Who are the uninsured with pre-existing conditions in the US, and will they bankrupt health care

Great Debates
61

This is a really good point. Most people with a chronic condition have or will develop a co-morbid chronic condition, whatever their age. In my profession (I work with a largely disabled and/or senior population - most eligible for Medicare, some waiting on eligibility), we see it all the time. Frequently, when someone becomes disabled for something like fibromyalgia, if they don’t already have it, they often develop depression. That can often lead to weight gain, which can lead to heart problems, Type 2 diabetes, asthma, etc. And that doesn’t even include some of the other issues we see, such as MS, cognitive impairment, other mental disorders - and those are just the adults. That doesn’t include the many children with disabilities or chronic health problems who live relatively long lives with those issues.

Even among the non-disabled population, many people with Type 2 diabetes will go on to develop heart disease or asthma or cancer or a combination. One really big flaw in our system is the lack of coordinated care - we treat the human body in parts rather than as a whole.

For example, if you have a heart attack, you’ll be referred to a cardiologist, but probably not otherwise evaluated for anything else other than issues relating directly to heart disease. If you have a seizure (which is near and dear to my heart because I have a seizure disorder), you likely won’t be asked questions about depression, which can occur alongside seizures, sometimes as a result of the seizures or the medications or preceding the seizures. You also won’t be referred to an endochrinologist, even though many seizures, particularly in women, are linked to hormones. Hormone therapy can interfere with seizure treatment.

Fortunately, under the new healthcare reform bill, there will be some demonstration programs (basically, pilot programs) that fund ACOs, or accountable coordinated care organizations, which will reward doctors, including GPs and specialists, for working together to provide patient care that centers on the patient as a whole, rather than the patient as parts. It’ll be interesting to see what happens.

Another part of healthcare reform is encouraging the growth in primary care practice. Wrapped into the bill is funding to encourage primary care education, demonstration programs and “telehealth” to provide primary care to individuals in rural communities who might not otherwise have access to care.

Having read it, I think it’s a pretty decent bill. Like many other pieces of legislation, it was created with good intentions. The true test will be the actual implementation. It certainly won’t fix everything, but it should help. And I think it’ll be nigh on impossible to repeal it, especially totally - you can’t just take away coverage from all the under-26s and suddenly make Medicare-eligibles pay for 100% of their drugs in the donut hole again, plus all costs for their preventive care without some seriously negative repercussions. Attempting to repeal it would be asinine.

62

If you pay $Y to the insurance company, and get $X < $Y back, you are not necessarily behind, since you need to include the benefit of not worrying about high cost if low probability health events. That was not at all clear from what you posted.

I was going to address portability last night when they took the board down on me. What does portability mean besides accepting people with pre-existing conditions? Otherwise, insurance is hardly portable. And if you require that, you need a mandate to keep the healthier part of the population from gaming the system. And that is where we are. I hardly think we need to worry about insurance companies going broke, unless they are so inefficient that they can no longer compete. The entire health care system is rife with inefficiency, from lots of overhead in dealing with insurance to incompatible forms to shuffling paper.
And, unless you think the pre-reform situation, with many uninsured and costs rising rapidly, acceptable, you do need to come up with something better. Otherwise, you are pretty much saying “drop dead” to the un-and under-insured. The bill that passed is hardly optimal, but it is a lot better than what we have now.

63

Absolutely. Now, people who bring high-risk conditions onto themselves (smokers) can and do get charged more. But if your condition is genetic, or just happened, are you okay with insurance companies refusing coverage to you? Wouldn’t it make sense for you to be included in a big risk pool, where you might pay more than you get for some years and have the reverse happen in others?

64

While I think I understand the economics behind it/understand the dire implications…I just can’t help thinking that health insurance that doesn’t cover unhealthy people is somewhat…counterproductive/silly.

If covering unhealthy people is not economically feasible…then maybe health insurance is not something for the private sector and should be covered entirely by the government. So, maybe…the private sector needs to cover unhealthy people or the private sector should get out of the health insurance business.

I don’t think this thinking is completely whacked. There are some things that the private sector cannot handle well. The military, roads…maybe health insurance is one of these things.

I also think we need to examine the costs/benefits of spending large amounts of resources on terminally ill people. The older I get the more I think assisted suicide is actually…humane and the current system of keeping people suffering is…evil.

65

So let me get this straight, Stratocaster. You’re saying one of the richest countries in the world can’t afford health care for it’s citizens, and yet all these other countries can? You’re seriously making this claim?

66

You can preserve a form of single payer system by turning the whole health care system into Medicare part C with a public option.

67

Sure, if you let microsoft collect all the premiums from every policy. I don’t think it makes any sense but if you insist.

68

You cannot as a population get more out of health insurance than you put in (at least you can’t get more than what you put in plus interest). The healthy always end up paying for the sick. The folks whose houses don’t burn down end up paying for the folks whose houses burn down. The 40 year olds with term life insurance who don’t die end up paying for those with term life insurance who die.

69

No, but nice straw man. I am saying that this particular abomination breaks even, per the CBO, only if Congress follows through on its commitments to cut costs elsewhere (e.g., $460B in Medicare), something they are not compelled to do, and something that they have actually refused to do in similar circumstances, year after year. This will cost a lot of money that we don’t have.

Why does everyone think “but other countries do it” is an argument? We can only react to what our country has on the table, right now. And this is unsustainable, unless you buy the fiction fed to the CBO about how this time Congress really means it when they say they’ll find the money elsewhere. It may well be unconstitutional as well.

70

I posted this:

You may have missed that.

I still disagree. Portability, by the way, was specifically in response to your question regarding the guy laid off, who is now vulnerable. He has no need for new coverage if his policy is portable.

Also, I don’t understand why we’re dealing with the rising cost of health care primarily as an insurance issue. How will this legislation realistically curb costs? How is it any better than “pre-reform”?

71

I know you weren’t addressing me, but:

  1. The primary care workforce will be expanded, presumably catching chronic diseases before they get so bad they need acute care and hopefully preventing chronic preventable disease from developing in certain individuals at all. The hope is that this will result in a healthier population that uses less healthcare, thereby cutting down on costs.

  2. Physicians (Medicare physicians anyway) will be penalized for poorer acute care/ER outcomes and rewarded for better outcomes. In other words, if an individual is hospitalized twice in the same 30-day period for the same condition, the attending physician or facility will have to provide an acceptable reason they were discharged in the event the physician knew there was a strong likelihood they would be re-admitted. The idea is that this will hopefully reduce the number of acute care or ER admissions, which can be very costly.

  3. Similarly, on a more general note, physicians under Medicare will be rewarded for better patient outcomes overall and penalized for poorer outcomes. That means they’ll have to report their morbidity rate, readmissions, the type and amount of care an individual received and a few other things. The idea is that more care does not equal better care, so hopefully the physician will use more effective treatment, whether inpatient or outpatient, rather than more treatment, reducing costs.

There are a few other ways the bill is meant to reduce costs, but my specialty is really Medicare. And for what it’s worth, many people assume that physician payment cuts are part and parcel of healthcare reform; they’re actually not - physicians and the government have been going back and forth over payment cuts for almost a decade now.

72

I am/was one. I graduated college just in time to be dropped from my parent’s insurance, and through some fluke I missed switching to COBRA in time so there was a one-month lapse in my insurance. When I got a job I paid for health insurance, but they refused to cover my epilepsy since it was pre-existing. Unlike some conditions it is not treatable with $30 drugs. Mine cost over $800 a month. Until my wife got her full-time job we were spending over 25% of our income paying for my pills. It got to the point where the pharmacists were trying to find loopholes or programs that would help pay for them. Under the new plan I wouldn’t have had that happen.

I went through a rebellious stage in college and didn’t take my drugs for a few months. It was all fine and dandy until I had four seizures in one day. I haven’t tried that since.

Since it was the other way around for a while, I like getting the bill for the EEG, CAT scan, MRI and three day hospital stay and seeing that I don’t have to pay it out of my pocket since I covered the deductible with my prescription drugs in January. But they make it up with my sister, who hasn’t been sick or injured in about 20 years.

On an odd side note, our insurance covers all the medical costs for my wife’s pregnancy and delivery, but not her birth control pills. Wouldn’t it be cheaper for them to do it the other way around? :dubious:

73

I think the supporters of this bill would say that its better than pre-reform because we will now be covering people who were not previously insured.

To me, all the “reform” in the world is useless without addressing the cost issue. If we can’t address the cost issue, we are simply rearranging deck chairs on the Titanic.

Sure some people will be more comfortable while we’re still afloat but eventually we’re all going to go under unless we address how to avoid that iceberg in the distance.

Even insurance company reform only lowers the height of the curve, the trajectory still points us straight into the iceberg. What I mean by that is that even a single payer system, health care costs are going to continue to grow faster than our economy and eventually we will be exactly where we are now (a bit healthier and living in a more just society but financially still headed towards that iceberg).

Don’t get me wrong, we need a single payer health system to buy us some breathing room even if we are still on an unsustainable trajectory but over the long run we have to bend the cost curve and that means rationing, denying coverage for some types of care. You can still buy it with your own money but the government won’t pay for it.

74

Is this supported by any studies? Not trying to be contentious, but it seems a little speculative.

What is an acceptable reason?" Who decides?

How will this work? What’s the calculus that determines the proper balance between outcomes and managed costs? This one in particular seems to encourage increased costs, on the surface at least.

75

We already have this, Cobra, which is good for 18 months. It doesn’t help kids who might have to buy their own insurance after getting out of their parents coverage (which at least happens at an older age now in some states) and doesn’t help people who take first jobs that don’t offer insurance benefits.

The legislation could have done better on this - but you remember the cries of “rationing” and “death panels” from the Republican side - even for things having nothing to do with rationing or limiting care. I’m happy to see the payment for end of life counseling has gotten restored by presidential fiat.
A little known part of the bill establishes lots of little projects to find ways of cutting costs. I read an article in the Times saying that these are ramping up and hiring heavily now. This is a much better, and decentralized, approach to finding ways of cutting costs than a Congressional fiat. An article in the New Yorker likened them to local agricultural agents, working for the feds, who have been very effective at finding and broadcasting ways of making farming more efficient. There is also the requirement that insurance companies spend a given amount of their revenue on actual patient payments, instead of overhead, which should help cut costs. When you are being regulated and are allowed to make a certain profit on net expenses, say, you have every incentive to increase your expenses. I used to work for the Bell System, I know about this.

76

So you’re basing your argument on American Exceptionalism? “other countries do it” is simply pointing out it’s possible. You seem to be stuck with only “what’s on the table”. I ask you why isn’t a more universal system on the table? Why is the American health care system spending 2 to 3 times as much for much worse results?

You’re telling me America the great is too incompetent to see to it that people like Gedd always have access to the medicine they need?

Let’s say Gedd couldn’t afford his/her pills, you’re saying the government should let Gedd do without?

77

For what it’s worth, that is the information as taken directly from the healthcare bill. Like I said, I had to read the whole damn thing - some parts sunk in. Some didn’t.

That said, here’s a cite about primary care. This relates primarily to Medicare and indicates that more primary care alone won’t rein in healthcare costs, but it does indicate that it can help manage them.

With respect to “acceptable reasons,” the sub-regulatory guidance hasn’t yet been issued on that; however, my guess is that an acceptable reason would be an unforeseen complication or otherwise undetectable issue. The reasons are generally developed by a task force comprised of physicians, specialists and other people who indicate what is acceptable and what isn’t.

And with respect to the calculus that determines the cost/benefit of certain care - according to the Medicare Payment Advisory Council report that was released to the Congress in March, part of the issue with care under Medicare is that the cost of using newer technologies is outstripping its benefit. In other words, the new technologies that are being developed for diagnostics and “improved” treatment offer so little actual improvement that, in many circumstances, the patient is better off using the older technology because it has been vetted more than the newer technology and costs less.

So, the recommendation is to use therapies that are currently understood to be most effective, while phasing in newer, even more effective therapies after they are vetted as being more successful than previously-accepted most successful therapies. Also, many physicians perform certain very expensive tests even when they know they’re not necessary because they are attempting to avoid liability. For example, MRIs are often overused because the patient demands them, not because the doctor actually recommends them. According to a NY Times article, “estimates of the amount of medical care that is unnecessary range from 10 to 30 percent,” but no one knows the true figure. Now, whether or not the healthcare bill actually makes any sort of dent in that remains to be seen.

I wish I knew the exact mathematics they use to come to these figures, but it seems to me that we’ve known for years that newer technology doesn’t always mean better. And more care doesn’t always mean healthier people. Also, from what I’ve read, people who use primary care physicians are more likely to have an annual screening to catch illnesses before they become acute, are more likely to be vaccinated (even adults need boosters) and are more likely to have better-coordinated care than people who don’t.

There’s a fairly decent (but inconclusive) paper on the Kaiser Family Foundation Web site about health technology: link.

78

I’m telling you, though you seem to be strenuously ignoring it, that this piece of legislation is unsustainable, and I provided the details for why I believe that. You seem to think a logical counter to this specific concern is some variation of, “But France does it!” It’s not. So, explain how we’re going to actually pay for this Utopia and then we’re actually debating the same point. That’s a reasonable question, right? How are we going to pay for it? Because it ain’t gonna be through Medicare cuts because Congress never follows through on those promised cuts, because shockingly a large percentage of their constituencies would eviscerate them for it.

Conversely, if they are in fact serious, they are pulling off the amazing sleight of hand of increasing health care coverage by–wait for it, this one is a doozy–decreasing health care coverage. It’s a feat of accounting prestidigitation that absolutely boggles the mind. Apparently your concern over those left out in the cold doesn’t extend to Medicare recipients. Now, if you answer yet again with something like, “But surely it’s possible, Canada pulls it off,” without addressing the specific concern, I’ll conclude you have no interest in doing anything but venting nonsense.

And I’m not responding to a more universal health system, because there isn’t one right now to consider.

I’m saying this particular piece of legislation is a boondoggle. Stop making shit up and assigning it to me.

79

I agree that part of the problem is the sense of entitlement to any and all procedures, cost and effectiveness be damned. But the devil is in the details of the mathematics in question. Without that, it’s just wishful thinking, “we need to do better” type stuff.

I’ll read your cites when I have some time. Thanks for the response.

80

Not an 18-month solution, a longer-term portability, that’s what I’m talking about. Let kids convert their coverage and carry it with them, into new jobs, etc.

I still see nothing concrete that will decrease health care costs.