The ethics of health insurance

Miscellaneous and Personal Stuff I Must Share
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I have some acquaintances that will go to the doctor/urgent care/ER for an ordinary cold. I’m not talking people with serious health problems here, or serious illnesses like pneumonia, just otherwise healthy people that get the sniffles. They also often demand medication, and will usually get prescribed a round of antibiotics purely as a placebo (since they do nothing for viral infections).

I personally consider this absurd, but on the other hand I’m not likely to seek health care unless I’m on death’s door (I’m probably an under-utilizer of health services). But regardless, from this I conclude there’s an enormous spectrum of what people consider acceptable thresholds for getting health care and there’s no reason to believe that my own acquaintances are the limit.

In general, medical care costs are dominated by a tiny fraction of total users. This isn’t too unexpected since most people are healthy most of the time, while some small fraction have a combination of serious, chronic diseases, and they can probably consume 100x or more the medical services as a typical person.

Those cases aren’t frivolous, but it illustrates that the spectrum of use is quite broad. I don’t know anyone in that bad of shape, but we know from the stats that they exist.

Co-pays are cheap (in both Canada and the US) because they aren’t meant to discourage anyone from getting legitimate care. They’re so small that they’re barely worth collecting–it wouldn’t surprise me if the admin costs exceed the actual value most of the time (probably why you see that they aren’t always collected). They’re just slightly above zero to reduce abuse.

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That’s aggravated by Americans not having health insurance. The emergency room is the only place where they treat you first, and ask for proof you can pay later.

I can give another example, that’s definitely not about lack of coverage. A friend has a son with hemophilia. Every time the son bumped into anything, they took him to the ER to get factor 8. After his health plan instituted a large co-payment for going to the ER, my friend learned how to inject factor 8 himself. The kids still got treated, but my friend’s utilization of healthcare dropped a lot.

Hemophilia is one of those outlier conditions that rack up huge healthcare costs, by the way. When his kids was diagnosed, before ACA, the social worker at the hospital that diagnosed the kid told my friend he had to apply for Medicare. [Medicaid? I can never keep them straight.] He replied that he had health insurance. Not so fast, said the social worker. Most health insurance had a lifetime maximum of $1M, and he would hit that in a couple of years. Now was the time to apply for benefits.

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Or we could go the opposite direction and state that the AMA treatment guidelines are THE canonical reference (or whatever set of guidelines we choose/generate), and insurance companies are forbidden from denying any treatment/prescription/etc… that adheres to those standards.

I feel like that would make more sense; doctors aren’t superintelligent beings who always know what to do; most of them probably were our peers (us here at the Dope) and just chose a different path than us. That’s probably what gives me the heebie-jeebies more than anything; knowing how much I don’t know about my own profession makes me wonder what doctors don’t know about theirs. Many of them are old and out of touch with the state of the art, many are just not as smart as we’d like, and many are just egotistical and conceited and think they know best, even in the face of treatment guidelines and good sense.

There absolutely needs to be a brake on doctors prescribing/ordering whatever they want, and someone else having to pay for it, whether that someone is the patient, their insurance, or the government.

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There’s a fairly wide range of recommendations. I’m thinking of starting a thread titled, “should i take metformin?”. And in response to the obvious question, i already asked my doctor, and he said it’s up to me. Both taking metformin and not taking it are within the accepted guidelines.

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Sounds like a half-assed doctor to me. I’d be annoyed if a doctor left a decision on a diabetes medication up to me, as if I know what the right decision would be.

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That really depends - there are always people on the border. My doctor left it up to me whether I wanted to increase the dosage of an injectable diabetes medication. My A1C was fine on the original dose and the increased dose might help me lose weight - but it also might bring on side effects and it was really my decision whether the possible weight loss was worth the risk of side effects.

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Alright, if you don’t want to rely on @wolfpup 's paraphrase, here’s what federal law requires of the provinces in order to be given the annual federal contribution to the provincial health-care system:

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And here are the key definitions for the terms used in those provisions. The definitions are also part of the statutory framework, set out in s. 2 of the Act.

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I appreciate anecdotes like this because I’m interested in health care economics and they help me better understand some of the details of the US health insurance system. But the two major things I get out of it seem to me to be yet two more negative strikes against the private insurance system: (a) your friend’s insurance plan suddenly instituted a large co-pay for going to the ER (presumably regardless of purpose), and (b) the lifetime payout limit which seems to fall into the category of yet another unexpected surprise one can get from a private insurer, just like Anthem’s plans to suddenly start limiting coverage for anesthesia.

Those are all things that one won’t find in single-payer in Canada. Not that limitations don’t exist, but where they exist, they’re there for good and rational reasons, and in many cases the physician has the authority to override them by providing a justification. But by and large, coverages are just automatic and unconditional and free of any user cost at all.

The argument that user fees (by which I mean both deductibles and co-pays) is simply a myth that has proven not to be true in within the Canadian single-payer systems, and conversely, it’s inevitable that these costs will discourage or even render financially impossible critically important access to health care.

To cite my own example, I still remember that fateful day, my second day of chronic chest pains, when I was tossing around in my mind whether or not I should go to the ER. My only hesitation was the inconvenience. Had there been a significant cost involved, that would have tipped the balance to “no”. Little did I know that I was actually having a heart attack. Had there been a significant cost involved, I’d probably be dead today. In the end, I was in hospital for nearly a week, got surgery, and went home with a total bill for $0.

This is why I keep saying that there are really foundational philosophical differences between private health insurance and public single-payer. The former is a business and acts like one, the latter is a public service and acts like one. It’s why I’m vehemently opposed to any role of private insurance for medically necessary procedures, though I don’t have a particular problem with them for supplementary coverage.

This is also why the statements of principle in the Canada Health Act that @Dr.Strangelove finds so “meaningless” are in fact very meaningful indeed, because they set definite bounds on what the provincial single-payer plans are allowed to do in the inevitable quest for cost containment. (And thanks to @Northern_Piper for posting more details on this.)

Here’s some good info I came across regarding hospital and surgery costs in the US and insurance coverage. The basic take-away is that the costs are enormous and even having good insurance can leave you stuck with co-pays, huge deductibles, coverage limitations, and outright denials. This is the short and simple bottom-line statement:

But even if you have excellent insurance coverage that pays 80% of the total bill, the remaining 20% can exceed $100,000 for major surgery.
Hospital and Surgery Costs – Paying for Medical Treatment

This is why medical bankruptcy is a major problem in America, despite the fact that a significant number of these victims are middle-class homeowners who thought they had adequate insurance.

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Agreed that that’s a problem. That’s not the situation with the people I know, but it’s definitely an issue.

Another huge factor are the homeless, especially the mentally ill / drug addicted, who get all their care from the ER. Expensive, repeated care with no possibility of preventative treatment.

That is interesting about the hemophilia case. That’s something where even in a UHC country it’s in everyone’s interest to get the person to self-administer the drugs. More convenient and it lowers costs. But it sucks that the insurance company forced the issue in that fashion.

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I once saw a depressing and horrifying documentary about the struggles of the staff in the ER of a public hospital to provide care for the uninsured. I’m not certain that the cited movie below was the one I watched, but it probably was and in any case is a similar theme.

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That’s true for Medicare, where there’s no limit to the amount of 20% coinsurance. But private ACA commercial plans put on cap on it, limited by the ACA to a $9450 max per person per calender year or $18,900 per family for covered in-network services, and many are less, A couple of times I reached my $2000 OOP max on my employer provided plan several years and after that my insurance paid for everything wtih no deductible, copays, or coinsurance.

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Here’s a plastic surgeon with a YouTube channel, commenting on his own opinion of UHC “insurance.” He won’t take it because it’s such a terrible plan, and does not authorize it for his employees either. He also does not consider the shooter to be a hero, on any level.

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Exactly. My numbers are in a range where either option is medically reasonable. And my point was that there are a lot of cases where there isn’t a single right answer, but a range of medically appropriate choices.

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The lifetime limit was eliminated with ACA. And yes, that was a bad thing.

The copay for the ER was not a terrible thing. It was meant to reduce over-use of the ER. And my friend WAS over-using the ER. When his kids was born i told him he’d have to learn to inject factor 8, and he was horrified. But of course that was the right thing for him to do. If he’d been disabled and unable to do it, then yeah, i would hope that a good system would arrange for a professional to do it. But there was no reason other than squeamishness for him to insist on having a professional perform what was basically routine care for his kid.

Heh, i thought you were referring to United healthcare until the third time i read this. But yes, and as soon as the kid was a teen, he learned to do his own injections. It was nuts how long it took for his parents to do so. My guess is that most well-run health systems would just have a nurse train the parents, and refuse to cover injections in the ER unless there wasn’t a competent person to do so in the child’s home. But i don’t know.

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Ugh, yeah, I actually tried to stop using the acronym previously because it’s become very confusing, and yet I still typed that on autopilot. As you concluded, I meant Universal Health Care, not United.

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It’s a terrible thing if user fees (any combination of deductible or co-pay) discourage legitimate use. As I indicated in my heart-attack anecdote, it was a toss-up for me as to whether or not I should go to the ER, and any significant cost would likely have tipped the balance to not going and I might not be alive today. Very stupidly, the idea that I was actually having a heart attack didn’t even occur to me and the revelation was quite a shock! I was mostly just put off by the inconvenience of going to the ER, but some people might genuinely not be able to afford any significant user fees.

It appears that in Canada such injections would have to be started by a doctor but could then be continued by the patient at home. It wouldn’t be a matter of either denying claims for continual ER or doctor visits or applying prohibitive co-pays to it, since both of those approaches are tools used by private insurance that notably are alien to the way single-payer works, but rather the doctor training the patient to be able to self-inject. The Canadian Hemophilia Society talks about this here (PDF), noting that it “helps avoid frequent visits to the hospital for the child with hemophilia and his family”. IOW, this is not a “must-do” enforced by onerous costs, but a “should-do” guided by a doctor in his role as gatekeeper to the health care system.

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And I think you would be wrong, with respect to treatment. “Medically necessary” is a legal standard, imposed by federal law. The provincial health systems have to comply with that standard, and not exclude things because of cost.

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Prescription drugs, as mentioned several times, are generally not covered by our UHC system. Whether or not a drug is covered by a drug plan does not prevent a doctor from concluding that it is the appropriate medical treatment, prescribing it off-label, and getting paid by the single-payer authority for providing treatment to the patient.

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I agree, but that’s got nothing to do with paying the doctor for the proposed treatment. The single-payer system is not a gatekeeper to medical treatment, unlike for-profit insurance in the States.

A doctor with admitting privileges at a hospital has to comply with the professional standards of that hospital. If a doctor were to try to schedule a trepanning procedure, they have to go through the internal professional controls of the hospital, since surgery involves much more than the particular doctor.

The key point is that those internal professional controls are not provided by the single-payer body, but by the hospital, the other doctors involved, and ultimately the medical regulatory body.

And yes, if a doctor develops a pattern of prescribing treatments that do not match the patient’s needs, and that comes to the attention of the medical regulatory body, that body can require that the doctor seek remedial medical training, and can impose practise restrictions on the doctor’s ability to treat patients. (I’ve seen the occasional newspaper article in my province where that sort of regulatory intervention by the College of Physicians and Surgeons is outlined). But again, none of that is to cut costs. It’s not the single-payer body that gets to make those decisions. The College has the statutory mandate to monitor and maintain professional standards by the medical community.