Geography is also a factor. Most insurers have well-defined coverage areas. When I lived in Wyoming and had to go out-of-state for complicated eye surgery, the insurer wanted me to ascertain that no doctor in the entire state could do the surgery. I eventually got it covered–hours before I had to board the plane.
I haven’t read that particular article, but even when people go to in-network hospitals, they may end up with an out-of-network physician with no way to predict or prevent that from happening.
Also alarming is the report from a hospital (I can find it if anyone is interested) that they actually did not know how much one of their standard surgeries (knee replacement) costs. The hospital itself did not know how much health care costs. Yet we have this fucked up notion that people can shop their way to savings.
Right, but those just are two sides of the same coin; what matters is that these restrictive networks exist, and that they create problems ranging from mild inconvenience to potentially disastrous financial consequences, like the case mentioned in post #360.
Such issues could be eliminated if health care costs were regulated and transparent and, by law, required to be uniform. Of course this would be anathema both to health care providers and to insurers; the former need to see high fees to offset the considerable costs of dealing with insurers, and the latter probably see their established networks as competitive advantages.
To me this raises the foundational issue with the entire system that makes the kinds of patchwork fixes that some are suggesting pretty futile. When the system is structurally broken, a patchwork fix is like a game of whack-a-mole: you fix one problem and another dozen pop up. It’s not that a government-run single-payer system is the only solution, it’s that any truly viable solution requires such a high degree of regulatory involvement that it can only be achieved with a similar level of political will and public policy transformation. The two most essential elements of a working UHC system are a uniform regulated schedule of provider fees, and – at least for the vast majority of people – a uniform rate structure, such that everyone pays the same for a guaranteed common set of coverages for medically necessary services. This is referred to as a community-rated model, rather than being individually risk-rated, which is inherent to commercial insurance as it exists today.
In my view, unless those transformational changes occur, along with subsidies or other mechanisms to ensure universal coverage, everything else is just a patchwork fix and costs will continue to soar, people will continue to face partial coverages or outright denials and continue to be bankrupted by medical costs, and many will continue to lack proper insurance.
HMOs like this still exist, like Kaiser in California. My teacher friends are forced to use it, since it is the only insurance the school district offers, and they have to go to the Kaiser hospital.
Besides the money there is the question of the customer base. Some doctors might not sign with smaller insurance companies to limit the number of people they have to deal with, and vice versa. When I was signing up for Medicare the Medicare Advantage plans available in my area had very small networks, and didn’t include some of the bigger clinics. The bigger insurers I had for work had very large networks, and I doubt they paid more to doctors than the small guys.
Is there no chance of, say, the professional medical organisations and the insurance companies establishing some sort of advisory benchmark figures, at least as a start? (And maybe doing so for entire courses of treatment, rather than for each individual pill and bandage). Or are they not trusted to do so fairly, in which case, who is?
Yes, I think a few tweaks to the ACA would make a huge difference. The ACA already has made a very noticeable positive difference. First, about 25 million people were taken off the uninsured status because of the ACA. Children up to age 25 are kept on their parents insurance. Poor people can either get Medicaid or subsidized private. Also, lifetime caps were removed. And a basic benefit package was mandated. In addition, community rating was put in place. Accountable Care organizations and a Medicare IPAC was put in place to help keep down cost growth. And cost growth has slowed since the ACA was ratified. There was also a system of risk adjustments, corridors, and reinsurance to help companies stay in the exchanges until their risk pools stabilized.
What is now needed in the near future, and it’s happening slowly, is that the rest of the states need to accept the Medicaid expansion. And we need to re-elect some Dems, so that the subsidy formulas can be fixed to induce more middle class people without employer-provided insurance to buy on the exchanges. Higher subsidies, combined with all 50 states getting the Medicaid expansion would be a very big win for this country, and would get us to almost full UHC. We could then survey the situation, and plug any remaining holes wrt universal coverage, and we could adjust our approach on things like the IPAC to deal with costs.
We don’t need single-payer to fix the problems that the country has. I think the ACA was a big achievement for incrementalists, like myself, who recognized that the government needed to expand its role, but not take over the entire healthcare arena.
I think smart regulation - without single-payer - can address the problems you bring up with your gofundme or twitter anecdotes. There are many ways to protect consumers without single payer. We have incrementally helped millions of people in this country with Medicare, Medicaid, S-Chip, Medicare Part D, and now the ACA - all of which have helped millions. You can go at the problem in a piecemeal fashion instead of an all-at-once government takeover. I like the government being involved, but with limits.
That’s exactly how it works in Ontario, for example. The entire fee schedule is negotiated between the Ontario Medical Association and the Ministry of Health, and published as the province-wide uniform fee schedule for all medically necessary services which all practitioners accept as full payment.
But when private insurers do this, their concern is entirely with their own networks and their competitive advantage and profits. Hence not only are there no uniform fees, medical fees vary tremendously across regions, insurers, and providers. Far from being uniform and transparent, medical fees in America are an enduring mystery, sometimes even to the providers themselves, completely without transparency or accountability, and geared only to the business objectives of insurers and providers.
The only thing reasonably certain about these fees is that they’re likely to be several times higher than anywhere else in the world for exactly the same services. Nowhere does the public interest enter into this equation, any more than the level of public interest in the competition between Maytag and LG in selling washing machines. Except here we’re talking about human health, suffering, and matters of life and death. This is what I mean by “structurally broken”: all the economic drivers inherent in the operation of traditional free markets are completely inappropriate for health care. And every single one of the problems in the present system are due to this gross mismatch between the imperatives of health care and the drivers of free enterprise, particularly in the area of health care funding.
…lets be brutally specific then. Lets address the anecdote I posted.
What smart regulation do you propose be passed to ensure that anyone who needs life-saving medication that costs as much as $175.00 per week can get that medication? Youcaring has 350,000 current active campaigns related to healthcare. How do your “smart regulations” go about addressing this problem?
You don’t **need **it.
But why don’t you want it?
Its cheaper. It covers everyone universally. Its patient-centric. What are the advantages of a “a few tweaks to the ACA” over single-payer/universal healthcare?
Providing millions more people the opportunity to get insured - which is what the tweaks I would advocate would do, and what the original ACA has already done - is not bullshit. There are millions who fall between the cracks because Republican ACA sabotage at the state, and then at the federal, level. We need to vote them out, and get the ACA finally implemented the way it was originally written to be implemented by the states.
THe thing is, some of you bemoan the politics that has made it so difficult to make changes in the US to our healthcare. And then you turn right around and demand the single-payer system that would be politically untenable, a much heavier lift than anything I advocate, and likely subject to the same inefficient kludge from all the backroom deals, and then would leave the entire US population under the boot of Republican sabotage if they ever come back to power. It’s nonsense, and no need for it.
Are you implying that we have to get single-payer to solve the problem of drug prices? If so, that’s crazy. The act of getting single-payer doesn’t guarantee jack squat about the price of medication. We can solve that without single-payer. Our government can regulate the drug producers to curb such abuses without single payer. The ACA itself took large steps to help consumers in this country with their healthcare.
I’ve explained over and over on this thread why I don’t want single-payer. I don’t believe our political system would ever design and legislate a single-payer system that would be good in this country, and even if they did, I don’t want the Republicans in charge of the entire nation’s healthcare, which they would dismantle at first chance.
Everything you mentioned above…covering everyone, patient-centric, lowering costs…it can happen without single payer. A properly implemented ACA would lower costs, and get us almost to full UHC, which is by definition better for patients than the old system. And any future improvements can be handled in technical mark-ups. And all of that could be done with minimal interference in the employer insurance market, which provides my coverage, an which I am happy with.
You guys live in a fantasy world if you think the realities of our US politics wouldn’t kill single-payer. Even if Dems put something together that’s great, the next Trump that gets elected would attempt to tear it to shreds. I prefer a patchwork quilt that they can’t attack all at once.
…nope.
I wasn’t. So not crazy.
My question wasn’t just about “medication.” It was also about the 350,000 other people using youcaring for healthcare related expenses. I don’t know how many hundreds-of-thousands of people are using other crowdfunding platforms.
You are still avoiding answering the question. What “abuses” are you talking about? What abuse is going on here?
This doesn’t make any sense.
The Republicans are in charge of the entire nation’s healthcare right now.
We have seen what they have done to the ACA. And if you vote them out at the next set of elections then when they get back in again they are going to do the exact same thing. The problem is the cycle: not the legislation.
“Almost to full UHC” isn’t UHC. What happens to the people that fall through the gaps?
Anything slightly better than before is “by definition” better than the old system. But thats a terrible metric for a healthcare system.
It is extraordinarily difficult to turn a profit-driven system into a patient-centric one. You aren’t explaining how that is gonna happen.
You’ve made it clear that you are happy with your coverage. But I think we are starting to get an understanding about why you favor “not making waves”. This is really about you isn’t it? “A few tweaks” is relatively risk free for you. Even surrounded by the madness that is going on at the moment you are still “happy with your coverage.” Its all about risk-to-you. The advantages of UHC over the US system are obvious: but moves towards introducing single-payer/UHC is inherently risky. But you are good. And as long as you are good: then thats all that matters.
And why the fuck do you have “employer insurance markets” in the first place? Why should the employer be involved at all?
The realities of US politics are killing the ACA. The realities of US politics are killing the people of the United States of America.
The solution isn’t to keep playing the same games. The solution is to change the nature of US politics. Something that has to happen if you want to break the cycle.
A “patchwork quilt” that keeps **your **healthcare affordable.
Lets stop worrying about yourself for a minute and start thinking about those that don’t have your privilege. I asked you a question before. In your response to me you’ve done everything you can **except **answer that question. So maybe give it another go.
This is rich. The guy who was all up in arms over supposed ad hominem attacks is now attacking me, saying it’s all me being selfish, all about me. I supported the ACA, even though it will ultimately cost more tax dollars to me in the long run, without increasing my own healthcare coverage. That is the exact opposite of selfishness, because I will be paying for something and getting nothing personally in return. So, what you’re saying makes no sense at all. You really need to insert some logic into your life.
As for almost UHC, well we’d have to find out how close it gets. I think we’d get it to 2 to 3% uninsured. I think we’d get it down to where the only uninsured are illegal immigrants and a few young invincibles who don’t want to sign up. And then, we can a provision that auto-enrolls those that refuse to sign up, or that reinstates the individual mandate penalty to a point that’s strong enough to force them to sign up. So, we’d then end up with UHC, and we wouldn’t have single payer. Technically, it’s an easy thing to do. The problem is political, as I’ve said repeatedly.
You say we have to change the nature of politics in the US. Give me your proposal to do that. How would you do that? ANd what do you mean by “change the nature” of politics in the US?
…it wasn’t an ad hominem. It wasn’t an attack on your character. It was an observation based on the contents of your post.
What I said makes plenty of sense.
You are happy with how things are.
You vehemently oppose a change to how things are because it will risk what you currently have.
So about 6 million people uninsured?
There were 27 million uninsured by the end of 2016. Over half of those people say they didn’t insure because it was too expensive. So I’m not sure how you get to 2% with a few tweaks.
To get to 2% you have to do a lot more than what you suggest. And you will still be paying twice what I do for equivalent care.
“Easy” is subjective.
The problem is bigger than “just one thing.”
How about you answer the question I asked you first? You’ve avoided it for a couple of posts now.
I don’t care if you think you were attacking my character or not. What you absolutely were doing is being illogical. Now, I’m gonna type it out again real slow for you: I got nothing out of the ACA in the way of benefits or premium decreases. But my taxes will go up (one day, if not already). And I supported it. That is the exact opposite of being selfish. You may not like what I said. It might be uncomfortable. But it’s a fact. I unselfishly supported the ACA. Stone cold fact. I can explain it to you, but I can’t get you to understand it or admit it if you do understand it.
One of my tweaks is to make the ACA subsidies more rich, thereby making it less expensive and more people wanting to buy, hence less uninsured. It’s not technically hard, and it would reduce the uninsured significantly…in addition to the rest of the states getting the Medicaid expansion, and actively marketing the exchanges. It takes some effort by the states, but it’s not technically difficult.
I have already explained to you ad neauseum why I don’t want single payer in the US, and why incremental changes will make a big difference in many people’s lives. Now I want you answer my question: WHat do you mean by change the nature of US politics? ANd how would you do it? Don’t avoid it. Answer it.
This thread has gone on long enough. Let me provide closure on the key points.
Yes, healthcare should be an economic game. Every citizen who fails to buy the extra insurance he needs (or for whom no subsidy allows him to afford it) may permit the insurer to lower premiums for the rest of us. Google “zero-sum game.” Any health-service which is mandated or funded automatically removes the ability of smart health consumers to profit. For this reason, programs like Medicare Advantage should be made more complicated, not simpler. The best citizens will hire health-insurance advisers to find their most economic option.
Isn’t this the same model that Communist East Europe used before it was liberated by Ronald Reagan? Your Marxist pipe dreams won’t fly in the Land of the Free. (Don’t forget that we have a different ethnic mixture than Canuckistan.)
…I wasn’t attacking your character at all.
Nope.
I never called you selfish.
Thats a stone cold fact.
Those tweaks would still leave 6 million people uninsured correct? And those that are insured are still paying twice as much as everybody else in the Western world?
My question to you was:
That 350,000 people fall well below your (unrealistic) 2-3% threshold that you concede would remain uninsured if we make the tweaks you want to make.
So what is the plan to deal with the people that fall through the gaps?
When you make an effort to answer my question (I’m talking about the actual question I asked you: not the imaginary question that you seem to be trying to answer) then I will make an effort to answer yours.
It is an interesting dynamic, when your insurance it tied to your employment. It encourages you to be loyal and perform well, because losing your job will typically mean that once you get hired by the next employer, you probably have to sign up with a different provider. In the past, this meant that the new provider could apply the classic “pre-existing condition” to deny coverage for just about anything you had or might have had prior to signing up.
Employers like loyalty, so it benefits them to be involved in the insurance marketplace. I am not sure of the status of restrictions on pre-existing condition denial that the ACA was imposing, but the Republicans might have reined in or trashed that in the past year.
Now let me give you my impression of all this from the perspective of a non-American outsider. The most pertinent terms there were highlighted by me. It’s hilarious in its naivety and sad in its futility. The language is a dead give-away of the kind of thinking that completely misses the point, completely misunderstands where the problems lie, and is about as likely to have productive results as a chicken running around with its head cut off.
I look at phrases like “wanting to buy”. No, just no. A new car is something you “want to buy”. A new TV is something you “want to buy”. Health care is a human right in any civilized society. If you have a system where access to health care – coverage for health care – is something you elect to buy – presumably only if you can afford it – then the system is doomed.
I look at words like “uninsured”. No. Of course if health care coverage is something you might “want”, and might elect to buy or not, then obviously there will be some who don’t have it – the uninsured. But the concept of “uninsured” is not something that should be “reduced”, it’s a concept that should not exist in civilized society. If you routinely need to use such a word in talking about your health care system, then your system is fundamentally broken.
I look at bureaucratic buzzwords like “Medicaid expansion”. Medicaid is in the same category as mandatory ER stabilization care under EMTALA: it’s intended to prevent the most blatantly inhumane atrocities that would be publicly visible due to the absence of a guarantee of universal health care, such as literally throwing patients out of a hospital and into the streets to die, although this happens anyway, in multiple ways, directly and indirectly. But it’s sorely inadequate, serves only a fraction of those in need, and is largely a conscience-assuaging pretext. Here’s how bad it is. Remote Area Medical, originally intended to bring medical services to remote tribal communities in third-world jungles, is now devoting most of its resources to bringing free emergency health clinics to Americans, in America.
So here’s how I would answer your followon question about what is meant by “change the nature of US politics”, though it wasn’t addressed to me. I think to effect the necessary changes many more Americans – especially those on the right – have to become more informed about the vital and central role of government in all successful health care systems around the world, whether it directly manages the funding of health care or whether it very closely regulates independent third parties, reflecting their critical role in a vital public infrastructure.
But what we hear from you and others is the exact opposite: an almost pathological distrust of government, the only institution that truly represents the public interest, and instead pushing the standard insurance industry propaganda, implying that trust should be placed in mercenary commercial institutions that exist only to make a profit. Commercial institutions operating with very little real regulation and for whom the patient is just an expense to be minimized – the very institutions that created this whole mess in the first place with reckless disregard for human health and human life in the pursuit of profit. Not that I would expect them to do otherwise; they are, after all, a business. But providing health care coverage for medically necessary services is absolutely not a business, and should never be treated as one or permitted to be run like one.
And indeed that hotbed of Stalinist totalitarianism that is Western Europe to this day: and most of those do it through some form of regulated private insurance, and still manage to ensure that everyone has access.
I was assuming that septimus was joking with his recent post.
It continues to be frustrating to hear the argument that “we can’t have single payer because future governments might take it away from us.” Applied universally, it means that nothing could ever be done. IMHO, once Medicare for all is established, no political party could win control of the federal government with its demolition as part of its plank. Precedent for that opinion is all around us.