# Who is going to pay for health insurance for those individuals who cannot afford it? **URL:** \ **Category:** Great Debates\ **Created:** [December 30, 2012, 8:37pm UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593 "2012-12-30T20:37:29Z")\ **Posts on this page:** 17\ **Page:** 4
**Author:** ![puddleglum](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/puddleglum/32/137_2.png) [@puddleglum](https://boards.straightdope.com/u/puddleglum)\ **Post date:** [January 3, 2013, 3:34pm UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/61 "2013-01-03T15:34:51Z")
> [@DSeid](#): > > Straw man. > > The idea that a couple of years of universal coverage is going to, in and of itself, going to result in huge savings, is not one that has been put forth. > > The fact that low severity ED visits decreased at all is honestly surprising. The fact that more people who had conditions that really required an Emergency Room visit actually went, when they had coverage, not so much so. > > As for the issue of prevention saving money - the article you link to then justifies its position by quoting [this one](http://www.nejm.org/doi/full/10.1056/NEJMp0708558). Its point? Not all prevention measures save money and we need to look at which ones give the best bang for the buck. Indeed when prevention measure are advised they are often explicitly not expected to save money; they are hopefully more often supposed cost effectively increase quality of life years saved (QALY). Sometimes measures touted as “prevention” do more harms than goods (prostate cancer screening for example). Placing a dollar value on a life year saved however is something that our society often fails to approach rationally - until we do we will irration care rather than ration it. > > Parts of the law that are under appreciated: > > 1. Insurance companies are limited to no more than 20% of their collected premiums on things other than direct medical care (things like advertising and administrative costs). If they do they need to rebate money to customers. > > 2. It transitions payment from predominantly fee for service to payment based on documented value provided. (See [here.](http://health.newamerica.net/sites/newamerica.net/files/profiles/attachments/dsr_provisions_final.pdf)) Health care delivery systems have already been changing in anticipation of this (we have been for several years) and [the cost curve is already inflecting](http://www.nytimes.com/2012/04/29/health/policy/in-hopeful-sign-health-spending-is-flattening-out.html?_r=2&pagewanted=all&). The idea that univerals coverage could lower costs by reducing ER visits was put forth several times. In discussing preventative care you switch from saving money to saving quality life years. Preventative care will probably cost more but is a good idea anyway. The amount of preventative care and screenings consumed is one of the reasons the American health care system is so expensive. Administrative costs include things like fraud prevention. Given that medical fraud costs the government around 70 Billion dollars a year fraud prevention is very important. Since Obamacare has not been implemented yet if costs are going down already that is a good sign Obamacare is not responsible. But if he can heal the planet and make the oceans recede, maybe he can reduce medical costs by sheer force of will. ---
**Author:** ![Bricker](https://avatars.discourse-cdn.com/v4/letter/b/977dab/32.png) [@Bricker](https://boards.straightdope.com/u/Bricker)\ **Post date:** [January 3, 2013, 3:59pm UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/62 "2013-01-03T15:59:25Z")
> [@Broomstick](#): > > If you want to live in a libertarian utopia go find an island or one of those “failed states” and carve out an enclave for yourself. The rest of us might want to live in a civilized society with a safety net. This suggests the people opposed to this application of the safety net are a tiny minority. But they’re not. Are they? ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [January 3, 2013, 4:23pm UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/63 "2013-01-03T16:23:40Z")
Yes they are. Some debate what the net should look like but the number who say there should be none are tiny indeed. ---
**Author:** ![Really\_Not\_All\_That\_Bright](https://avatars.discourse-cdn.com/v4/letter/r/e8c25b/32.png) [@Really\_Not\_All\_That\_Bright](https://boards.straightdope.com/u/Really_Not_All_That_Bright)\ **Post date:** [January 3, 2013, 4:24pm UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/64 "2013-01-03T16:24:54Z")
I think you’re supposed to read the sentence with the emphasis on “this” - as in, universal healthcare/Obamacare, “this particular application of the net”. ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [January 3, 2013, 5:24pm UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/65 "2013-01-03T17:24:03Z")
In which case it is a silly comment given that the subject had been a statement by **DJ Motorbike** about “wanting to keep what you earn and make your own decisions on how it gets spent” … ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [January 3, 2013, 6:03pm UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/66 "2013-01-03T18:03:05Z")
> [@puddleglum](#): > > The idea that univerals coverage could lower costs by reducing ER visits was put forth several times. > In discussing preventative care you switch from saving money to saving quality life years. Preventative care will probably cost more but is a good idea anyway. The amount of preventative care and screenings consumed is one of the reasons the American health care system is so expensive. > Administrative costs include things like fraud prevention. Given that medical fraud costs the government around 70 Billion dollars a year fraud prevention is very important. > Since Obamacare has not been implemented yet if costs are going down already that is a good sign Obamacare is not responsible. But if he can heal the planet and make the oceans recede, maybe he can reduce medical costs by sheer force of will. 1. ED use. Long term and as part of a complete package including having adequate primary care services available and accessible. Yes, universal coverage is expected to decrease those costs - and as per your link even in the short term visits for the sorts of problems that do not need to be seen in an ED were decreased some. Within three or four years? No. As per number 4 below, these are changes that take time. 2. I make no switch whatsoever. I merely explain that preventative care measures are not all motivated by cost savings and that indeed some, maybe even many, recommendations are made without adequate analysis of whether or not it is a cost effective use of resources. I do believe that this needs to change and in fact systems to analyze (and reward) that which gives value for the level of investment are part of the Affordable Care Act. 3. As someone who has an insider’s view of a large medical group I can witness to how we make decisions. Some groups wait until a law is in place. Most however recognize that building the systems that allow us to successfully compete under a changing system take time to build and begin early. For their part the payors also try to stay ahead of the curve and begin emulating what is coming down the pike well before the laws implement. These are big ships; you start your turn well before you need to be facing a different direction, or you risk running aground altogether. Our 350 plus doc group has been developing and implementing the systems to provide the best healthcare value, to provide the evidence (the metrics) that we do, and to spearhead Accountable Care Organizations, for years now. It was clear enough a final package would include these items. You do not wait to see where the ball lands and run after it; you make an intelligent appraisal of where the ball will be and position yourself ahead of time. 4. If you have some source for how much the insurance companies spend on fraud detection I’d love to see it. Most fraud detection work that I am aware of is done by the government and administrative costs of government run programs are a fraction of the private sector’s. Medicare’s administration costs are a fraction of the private sector’s and countries with single payor have a small fraction of Medicare’s. Administration costs are mostly sales, marketing, and underwriting. ---
**Author:** ![Zeriel](https://avatars.discourse-cdn.com/v4/letter/z/58956e/32.png) [@Zeriel](https://boards.straightdope.com/u/Zeriel)\ **Post date:** [January 3, 2013, 8:13pm UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/67 "2013-01-03T20:13:19Z")
> [@Magiver](#): > > My insurance went went about $500 with the passage of the healthcare bill. Mine stayed pretty close to pre-Obamacare yearly rate change levels. Now granted, my employer’s existing insurer claimed they’d have to charge a 40% increase in premiums “due to Obamacare”. However, they also had just been bought out by one of the bigger players, and a few other things (like the fact they DIDN’T pay out a refund for the administrative costs cap like so many others did, or the fact they service mostly rural/conservative area small businesses) may have led them to believe they had room to push up their rates and lay the blame at the feet of the administration. So we shopped around and found that literally every other major provider in the state was going to do an increase of less than 10% (and we’d been averaging 5-7% increases a year for this century BEFORE Obama was elected the first time), and that there were three providers willing to give us identical coverage for a rate more in line with what we were seeing. ---
**Author:** ![Bricker](https://avatars.discourse-cdn.com/v4/letter/b/977dab/32.png) [@Bricker](https://boards.straightdope.com/u/Bricker)\ **Post date:** [January 3, 2013, 10:22pm UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/68 "2013-01-03T22:22:55Z")
> [@DSeid](#): > > Yes they are. Some debate what the net should look like but the number who say there should be none are tiny indeed. > [@Really\_Not\_All\_That\_Bright](#): > > I think you’re supposed to read the sentence with the emphasis on “this” - as in, universal healthcare/Obamacare, “this particular application of the net”. Correct: > [@Bricker](#): > > This suggests the people opposed to this application of the safety net are a tiny minority. Are they? ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [January 3, 2013, 11:10pm UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/69 "2013-01-03T23:10:48Z")
As per my subsequent comment then: what a silly comment - no, “this” (a reaction to someone saying that he wants to keep what he earns and decide for himself how it gets spent, not exclusive to the Affordable Care Act) does NOT imply that only a tiny minority are against the Act. In fact even if he had made a comment specific to the Act it would _not_ imply that. It implies ONLY that in our society we agree to vote for men and women to represent or perspectives and if those representatives decide (on our behalf) that we will or won’t have any particular safety net those who disagree have some choices: live with it, you lost; vote in enough different people who will decide differently; or go live on your own island where you do not have to compromise with anyone. Hey a majority voted against G.W. Bush but the rules being what they are (and the judges being who they were) he was still President. Those of us who had vote against him, no tiny minority, groused some, but ultimately we sucked it up and tried to win the next time, and then the next time. That is the way this society works. ---
**Author:** ![Mdcastle](https://avatars.discourse-cdn.com/v4/letter/m/958977/32.png) [@Mdcastle](https://boards.straightdope.com/u/Mdcastle)\ **Post date:** [January 4, 2013, 12:15am UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/70 "2013-01-04T00:15:24Z")
Buying health insurance is a bit like buying car insurance in that the competition is so cuthroat that insurers will throw out an attractive offer to get you as a customer, only to jack up your rates later. You can save money by switching periodically and getting new bids, but this process is obviously disruptive for the employees. The 40% figure is what we talked about earlier regarding laying of employees, businesses throwing out “Obamacare” as a red herring for all kinds of unpallatable things they’ve wanted to do anyway. I’m sure even if I could get someone to tell me how much money my company spends on fraud prevention it would be a company secret anyway, but it’s one of the largest insurers in the state and we have a couple of people working in the department. ---
**Author:** ![Magiver](https://avatars.discourse-cdn.com/v4/letter/m/4491bb/32.png) [@Magiver](https://boards.straightdope.com/u/Magiver)\ **Post date:** [January 4, 2013, 4:40am UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/71 "2013-01-04T04:40:43Z")
> [@Zeriel](#): > > Mine stayed pretty close to pre-Obamacare yearly rate change levels. > > Now granted, my employer’s existing insurer claimed they’d have to charge a 40% increase in premiums “due to Obamacare”. However, they also had just been bought out by one of the bigger players, and a few other things (like the fact they DIDN’T pay out a refund for the administrative costs cap like so many others did, or the fact they service mostly rural/conservative area small businesses) may have led them to believe they had room to push up their rates and lay the blame at the feet of the administration. > > So we shopped around and found that literally every other major provider in the state was going to do an increase of less than 10% (and we’d been averaging 5-7% increases a year for this century BEFORE Obama was elected the first time), and that there were three providers willing to give us identical coverage for a rate more in line with what we were seeing. I’m buying insurance directly. I’d have to dig through old bills but if I remember correctly the increase was more than double the normal rate increases by year. You can’t bring the difficult-to-insurance into the mix AND mandate additional services and not raise the rates. This is not even an argument to be made. The question is who is paying for those who cannot afford insurance at all. The answer is the insured. It use to be our grandchildren in the form of debt. ---
**Author:** ![Really\_Not\_All\_That\_Bright](https://avatars.discourse-cdn.com/v4/letter/r/e8c25b/32.png) [@Really\_Not\_All\_That\_Bright](https://boards.straightdope.com/u/Really_Not_All_That_Bright)\ **Post date:** [January 4, 2013, 4:50am UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/72 "2013-01-04T04:50:06Z")
Actually, the answer is the newly insured. It’s the low risk people added to the market that make the whole thing work. ---
**Author:** ![Zeriel](https://avatars.discourse-cdn.com/v4/letter/z/58956e/32.png) [@Zeriel](https://boards.straightdope.com/u/Zeriel)\ **Post date:** [January 4, 2013, 4:00pm UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/73 "2013-01-04T16:00:07Z")
> [@Magiver](#): > > I’m buying insurance directly. I’d have to dig through old bills but if I remember correctly the increase was more than double the normal rate increases by year. > > You can’t bring the difficult-to-insurance into the mix AND mandate additional services and not raise the rates. This is not even an argument to be made. The question is who is paying for those who cannot afford insurance at all. The answer is the insured. It use to be our grandchildren in the form of debt. > [@Really\_Not\_All\_That\_Bright](#): > > Actually, the answer is the newly insured. It’s the low risk people added to the market that make the whole thing work. RNATB is right, and you can also factor in the reduced costs from fewer uninsured emergency room visits and more preventative care. Honestly, I think it’ll wash out close to even–the current solution doesn’t address a major driver of rising health costs, namely the administration costs of the whole system. ---
**Author:** ![Endopotential](https://avatars.discourse-cdn.com/v4/letter/e/6de8d8/32.png) [@Endopotential](https://boards.straightdope.com/u/Endopotential)\ **Post date:** [January 5, 2013, 1:49am UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/74 "2013-01-05T01:49:03Z")
I’m coming from this as a physician and surgeon. Our American health care system is broken in so many ways. We all expect the very best in care, yet no one is willing to pay for it directly. For instance, a patient comes in demanding a $2000 brain MRI because of a simple headache. If he has some form of insurance coverage with a low copay, no problem for him because he doesn’t have to pay for the very expensive test. The doctor may not think the MRI is warranted at all, but will still go ahead and order it on the off chance he may miss a brain tumor and get sued for it. Which leaves the insurance company with the bill, which it will do its best to avoid paying. One key aspect of the current problem is that the three legs of the puzzle don’t work in concert, with one corner not always acting in the best interest of the other two. Back to the original question - the only way that universal coverage will work is that it covers EVERYONE. The money that is saved from healthy patients will be used to cover the sicker ones. But given that resources are not infinite, we’ll have to address the hard issue of how much is covered, such as end of life care. Some studies quote that we spend more than 80% of health care dollars in the last 20% of life. At some point care has to be rationed, or limits set for what is covered. Does an 80 yo with end stage heart failure get a $75,000 pacemaker when he may only survive another year? Does a premature newborn with multiple birth defects get the $2million to get it through its first few months, not to mention the many years to come? These are the unpleasant issues that no politician - or the public in general - wants to tackle. Other things: - individuals need to take more resposibility for their health and the cost of their medical care. Do we pay billions every year for gastric bypass surgery, or put in place measures to ensure people watch their diet and exercise? Do smokers expect their neighbors to cover costs of their eventual heart and lung disease? - malpractice and tort reform is key. So much of current cost overruns come from defensive medicine, where doctors order excessive tests just to make sure they protect themselves from the possibility of frivolous lawsuits ---
**Author:** ![vivalostwages](https://avatars.discourse-cdn.com/v4/letter/v/d07c76/32.png) [@vivalostwages](https://boards.straightdope.com/u/vivalostwages)\ **Post date:** [January 5, 2013, 4:28am UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/75 "2013-01-05T04:28:11Z")
> [@Endopotential](#): > > I’m coming from this as a physician and surgeon. > snip > > But given that resources are not infinite, we’ll have to address the hard issue of how much is covered, such as end of life care. Some studies quote that we spend more than 80% of health care dollars in the last 20% of life. > > At some point care has to be rationed, or limits set for what is covered. > > Does an 80 yo with end stage heart failure get a $75,000 pacemaker when he may only survive another year? Does a premature newborn with multiple birth defects get the $2million to get it through its first few months, not to mention the many years to come? These are the unpleasant issues that no politician - or the public in general - wants to tackle. > snip DEATH PANELS?! WHY DO YOU HATE BABIES?! (That’s not from me. I’m just imagining what certain groups in this country would say in response to what you’ve brought up.) ---
**Author:** ![supery00n](https://avatars.discourse-cdn.com/v4/letter/s/5f9b8f/32.png) [@supery00n](https://boards.straightdope.com/u/supery00n)\ **Post date:** [January 5, 2013, 5:14am UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/76 "2013-01-05T05:14:17Z")
How about this idea? Allow certain health insurance companies to discriminate as much as they want in selecting their patients. Individuals that are very healthy and have minimal risk factors and no pre-existing conditions, do not smoke, etc. would that wished to obtain health insurance from such an insurer would be required to submit to a comprehensive battery of health examinations, both physical and mental, in order to meet the qualifications. In exchange for allowing them to heavily discriminate who gets to join their insurance pool, pass a law that requires such insurers to provide coverage for those who couldn’t get insurance in the “standard” health insurance market. Let some insurers discriminate, on the condition that they insure a certain number of people who can’t afford insurance because of pre-existing conditions, and require that the super-healthy people and the super-unhealthy people have to exist in some ratio that is at most 10:1? ---
**Author:** ![septimus](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/septimus/32/410_2.png) [@septimus](https://boards.straightdope.com/u/septimus)\ **Post date:** [January 5, 2013, 6:15am UTC](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593/77 "2013-01-05T06:15:09Z")
> [@vivalostwages](#): > > DEATH PANELS?! > WHY DO YOU HATE BABIES?! > (That’s not from me.) Not quite. "If by death panels, you mean incompetent and lazy government workers, suckling at the taxpayer’s teat and eagerly imposing their crypto-Islamist Marxism on hard-working Americans, then I condemn such sniveling murderers, and seek 2nd Amendment remedies for the deluded imbeciles whose votes brought the Kenyan traitor to power. “But if by death panels, you mean the elegant operation of Free Market institutions seeking to maximize shareholder returns, and operating perfectly in a robust competitive environment, then I applaud such cost analyses and thank the fine, but under-achieving, Americans who give up their miserable health-impaired lives for the good of the Real Americans, the Job Creators.” [Previous page](https://boards.straightdope.com/t/who-is-going-to-pay-for-health-insurance-for-those-individuals-who-cannot-afford-it/645593.md?page=3)