The ethics of health insurance

Miscellaneous and Personal Stuff I Must Share
101

Is the US agricultural industry really “fantastic”? It’s obviously very productive, but I can point to examples from companies like Monsanto or Arthur Daniels Midlands plus plenty of examples of how produce and livestock are produced that demonstrate the same sort of profit vs public good conflicts of interest seen in healthcare.

What makes healthcare different from other free markets is that we believe that on some level, everyone is entitled to some level of healthcare, regardless of their ability to pay for it. And in any free market, there will always be people who are priced out of the market.

102

If the providers are billing for services not provided, all they should have to do is ask the patient if they got them; possibly with backup from other witnesses for whether the patient was there that day, or whatever. My statements tell me to check and report anything I don’t recognize. If they’re finding kickbacks on referrals, but the referral was medically useful, refusing to pay for the service is utterly unfair to the patient. Censure the doctors involved.

If the service is genuinely unnecessary, that’s another matter. But there are two issues with that: one of them is defining “unnecessary”; and the other is, do the people making the decisions have the relevant medical degrees and experience to make them qualified to tell?

Maybe sometimes the patient is in on it. That would involve a kickback of some sort to the patient, no? How often is “sometimes”, and how often are they caught?

Because the public was imagining waking up in agony from an incomplete operation? Or waking up in agony while the doctors completed the operation after the anesthesia wore off? Or waking up not in more than ordinary post-operative pain, but with the operation unfinished because the time was running out? “Sorry, we had to leave some of your cancer in there, it was taking too long to get at it all”?

Yes, I know; they’d probably actually have woken up with the operation properly finished, and just to the discovery that they now owed a large bill that some of them couldn’t pay. But the thing is – they paid for their insurance in order to avoid winding up with large bills that they couldn’t pay. If the insurance isn’t going to accomplish that – then what were they paying for?

The farmers don’t set their prices. Farmers have to take what the market will pay, even if it’s less than the cost of production; because most of the buyers are indeed very large corporations, and even the large farmers aren’t usually in a position to do anything else. Direct-market farmers have some say in prices, but not all that much, because their customers can always go to the big chain groceries instead.

That’s why farmers have been going out of business steadily for the past century or so. When we get down to a couple of “big corporations” growing as well as marketing almost all the food – then we’ll see the results you’re describing. We’re not there yet.

(I’m not going to get into the quality issue, or the issue of topsoil disappearing into waterways and the wind, or the issue of pollution of those waterways and that wind. It would be a really long post.)

– also, what @puzzlegal said, post #64.

It gets complicated if you travel outside the USA, also. I believe travellers’ insurance is strongly recommended.

I’m sticking with the original, thangyewverymuch.

The quantity of advertising I get trying to convince me otherwise makes me suspicious in itself.

103

Reading this discussion, it occurs to me that one side effect of socialized medicine is that the rich would pay a larger share of the total bill.

See thread about whether the rich pay enough taxes:

This strikes me as a good outcome, speaking as someone who would probably pay more, but who would find the freedom from worry with it even without the benefit to others. But i suspect that’s one of the reasons we didn’t have it. Heaven forfend that wealthy white property owners pay to subsidize the healthcare of poor brown laborers.

104

I agree environmental damage and animal care are a big concern. I don’t think any other industrialized country in the world is much better in this regard.

My question to you is, are you willing to pay more for your food to protect the environment and animal welfare? I certainly am because this issue matters a lot to me. I buy free range eggs whenever I can, etc. I do everything I reasonably can to try to minimize my environmental footprint and promote animal welfare practices. They’re small gestures but it still costs money and it all adds up. I’m voting with my wallet. And no, the problem isn’t evil corporate greed. There is no physical reality where free range eggs and pork meat does not cost more than horribly abusive industrial farming.

What makes healthcare different from other free markets is that we believe that on some level, everyone is entitled to some level of healthcare, regardless of their ability to pay for it. And in any free market, there will always be people who are priced out of the market.

I agree with that, which is why I defend some sort of co-pay or paid-for insurance system. I haven’t worked out all the details but nothing I said should be understood to be against providing some basic level of healthcare to everyone for free. Although again, the value of human life is a finite quantity so the amount of effort (=cost) that should be put into any one individual is also finite and has an indirect impact on everyone else.

Obviously to me mine and my children’s lives have infinite value. But we can’t expect government officials in positions of power to govern as if every constituent is his or her child.

potential hijack spoilered

How many Hunter Biden pardons do want?

105

This is definitely an issue.

And I just typed out a whole long rant about it but I’m pretty sure it’s off topic.

106

Those are all great points but it doesn’t seem to point to a fundamental problem with the free market system and healthcare. The lack of information and power imbalance problem is common to a lot of industries for example.

Seems like a big part of the problem with the system in the US is tying health insurance to employment. This is something that could be fixed with political action without implementing socialized healthcare.

107

That’s not how it works in Canada. The government sets the scale for all the medical procedures, but most doctors are in private practice. Their pay will be based on the number of patients they see, not on a salary. And the patients can move around from private clinic to private clinic, so they have choice. There can be issues when a doctor has a full patient list, so then the patient will have to go to a walk-in clinic. Once the doctor provides care to the patient, the doctor bills the central billing agency, which pays.

Hospitals are largely funded by the government, but are not necessarily owned by the government. There are hospitals run by charitable foundations, or by local health authorities.

Government is heavily involved in the provision of health care, but the hospitals and doctors have professional freedom to treat their patients without a government agency providing oversight on the treatment for an individual patient. They are not employees of the government.

108

That’s not the case in Canada. We often get compared to the US because we’re on the same continent with many social and cultural similarities, but our system of single-payer health care has not led to the picture you paint.

Nor is it the case when the US is compared to other OECD countries.

This brief using 2021 data is helpful:

Nor is this accurate:

If I want to go to a doctor for a simple consultation, I go to the walk-in clinic in my neighbourhood. I may have to wait an hour or so, and then I see a doctor (oh, the horrors of wait times in socialised medicine).

After that, it depends on how serious the issue is. At one point, I was tested for a possible heart issue, right in the clinic, as part of my initial consultation, and was told that if I needed to go to a hospital as a result of the test, that would be immediate. Fortunately, I passed the test and they just sent me home, with better blood pressure medication.

On the other hand, I’ve had the occasional skin lesion that the clinic doctor has said needs to be looked after by a skin specialist, but it wasn’t a crisis. For that I had to wait a few months, then saw the specialist. In a couple of cases he diagnosed that the lesion needed to be taken off, and a month later that was done. Other times, he’s concluded that there was no issue.

So yes, for non-emergency issues, I had to wait. But that’s the basic principle of medical triage. The key there is that the triage was based on the doctors’ professional judgment, not a bean-counter watching over the doctors’ shoulder.

Anecdotes aren’t data, of course, but I’m just saying that your uncited assertions of how socialised medicine work do not match my personal experience. Got cites for what you’re saying? That apply generally to all systems of socialised medicine? And rebut the study cited above?

(That study is just one of the many I found from a quick Google. I didn’t find any that contradicted it.)

Bottom line: the US spends more per capita / GDP on health care through its private insurance system, for worse outcomes.

109

This is probably duplicating @Cervaise 's point, but yes, that’s how UHC works in Canada. You get UHC because you live in the province. It’s not tied to a job in any way, and in my province there are no premiums. All my health care is covered by my income taxes. (And it’s not allocated in any way by your income: a person on social assistance gets the same health coverage as a high-flying executive.)

If you leave one province for another province, there’s usually a qualification time at the new province (eg three months), and during that time, you stay covered by your old province.

If you get fired or quit, you’re still covered by medicare, because it’s not tied to the job in any way.

If you want to start a new business, fill your boots - you’re covered. UHC is more encouraging of entrepreneurialism than the US system, it seems to me.

If you travel outside Canada, travel insurance is highly recommended, especially in the US, because the provincial plan will only cover your medical care in the US at provincial rates, which normally don’t come anywhere near what you need if you’re in the US system.

If travel is part of your job, in that case your employer may offer health insurance for out-of-country, but if you are just travelling on vacation, you have to get it yourself from your local insurance broker. I get mine from the same insurance office that does my house and car, and it’s always been reasonable.

A friend of mine was travelling in the UK and broke her leg hiking. She got health care from NHS, and they essentially just covered her for free; would have been too much of a bother to try to bill her for a routine matter like a broken leg.

Snowbirds, going to Florida or Arizona, have to get travel insurance for their stay, but they don’t lose their Canadian coverage, so long as they spend at least half the year in Canada. Snowbirds I know are very careful to keep track of the length of their stay down south, and always make sure to come back within the ~180 day period necessary to maintain their Canadian health coverage.

When you retire, there’s no change in your medicare coverage, but as @Spoons mentioned, you may get increased coverage that working folk don’t have, such as prescriptions. But, there is none of the analysis of different Medicare plans for retired folk that I’ve seen discussed on these Boards and which makes my head spin.

110

That’s an interesting perspective on the matter, though I would stress that it’s definitely only part of the problem. Insurance only for catastrophic health issues still leaves at least three major problems unaddressed:

  • Everyone needs ongoing health care and not everyone can afford it. As a basic principle recognized by all other advanced democracies, access to such care is a fundamental human right and for both ethical and practical reasons cannot be treated as a free-market commodity. Access to critical health care is simply not in the same category, ethically or practically or by any other measure, as a new TV or a new car. Furthermore, some of that ongoing care, such as surgery, can be ruinously expensive while not necessarily meeting the criteria for being “catastrophic”.

  • Health care is essential and so doesn’t conform to normal economic rules of elastic demand. So the costs tend to spiral out of control without regulated controls. Such controls are intrinsic in publicly managed universal health care, especially single-payer, and almost impossible to implement otherwise, as we see in the US.

  • Another perfect illustration of how free-market principles do not and can not ever apply to health care is in a post I made over here. It unfortunately furthered a hijack in that particular thread, but I think it’s very relevant here and well worth a read. To put this point very briefly, those who’ve never known anything other than the private insurance system (and by “system” I mean the whole economic landscape of American medical care) take it for granted that for every medical expense, you literally put in an insurance claim, sometimes requiring “pre-approval”, and that the claim may be denied or the treatment option may be downgraded to save costs. This kind of clinical meddling is inherent in the insurance system, but simply does not exist in single-payer, for the reasons I discussed in that post.

111

@wolfpup 's post reminded me of another point I’ve made on these boards in the past: for us, healthcare isn’t a commodity; it’s a government service. Just like other government services, it’s paid for by our taxes:

  • need to call the cops for a break-in at your house? You don’t need police insurance to pay for it.
  • need to call the fire department because of a house fire? You don’t need fire department insurance to pay for it.
  • need to send you kid to school? you don’t need school insurance to pay for it.
  • need to drive to work every day? you don’t need road insurance to pay for it.

All of these are government services, paid for from your taxes. Health care is just the same.

I guess someone could argue that public police, public fire departments, public schools, and public roads are all socialism, but they seem quite common in the US.

112

I also prefer to think of health care as a public good rather than a fundamental human right:

Years ago, I got sucked into an argument with my beloved (but MAGA) brother. When I asked him if a thriving economy didn’t heavily depend on a healthy and educated workforce, he responded with:

That’s just so much liberal bullshit.

It’s tough to work with that. And … yet … here we are.

Oh, and … in addition to it being a common good, it’s also become a major national security issue (very simple, 2pp PDF):

Addressing the ethics of health insurance – again – is, IMHO, a discussion best predicated upon reaching agreement on certain fundamental issues and statistics.

On a somewhat happier note, it isn’t just us:

Summary: Obesity is adversely affecting the welfare, economic, and in some cases military security of these three countries (ed: US, China, Mexico).

But the threatened tariffs ought to fix that nigh unto immediately (/s).

113

I know almost nothing about Canada’s health system but from what little I have already learned from you and other sources it is not a fully socialized system, to keep using that term, so it doesn’t match my reality and I really have no opinion on its merits or lack thereof. Sounds better (similar care for less money) than what I have in the EU.

114

Ah, the “No true Scotsman Socialist”.

115

It’s literally what it says on the Medicare Wikipedia page:

With rare exceptions, medical doctors are small for-profit independent businesses. Historically, they have practised in small solo or group practices and billed the government Canadian Health Care system on a fee for service basis. Unlike the practice in fully socialized countries, hospital-based physicians are not all hospital employees, and some directly bill the provincial insurance plans on a fee-for-service basis.

In summary, the system is known as a “public system” due to its public financing, but is not a nationalized system such as the UK’s NHS: most health care services are provided privately.

So I have no idea what bone you are trying to pick with me. It’s a different system.

116

It’s a distinction without a difference, just like other terminologies that elicit different degrees of public support because particular words trigger preconceived prejudices even though they mean exactly the same thing. Just like surveys of Fox viewers showed that they hated “Obamacare” but were fine with the “Affordable Care Act”, or hated “government health care” but were fine with “public health care”.

Yes, accessible health care should be regarded as a public good, but the reason for that is that it’s a fundamental human right. Some may not like the latter terminology because they associate it with the various policy edicts of the UN, an institution which some dislike, but AFAIC that’s their problem. The term is accurate. Even in the US, when someone gets into an accident with serious injuries, they get taken to hospital without immediate regard for costs, even if a Coast Guard helicopter has to pluck them out of the water at enormous cost. Someone who is so desperately poor that they can’t afford any medical care at all will likely have access to Medicaid. The human right aspect is already established; the problem with the US health care system is the huge gaping holes in it that allow millions of Americans to be uninsured or underinsured, its sordid history of coverage denials, and its astounding, unsustainable inefficiencies.

The description of a “public good” in your cited article is also not entirely accurate:

In economics, a public good is something that is non-excludable and non-rivalrous, meaning that (a) no-one can be excluded from its use, (b) and its use by one person does not diminish its availability to others.

I can see conservatives pouncing on point (b), arguing that this is manifestly false, since health care resources are finite and limited. I mean, if an ER doctor is seeing someone, then clearly they’re not seeing me or anyone else in the ER queue.

I think this is actually one of the basic reasons that many people oppose UHC. They’re OK with the health care they have, even if they’re not thrilled with it, and they fear that UHC will open the floodgates to millions of “undeserving” poor people who’ll flood the queue in front of them. What they fail to understand is that a well-managed UHC system works far better for everyone, at far, far, lower costs, and provides timely treatments commensurate with urgency without any risk of ever being denied treatment because some insurance bureaucrat gets a bonus for saving the company money by screwing you over.

117

Which I think is, in general, a semantics thing. Any hospital can claim it’s not-for-profit. Doesn’t mean they bill any less, doesn’t mean they won’t go after you for every penny they can. But they are able to make their accounting show that there isn’t really any “profit”.

Health insurance in general is hideously wasteful. Every penny paid to the various CEOs and 99% of other salaries paid is money that is, from a health standpoint, thrown away. It adds no value to the patient. Nor do many drug plans that use PBMs. In a lot of cases, the meds you are allowed appear to be the ones that provide the most profit for the pharmacy benefits manager; they can keep the difference between what you pay and what the drug company has agreed to accept.

Do I believe that some oversight can help reduce unnecessary expenses / unneeded medical care? Absolutely. But in my personal experience it’s been utterly arbitrary.

For yucks, I looked at what all my meds would cost on the various Part D plans when we go on Medicare. For half a year, my premiums + copays were anywhere from 1,200 to 5,000 dollars. A friend who’s on part D found that one plan covered only the expensive brand-name of something she uses, NOT the generic. WTF???

I find the idea quite plausible that the murder is a result of someone out for revenge for a bad outcome, for himself or for a family member, due to insurance delays. I don’t know if that’s what went on - but given all the horror stories, it’s not hard to believe. But no, the victim did not deserve to be murdered. If that were an appropriate response to any kind of deserved dissatisfaction, we’d have a lot fewer politicians, for one thing!

118

I think this is really understating just how fundamentally corrupt the medical insurance ‘business model’ has become. The entire point of insurance is that it distributes costs across its customer population using statistical (actuarial) methods to minimize individual costs while assuring that their customers are able to receive necessary treatment. To that end, some customers with critical trauma, unusual illness, or chronic conditions are going to cost a lot, while most customers will underburden the system relative to the premiums they pay. The insurance company has to clear sufficient profit to cover legitimate administrative costs and make a modest profit for investors (shareholder dividends) as well as being able to invest in improvements, but these companies have now become so profit-oriented to the extreme of abandoning their essential mission of providing coverage for their customers.

When an insurer is showing record EBITDA and avoiding paying taxes and paying massive tens-of-millions of dollar compensation packages to their execs while systemically shrifting and frankly defrauding customers out of the legitimate coverage for which they have paid in a system in which most people have few real options, the industry has become epically reprobate and exploitative. It is one thing to optimize the business for greater efficiency and show value, but it is quite another when that ‘efficiency’ comes out of refusing to provide the essential service for which they exist.

This comparison is incredibly risible given how deeply subsidized and exploitative of producers most sectors of mass agriculture, from dairy and grain production to chicken and pig farming are. Notwithstanding, of course, that the notion that health care is a competitive free market service for which customers have an array of choices with transparency in costs and quality.

In fact, even setting aside emergency situations where there is no time to evaluate costs, customers have few options when they are tied to employer-provided health plan offerings and even on the ‘open market’ what is available is often of very marginal value (something the Affordable Care Act was supposed to ‘fix’ but was almost immediately gutted), and health care costs are obfuscated from even the most diligent and informed consumers, with providers refusing to provide estimates even for basic surgical procedures and standard services such as childbirth, and are able to present surprise charges and almost inexplicable lists of charges with virtually no recourse by consumers who must either pay or spend months contesting them at the risk of damage to their credit rating.

Stranger

119

I meant great as in high yields at low cost and the example was inspired by some books I read recently about the Soviet Union and comparisons with. Not that the US agriculture industry doesn’t have any problems. you could argue subsidies make it a bad analogy to a free market, fine, whatever, but that is a legitimate form of government policy action and I never meant to equate free market with the worst excesses of capitalism.

In fact, even setting aside emergency situations where there is no time to evaluate costs, customers have few options when they are tied to employer-provided health plan offerings and even on the ‘open market’ what is available is often of very marginal value (something the Affordable Care Act was supposed to ‘fix’ but was almost immediately gutted), and health care costs are obfuscated from even the most diligent and informed consumers, with providers refusing to provide estimates even for basic surgical procedures and standard services such as childbirth, and are able to present surprise charges and almost inexplicable lists of charges with virtually no recourse by consumers who must either pay or spend months contesting them at the risk of damage to their credit rating.

Good points and I agree lack of information and hidden charges is a huge problem across the whole industry.

120

And the CEO of the UnitedHealth Group (I assume the overall holding company) says the quiet part out loud: