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Thread: Health care and health insurance

  1. #1
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    Default Health care and health insurance

    I'm curious how much of the following we can generally agree on:

    1. You shouldn't be denied health care at a new job because you're being treated for a covered pre-existing condition at your current job.

    2. A health problem shouldn't bankrupt you.

    3. You shouldn't lose buying power relative to large companies just because you're an individual or owner of a small business.

    4. A country as wealthy as the United States shouldn't have 47 million people (roughly 1/7th of the population) uncovered.

    5. Health care is already rationed--everyone can't get everything they want.

    6. Health care costs shouldn't be rising so much faster than just about every other area of our economy. (Bonus points if someone can explain what makes up each dollar of health care and what's driving the increases.)

    7. Medicare and Medicaid do a pretty good job of providing cost-effective coverage.

    8. Private health insurance providers have an economic incentive not to cover health care costs.

    9. A public option to cover those who can't get health insurance elsewhere isn't remotely the same thing as a single payer system.


    Any I've missed?

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    Default #4 - assuming that those with no coverage have no choice

    Of those who do not have health care there is a portion who choose not to buy it. I grew up without health insurance.

    Should the government "force" people to have health insurance?

    Why should government be involved in health insurance? Why should employers be involved? That's so odd.

    Should the government sell car insurance too? Somehow people who don't have a lot of money manage to buy car insurance. Car insurance is mandated by most states, yet the states aren't involved in providing it for those who don't have lot of money. Not having car insurance is considered negligent.

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    Quote Originally Posted by Elizabeth Price View Post
    Of those who do not have health care there is a portion who choose not to buy it. I grew up without health insurance.

    Should the government "force" people to have health insurance?

    Why should government be involved in health insurance? Why should employers be involved? That's so odd.

    Should the government sell car insurance too? Somehow people who don't have a lot of money manage to buy car insurance. Car insurance is mandated by most states, yet the states aren't involved in providing it for those who don't have lot of money. Not having car insurance is considered negligent.

    If somebody doesn't have health insurance, they still have health insurance. The difference is that everybody else pays for it. A person without health insurance can show up at a hospital emergency room and get free treatment (albeit not the most convenient or cost effective) all at the expense of everybody else.

    If not everybody had car insurance then this would put at risk everybody because you could have a collision with an uninsured person and your own insurance would have limitations. So all drivers must have car insurance. (Except in Nevada still?)

    Employer's are the natural focal point for health insurance the way things are now because of the bargaining power of the group. If health insurance was single payer then each person would be able to equally get insurance at group rates.

    After the 2nd WW, the UK made the decision that no british citizen would go without health insurance (probably due to the blitz and the suffering from it)... they have nationalized health system. Nobody goes bankrupt and yes, its rationed just like it is here. If you are very sick you move to the front of the line. If you can wait then you will. If you don't like the system you can suppliment it with your own private insurance and some do. In the US we have 'boutique' Primary Care doctors who charge a yearly fee and see a fixed number of people.

    PCP's are going extinct. Out of 16,000 doctors graduated last year 320 went into PC. Why? PCP are getting squeezed out and dumbed down into a system where you will go to a mall soon and get a nurse practitioner to be the PCP.

    There will be nurse practitioner's and doctor specialists soon... no more doctor PCP's... its coming.

    Ultimately, the US will go to a single payer system but it will evolve that way. No other solution will stop the cost basis, abuse etc...

    England, France, Canada have these systems... we will too.
    I'm not advocating for them, I'm just being realistic about this.

    What about the costs?
    Look at hospitals... they constantly grow in size and equipment. Why? They are mandated to do that. If they don't do that then they don't get the same money next year. This is good for the equipment suppliers too... ie. GE medical and others.

    Another cost... torts.
    We need tort reform in the US. Medical should be paid for in full on lawsuits but compensatory should be capped at 250K... the AMA suggested this themselves. Torts reform is one of the single biggest drivers in health costs and medical technology innovation. No more 3rd party lawsuits.... ie. the maker's of Teflon (Dupont) are not responsible for a heart valve failure unless you can provde that Teflon is no longer Teflon. Dupont purposefully doesn't not guarantee the use of its materials in medical for this reason.

    Of course the lawyers won't like this and this is why it hasn't happened yet.

    Now if a doctor comes into the operating drunk or cuts off the wrong leg then thats wonton and the cap is off... but under normal circumstances nobody is guaranteed of life or medical success. We all bit the dust eventually.

    This was my 25 cents.

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    Great stuff, here, which I'll address tonight/tomorrow morning. I don't want my original question to get lost, though--I'm looking for points on which we can generally agree.

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    Elizabeth, the first time I read your post, I missed that you were referring specifically to my point 4. Since my intent was to find ideas for which there is general agreement, perhaps I should have written that the US shouldn't have tens of millions of people unable to get coverage that they want.

    It would be interesting to know how many of the uninsured choose to be uninsured.

    Mandating insurance is a separate question. We are required by the government to have auto insurance (and recently in MA, health insurance as well). Mortgage lenders require us to have home owners insurance, but to my knowledge, the government does not. No one requires us to have life or disability insurance. Why the difference?

    Of the insurance types above, automobiles are likely to have the largest direct impact (no pun intended) on others, so mandatory insurance in that arena makes the most sense. If the $1,000 per year that each person with health insurance pays to cover individuals without such insurance is correct, then that's a fairly direct impact as well. Assuming that there's no constitutional prohibition against mandating health insurance, it comes down to the will of the people exercised through the legislature. For my part, I'm in favor of the mandate provided that there are mechanisms in place to permit all to acquire it in a practical manner.

    Mandatory home owners, disability, and life insurance is a different matter. To be sure, there's likely some indirect cost to society when some go without those types of insurance. But that cost seems significantly different than for auto and health. Nonetheless, I'd be interested to know the magnitude of that cost relative to the $1,000 for health.

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    Some interesting findings in this piece on wbur.org, which I heard this morning (accompanying chart currently on the wbur.org home page).

    • 50% to 70% of the general public supports a public option

    • 63% of doctors support a public option, 10% support a public single payer system, and 27% favor private only

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    Default personal public and private insurance comparison

    In 2003 I had the once in a life-time experience of two family members hospitalized at the same time for life-threatening conditions. My mother was covered by Medicare and my son was covered by Harvard Pilgrim Health Care. They both died within 2 months of each other despite very good care.

    Towards the end of my mom's life she was on a ventilator at a nursing home, barely conscious. My son's last day was in PICU, also on a ventilator.

    We had been told that my mom's medicare cap was nearing it's limit and that soon my dad would be responsible for her healthcare (my father immeadiately bought supplemental insurance for himself!) She had suffered MR staph infection following bowel surgery and nearly died 4 months before. The medicine caused kidney damage and her lungs were not strong since she had been a smoker until 10 years before. So, did money enter into our minds when deciding that she had suffered enough?

    I have no idea if my son's insurance was limitless - but his care was excellent. The bill was $350,000.00 for 4 months of care. I believe MGH got a contracted amount of $176,000.00. But our decision to remove care was based on his severe symptoms of mitochondrial disease, not finances. I credit HPHC for never mentioning any cap.

    BTW in Denmark when children are born with mitochondrial disease as severe as my son, they do euthanize them. Denmark has an excellent public insurance, but they do kill. If we are to pay for this enormous government-run insurance, we have to face the fact that other public options do rely on people dying. What do we think about that?

    I'm still pondering this healthcare issue and am completely undecided, but my gut-instinct is that the federal government should not be in charge of it.

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    Whether the government should be "in charge" of health care and/or insurance raises all sorts of interesting questions.

    Q1: Are we talking about health care, or health insurance?

    Q2: What's the difference between the government being in charge of something (e.g., Medicare/Medicaid) and regulating it (e.g., all medicine)?

    Q3: Are any of the current proposals to have the government be in charge of health insurance?

    Q4: Does the answer to Q3 depend on whether or not there's a public option?

    Q5: The government is in charge of the military, Social Security, K-12 education, OSHA, EPA, and countless other endeavors both well run and not; is it necessarily bad that the government might be in charge of health insurance?

    I'm just finishing an interesting book called Predator State by James K. Galbraith. Galbraith lays out some pretty compelling reasons why "markets" shouldn't be the be-all-end-all of decision-making, particularly when it comes to non-commodities in areas where information is asymmetric and time spans aren't measured in mere low single digit years. The reviews at amazon.com do an nice job of summarizing this important book.

    Galbraith's thesis sheds some interesting light on what role the government should play in health care/insurance given that predator corporations might be the alternative.

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    Quote Originally Posted by Jeff Dieffenbach View Post
    Private health insurance providers have an economic incentive not to cover health care costs.
    This is equivalent to saying "private automobile manufacturers have an economic incentive to build the lowest-cost automobiles".

    While some automobile manufacturers go this route, others differentiate themselves with higher quality or lower operating costs or higher performance.

    With insurance, one pays for a future service. The question is why there aren't insurance companies that differentiate themselves by offering a higher-confidence contract -- for example, one that guarantees that the buyer can never be denied benefits for any reason. I suspect that the answer is "because our health care system is so inefficient and expensive, few people could afford the premiums that such a contract would require".

    I'm not defending the nefarious practices of insurance companies that drop coverage when someone who's covered becomes seriously ill -- this is either fraud or breach of contract. But its a symptom, not the disease itself.

    While we've learned a lot over the past 50 years, our knowledge of "the human system" remains primitive. The development of vaccines and their adjuvants, for example, is a largely empirical process. Because our understanding of the human immune system is incomplete, a fraction of those who receive vaccines are harmed, some grievously. Should the medical community refuse to administer vaccines until we gain a comprehensive understanding of the human immune system and can reliably eliminate all negative side effects? Probably not, as this course would cause much more harm and many more deaths over the years that reaching this understanding will likely entail. Nonetheless, those harmed by vaccines routinely sue and receive large settlements, which forces practitioners to pay large premiums for malpractice insurance and practice defensive medicine, which drives up costs and reduces efficiency. It also drives pharmaceutical companies to do the wrong thing. Immunology is not unique; the same effects can be seen in oncology (read "Dr. Folkman's War"), organ replacement, and neural-anything.

    This conundrum is, in my opinion, one of the two root causes of our health care problem. The other is the absolute chaos that masquerades as a medical information system in this country.

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    Quote Originally Posted by Dave Bernstein View Post
    While we've learned a lot over the past 50 years, our knowledge of "the human system" remains primitive. The development of vaccines and their adjuvants, for example, is a largely empirical process.
    An article entitled "Benefit and Doubt in Vaccine Additive" appearing today in the New York Times addresses this point.

    "Are Americans obligated to use an unproven vaccine to help protect people in other countries from the flu pandemic? That is the crux of a debate over adjuvants a class of substances that somewhat mysteriously increase the potency of vaccines..."

    The full story is available here

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    Q: How many of you get a physical each year (or no less than every other year)?
    Q: Same question for dental check-ups?

    Here's why I ask (and I appreciate that getting into issues of health puts us in an area where people are naturally private):

    I heard a piece on NPR today discussing dental care and dental insurance. During the course of the broadcast, the difference between "coverage" and "insurance" struck me.

    I've always thought of insurance as something you purchase to guard against the consequences of a relatively rare occurrence. I have yet to tap my life or homeowners insurance policies (fingers crossed!) and have made auto insurance claims for only a few minor incidents. In short, I've been the near-perfect customer.

    On the health and dental side, I've been fortunate enough to avoid significant needs as well, and vanishingly few of the minor needs have been of the unexpected sort. For the most part, I've just scheduled appointments (physicals, flu shots, dental cleanings), made my co-pay, and "benefited" from the insurance company's share (which of course, came out of the pockets of my employers and me).

    In short, while I think of my family's situation as having health (and dental) "insurance", what I've really had is "coverage" since most of my "claims" haven't been for unexpected occurrences, but rather, *planned* occurrences.

    I think this goes a bit further than semantics. Presumably, reasons that "insurance" companies are also in the "coverage business" are (a) that they can charge for the coverage and (b) that by encouraging routine check-ups, they can reduce the risk of much larger outlays for serious problems.

    I don't know off-hand what the cost of a physical is, but I know that I only pay $25 or something, which is probably less than 10% of the fee. Besides the general wisdom, one reason why I get a physical each year is that it costs so little. It would be harder to part with the full $250 (if that's in fact the amount), even if I hadn't paid a large premium and therefore had more than the $250 in the bank as a result.

    I wonder, then, if it might make sense for both my health and my coverage company's bottom line (over the long run) to drop the co-pay and instead *give me* $25 (or some other amount) for each physical and check-up I get. Such visits could of course be limited, say to once or twice a year, so that people aren't visiting the doctor just to pick up a little extra cash.

    I'll finish by saying that the reason for my informal "poll" at the beginning of this post is to get a sense for how much of an incentive current co-pays serve with respect to motivating people to get regular check-ups. The natural follow-up, then, is whether being paid to get a check-up would increase the frequency of those check-ups.

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    Jeff, you know you can post an actual poll, don't you?

    Anyway, to answer your question, my family and I all get annual physicals and dental check-ups twice/year. Like clockwork. (Annual flu shots, too)

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    Quote Originally Posted by Jeff Dieffenbach View Post
    Q: How many of you get a physical each year (or no less than every other year)?
    Q: Same question for dental check-ups?
    Yes to both questions.

    Quote Originally Posted by Jeff Dieffenbach View Post
    I think this goes a bit further than semantics. Presumably, reasons that "insurance" companies are also in the "coverage business" are (a) that they can charge for the coverage and (b) that by encouraging routine check-ups, they can reduce the risk of much larger outlays for serious problems.
    Insurance companies can exploit the infrastructure they establish to deliver insurance to also deliver what you refer to as coverage. This allows employers to more economically offer additional benefits that lower their insurance premiums due to your point (b) above. In business terms, its a complementary adjacent market.

    Quote Originally Posted by Jeff Dieffenbach View Post
    I wonder, then, if it might make sense for both my health and my coverage company's bottom line (over the long run) to drop the co-pay and instead *give me* $25 (or some other amount) for each physical and check-up I get. Such visits could of course be limited, say to once or twice a year, so that people aren't visiting the doctor just to pick up a little extra cash.
    Given the miserable state of our health information systems, determining the efficacy of your proposal would require a long-term study. During the current health care debate, there have been assertions that preventive care is not economical, but I've not pursued them to see if they are based on facts or partisan maneuvering.

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