerance, and so on, including effects that you as the patient may not be aware of until after damage is done. For example, many common anti-seizure medications can damage the liver, requiring dose adjustments or even switching meds.)
Secondly, how well-equipped are you (and how well-equipped do you think the average American is) to determine whether it was the doctor’s treatment that brought you back to good health or whether the illness that laid you low simply ran its course and the miracle prescription amounted to sugar pills? For example, it is pretty easy to find “endorsements” of homeopathic remedies for poison ivy that claim a cure within a week, but poison ivy usually clears on its own, in about a week.
Fine, if the discussion is about what is possible in the US within the next few years, then yes, it’s not within the scope of the discussion. It still seems relevant to point out the rather crucial fact that the solutions being proposed are band-aid solutions at best, and won’t work in the long term because the basic underlying health care system the US is struggling with has not worked anywhere in the world, ever. The comparisons that are sometimes made that “country ‘x’ has a system much like the US except for a few differences” turn out to be entirely superficial and ignore vast structural differences.
What you are saying, essentially, is “we want to fix the health care system, and are willing to do anything it takes to make it work, as long as we continue to do it wrong and ignore the lessons from the rest of the world.” Good luck with that.
First of all that wasn’t actually what I was saying. Universal community-rated health care is less expensive primarily because the whole risk-rating insurance bureaucracy is taken out of the system and because a centralized agency can control provider costs. The importance of those two things together cannot be overestimated – they account, in essence, for most of the enormous cost differences between the US private system and all the rest of the world. This is the basis of workable health care that addresses both the moral issue and the cost problems. You cannot call something “wasteful” if it saves money, though an ideologue might still reject it on ideological grounds. That a healthier population may reduce demand for health care is just a bonus.
Secondly, read post #29 above from usedtobe.
That is either a savage view of the nature of civilization or an inconsistent one, as you keep hopping around between having no obligation to your fellow citizen and having a “moral” one. It could be interpreted as believing that society has no obligation whatsoever for any kind of social assistance or social safety net, let alone the moral imperative of universal health care.
I’m familiar with the concept of moral hazard. But the whole concept only arises if health care is viewed as a free-market commercial transaction. Unless you’re willing to walk past a sick and dying person in the street with the attitude “sucks to be you”, then the free-market model is a non-starter – health care must be a foundational moral obligation ingrained in the fabric of any society that presumes to call itself civilized. The US has tried to assuage its national moral conscience with half-baked measures like Medicaid and EMTALA, and both are underwhelming and basically utter failures that do nothing but drive up health care costs even further while providing minimal benefits in a way that is simultaneously inhumane and hugely expensive.
Moreover, even from a market-oriented standpoint, the concept doesn’t work in health care:
This article examines how moral hazard-based CDHC [comsumer-driven health care] plays out in both private plans and public programs. The author identifies seven ways in which this concept fails the public interest, while also failing to control health care costs. Uninsured and underinsured people, now including many in the middle class, underuse essential health care services, resulting in increased morbidity and more preventable hospitalizations and deaths among these groups than their more affluent counterparts. A case is made to reject moral hazard as an organizing rationale for health care …
What you’re really asking for is finer grained rating of your specific health risks. The issue is that ok, if you let them charge a woman who had a hysterectomy less, then why can’t the insurance company charge people who have negative information more? In fact, that is de facto what a “discount” means. The total amount paid by the insurer is the same, so…
Or, another way to look at it : let’s suppose we pass a special exception to Obamacare where insurers can grant a discount if a particular woman had a hysterectomy. Insurers do this, and discover that these women actually cost more, because the average woman who had one has serious medical problems of some sort.
Anyways, that’s not what Obamacare is about. It’s supposed to be a bad copy of the socialist systems in Europe, that do work pretty well, where everyone just pays a tax that is dependent on your income and gets government health care.
Oh, except the “tax” is a “mandate” and instead of the amount you pay going down if you make less, you get a subsidy (which means the same thing). And instead of a government system where there’s just 1 set of bureaucrats, they have created a system where there are hundreds of sets of infighting bureaucrats, a system with more red tape than Soviet Russia. Great plan, guys. But it beats the VA, a realistic example of the U.S. Federal government providing health care.
The US government also runs Medicare - which is generally (where I live) considered a good, functioning Health Care system.
It would be a whole lot better if it didn’t have to provide services under the US ‘Free Enterprise’ model.
On the plus side: at least we are discussing a national health care system at all.
Until VERY recently, the mere hint of ‘Universal Coverage’ would be labelled as “Socialized Medicine”, which is anathema to the American Way of Life - the finest in the World! :smack:
I truly do sympathize with your health issues and I wish you the best of luck in finding a speedy treatment to bring you back to health. I really do. If it was me or a close family member suffering something similar, I would be clamoring for a health care system which paid for what I needed.
Please don’t take this the wrong way, but the policy of the United States with regard to health care should not focus on your personal illness or experiences in dealing with the health care system. Your story is very easy to sympathize with. However, the health care system must treat 320 million Americans, most of whom will never suffer your illness. We must take that into account and come up with a system that works for them as well as you.
If we had a system where regular doctor visits, not subject to emergencies or other things which would skew the free market, were loosed from the bonds of government regulation and third party payment where the consumer doesn’t see the true cost, then those prices would come down. And when prices come down, consumers will make those early visits.
You change your oil in your car, right? You don’t need car insurance to cover it, nor do you just say to hell with it because you have an extended warranty. That’s because there is little government regulation in routine car maintenance. You could have your brother change your oil if you don’t know how to do it yourself. There is a thriving market where companies advertise very low cost oil changes. It brings the price down to where people maintain their vehicles properly.
The same thing could happen in health care. Why do I need a doctor to immunize my child? Any RN, LPN, or CNA can inject a needle. Why do I need a doctor to prescribe maintenance meds every six months? I can research these things. Blood tests? The doctors already don’t do them, but we get charged premium prices (because, again, insurance is paying, not the consumer).
The monopoly the government has created doesn’t beg for a solution where there is more government.
The kidney damage was discovered in 2008 - because the doc had seen enough of my blood work to suspect it and set up an ultrasound exam.
The operator scan the left kidney which was normal, first. When she started on the right one, she really started to dig the sensor in and around the organ. Always a bad sign.
If I had not seen the doc for other reasons, I would have not been tested by ultrasound and I’d be in much worse shape before the diagnosis was made.
Now: Want to talk about my osteoarthritis? That one will send you to a doc real fast (bone-on-bone pain is a bitch). The only treatments are steroid shots and surgery, often joint replacement. For now, I am on opiates for the pain.
Check the prices on Morphine Sulfate ER and Hydromorphone.
Should insurance cover the cost of joint replacement? How about the pain pills? The X-rays? The MRIs?
Please don’t take this the wrong way, but that is just such utterly wrong-headed thinking that it’s intellectually offensive. It stands out as a prime example of just how much the entrenched American conservative knee-jerk promotion of free enterprise has infested the thinking on health care, as if the life of a human being and the alleviation of human suffering is exactly the same as Saturday afternoon price-shopping for a new high-definition TV.
How the hell do you think every country on earth controls health care costs? It isn’t through advertising competitive bullshit health insurance scams on late-night talk shows. It’s through government regulation of health care provider costs, government regulation of common community-rated rates or else entirely government-run insurance systems, and a culture of social solidarity that supports them both and is embodied in government. Every single one of these systems is one in which the government is front and center of the solution, because what you regard as the evil “bonds of government”, civilized nations regard as the one and only empowered representative of the people and their best interests. They can do this because they don’t have American-style 19th century reactionaries running the place. They have actual social democracies.
That has nothing to do with anything. The health care delivery system has to be well regulated or else you’re going to get quacks involved in the business and the kinds of scam treatments you find in third-world shitholes. If your system is improperly regulated, then fix it. It has nothing to do with how health care costs are covered.
Well, it can be more competitive. Let’s assume that we’ve all agreed that we’re subject to a society contract and that basic care is a fundamental right, and it’s in the government’s interest to provide this to everyone. Certainly these are all debatable, but let’s assume the matter is settled and we’re going to do this thing.
Instead of insurance covering these, just issue a cash payment to every living resident every year. I don’t mean that basic income nonsense; this is an amount that’s meant for routine medical care, but as a cash payment you’re entitled to use for whatever you want to. Let’s say, $3000 per person per year. We’ve got insurance in place for “catastrophic things” after you meet your $3000 deductible.
At this point, the market should become a factor and pricing should be transparent, and competition should begin to exist (in places where the government doesn’t interfere via “need assessments” and other b.s.). Why should I pay $1800 for an MRI there, when I can have it for $600 here? That doc sends my tests to a lab that costs $150. This doc sends it to the $100 lab, so I’ll go here.
Whatever is left at the end of the year is mine. Cool. If I need hospitalization, then hey, I’ve used $2100 of my deductible, I’ll pay another $900, and my insurance picks up the rest. Of course if we’ve achieved pricing transparency, then the amount that insurance pays should be substantially less (no more $50 Tylenol).
Of course under ObamaCare insurance companies now make their profits based on margins, so reducing the cost they pay is really a disincentive.
Certainly dumb people will have incentives to regard the lump sum as a windfall and spend it on hookers and blow (or childcare or car repairs), and therefore avoid routine medical care, but overall this will be such a small percentage as not to matter, and only the most bleeding heart will feel sorry for them.
Even third-world shitholes have private medical industries that are quite advanced. Transparent pricing keeps things dirt cheap in India, Thailand, Hong Kong, Mexico, etc., relative to the USA, and for all but the most advanced procedures the quality is just as good. Imagine if economies of scale were applied so that everyone could enjoy these world class procedures?
Price controls, on the other hand, have the advantage of being predictable but possibly not efficient. How many countries have failed as a result of central planning? Efficiency isn’t a bad thing, but it requires a free (and non-crony) market to make it happen.
Because my doctor’s office is coordinated with ExpensiveMRI, likes working with them, and transfers information seamlessly. They don’t like CheapMRI, their systems aren’t set up to transfer information, I have to hand-carry the films, and it’s a pain trying to get them to talk to each other.
Because my cousin’s wife’s sister’s ex-boyfriend’s babysitter had this really awful horrible no-good very bad experience with CheapMRI.
Because CheapMRI isn’t set up to work with my insurance, so I have to pay them upfront and seek reimbursement, while ExpensiveMRI will deal with all the paperwork after my deductible is met.
Because they’re CheapMRI; that means there’s something wrong with them. They’re not as good or as talented, and my health is far too valuable to trust to cheap doctors.
Because I’m too sick to spend all of my time trying to figure out the cheapest place. I need an MRI, some physical therapy, a pharmacy, home health, a surgeon, and an anesthesiologist; which is the cheapest and best and most convenient for each of these specialties, and how much time do I have to spend on the phone trying to figure these all out and schedule something?
Because this whole illness is going to cost a hundred grand; paying an extra one percent somewhere isn’t going to make or break my finances, and if I pay more for the MRI that just means I hit the deductible sooner and the insurance company has to pay more for the surgeon or whatever other followup I get.
Because I can have an appointment at ExpensiveMRI tomorrow, and CheapMRI will schedule me in two weeks from Thursday.
Because ExpensiveMRI is in the same building as my doctor, while CheapMRI is on the other side of town. I’m sick, I don’t want to go tromping all over creation.
Because I’ve always gone to ExpensiveMRI, and I like and trust the radiologist who works for them. I don’t know the people at CheapMRI.
I’m sure you can think of a bunch of other reasons. Obviously some are more important than others, and some will be more important for some people or in some situations than others. However, I don’t think many people even want to get the cheapest health care; trust and reputation and convenience count for a lot more.
Yes. Another issue is that people will spend what they have if they think it will make any difference towards whether they remain alive. Extra money in your bank account (or less debt) doesn’t help if you are dead. This creates bizarre medical economics where goods and services that are simply priced more can have more sales.