For the second time this week, I’ve learned some remarkable news. I’ve learned that the 47 million uninsured Americans don’t really want health insurance. They are young, healthy, and Republican.
Steve Green writes,
Let’s be honest about something here. The biggest reason to
mandate health insurance is to force young, healthy people (millions of
whom neither want nor need insurance) to pay in, thus lowering rates
(and thus transferring wealth) to millions of old people who have a lot
more money than young people. But old people also vote a lot more than
young people. And by and large they vote for Democrats.
This news has been picked up elsewhere. Someone on Fox News must have been mumbling some of this nonsense, since my mom started lecturing me about this over the weekend. Let’s get our facts correct.
First of all, old people aren’t all Democrats. 42% of Americans aged 65 to 74 identify as Republican.
Secondly, most of the uninsured are from working families. "Over 8 in 10 uninsured people came from working families – almost 70
percent from families with one or more full-time workers and 11 percent
from families with part-time workers." More real facts about the uninsured here.
Apt. 11d 
There’s a little bit of truth in that nonsense.
Most of the uninsured are uninsured because they can’t afford it, and if they could get affordable health insurance, they’d get it in an instant, and don’t need a mandate.
What a mandate does it it takes the people who are young and healthy forces them to contribute to a system that will make health care available to them when they are not-so-young and not-so-healthy. There are some people like that now — who can afford insurance, but think they’re immortal and are willing to play the odds. (Because after all, if they have a freak accident, the hospital can’t turn them away for not being able to pay.)
But one of the reasons that more people don’t voluntarily skip insurance when they’re healthy, is that under the current system, if they get sick when they’re uninsured, they’ll never be able to get insurance. Under all the universal programs, insurers won’t be able to deny coverage based on your health history. So there will be more of an incentive to free-ride on the system until you get sick. Which is why most experts think that we’ll need mandates.
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“What a mandate does it it takes the people who are young and healthy forces them to contribute to a system that will make health care available to them when they are not-so-young and not-so-healthy.”
What if the system collapses under its own weight in a few decades–in that case the young folks will have paid in, but won’t be able to collect. People are always saying that Social Security isn’t the problem, but that Medicare is a ticking timebomb.
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Of that 47 m, how many are young, healthy people who think that insurance is immoral and unnecessary for them. It’s got to be like five people.
When I was young, healthy and uninsured, I would have killed to have insurance. I was a grad student who couldn’t afford it. I got a sinus infection and couldn’t get antibiotics, so it got worse. Finally, a friend who had just finished med school diagnosed me with pneumonia by listening to my cough over the phone and sent over a prescription for the good antibiotics.
Even if you are young and healthy, you still need insurance for sinus infections, Pap smears, urinary track infections, and strep throat. Also, young people have a way of getting pregnant. Making babies is very, very expensive.
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“Even if you are young and healthy, you still need insurance for sinus infections, Pap smears, urinary track infections, and strep throat. Also, young people have a way of getting pregnant. Making babies is very, very expensive.”
All the things you mention except pregnancy aren’t that expensive and you could theoretically pay cash for all of them out of a fairly moderate income as a single person–hence the temptation for the young and healthy to go without insurance. It’s a sign of the perversity of our medical system that we think of “needing” insurance for stuff that really ought to be out of pocket. Hopefully Walmart doc-in-a-boxes will bring a dose of market reality to the medical world. You should be able to go online and price pap smears, just like you price any medium-to-large purchase from toasters to cars–it’s ridiculous that we “buy” non-emergency services having no idea how much it’s going to cost.
I like the idea of catastrophic insurance plus health savings accounts (and if you like, the feds can top off the accounts of low-income people) with surplus turning into retirement savings after age 65, or whatever. I realize that there needs to be an incentive for people to do regular checkups and preventative care. It’s tricky. On the one hand, you want people to take good care of themselves. On the other hand, you want people to realize that their prescriptions and specialists’ appointments don’t really cost $20 a piece.
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The absolute LAST thing I want to do is have to go online and price PAP SMEARS. Really Amy, is that what you want to do with your time?
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Not really, but it could be really simple. You’d punch in your zip code and get all the prices for pap smears within a certain range (10 miles, 25 miles, etc.) Ideally, that would be cross-referenced with malpractice suit information and patient ratings, plus class ranking and name of medical school graduated from. You also might want to know which OB/GYN likes to crack inappropriate jokes and tends to botch prescriptions, or which lab has a technician who gives patients unsolicited hugs after transvaginal sonograms (that last item is unfortunately a personal experience–ugh!). Average wait times would be nice, too.
I think that doctors often have very little concern for how much things cost the insurance company or the patient or how much time and inconvenience their office procedures cost patients.
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I think calling it ‘health insurance’ is confusing, damages the debate. I buy insurance to help me if something I can’t afford – something big – happens. House burns down. Car crash. Giant liability judgment against me when somebody slips on ice on my sidewalk. Calling Kaiser an HMO, a health maintenance organization, is more straightforward.
There’s an insurance component, and a maintenance component. My wife got breast cancer four years ago – blam! Huge amounts of money, appointments, surgeries. This was like insurance. Now we are back on regular mammograms and tamoxifen and the news, so far, is good – that’s like maintenance.
Taking the kids to the pediatrician – or to the doc-in-a-box – for sore throats and flu shots and eczema and yearly checkups. That is like maintenance.
I think the challenges of making sure that health care is available, but not wildly overpriced and overused, are different in the maintenance and insurance areas. They shade into each other, for sure. But the proposal Amy endorses – catastrophic insurance and HSAs – seems to me to put the incentives right for routine care and to avoid putting people on the street when things go into crisis.
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Laura,
1.) Why didn’t you have health insurance in grad school? Every grad school I ever applied to offered cheap insurance.
2.) Why didn’t you go to the university student health services? It would have cost (at most) $40.
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Our grad school (a public graduate school in NYC) did not offer health insurance, did not give out stipends, and did not have a student health service. I ended up getting a research job, where I worked 20-35 hours a week while taking a full course load. This provided me with some crappy insurance and money for rent. Still, I ended up getting a tumor on my side, which had to be removed. It cost me $800 with the crappy insurance. Later, after I had Jonah and was working full time on my dissertation, we were on Steve’s even crappier adjunct health insurance. Because we were so stressed out about money, I got shingles. More out of pocket money.
Young people get sick. Young people get pregnant. A C-section can cost $100,000 at a local hospital around here.
Why are we using the word “mandate” here? Should I call all public expenditures that I don’t directly benefit, mandates? How about the fact that the gov’t forcibly takes money from me to pay for cattle subsidies, when I rarely eat beef? How about the trillions of dollars that is going to a war that I always opposed? How about money for bridges in states that I will never visit? How about all the money that NASA sucks up, even though I’m skeptical about some of those projects? I could go on and on.
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It’s true that grazing land is leased by the feds at below-market value in the West, but if you google “cattle subsidies” you don’t (as far as I can tell) get links to American stories–it seems to be all international. Cheap grazing rights benefit only those who hold the leases, hurting those who have their own land and have to compete with those who don’t. Lots of ranchers have their own land, like my parents and grandparents. My dad has always been vociferous against agricultural subsidies, particularly since the artificially high price of wheat makes beef more expensive than it ought to be. Likewise (as with the feds’ big dairy buy-out and mass slaughter of dairy cows years ago, which was catastrophic for beef prices), dairy subsidies have also been hard on cattle ranchers. In any case, while there are a lot of agricultural subsidies (ethanol!), they aren’t spread out equally among farmers. There’s no such thing as big “not-farming” checks for cattle ranchers.
That’s a small point. The more global point is that if you think the federal government spends money unwisely now (NASA, ag subsidies, military, bridges to nowhere), you really don’t want to give it large new responsibilities. Plus we are where we are today because we have disengaged the consumption of medicine from payment for medicine, and widening that gap is not the way out.
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“The more global point is that if you think the federal government spends money unwisely now (NASA, ag subsidies, military, bridges to nowhere), you really don’t want to give it large new responsibilities.”
My point, when I use an argument like the one Laura made, is not that I want the government to stop paying for those things. I’m usually making the larger point that we all make sacrifices and pay into a system that distributes funds to things I don’t benefit from directly because it benefits our society as a whole. I don’t eat (much) beef, but if cattle subsidies (however they work) help keep the economy booming and make it possible for families to contribute in a positive way to our society, I say go for it. As Obama said in 2004:
“A belief that we are connected as one people. If there’s a child on the south side of Chicago who can’t read, that matters to me, even if it’s not my child. If there’s a senior citizen somewhere who can’t pay for her prescription and has to choose between medicine and the rent, that makes my life poorer, even if it’s not my grandmother. If there’s an Arab American family being rounded up without benefit of an attorney or due process, that threatens my civil liberties. It’s that fundamental belief—I am my brother’s keeper, I am my sisters’ keeper—that makes this country work.”
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To me, this whole “personal choice” argument totally falls apart when people intrinsically expect catastrophic care to be provided regardless. If you decide you’re going to manage your out-of-pocket costs but looking up pap smear costs on-line, that’s fine. But if as part of that approach you choose to go without insurance and you get hit by a bus, then the entire country pays the price for your trauma care because the hospital will not turn you away.
I should also note something that I’ve learned through my exposure to health care IT — that if you think your provider knows how much a given procedure costs to deliver, you’re most often wrong. Today’s hospitals DO NOT KNOW how much their procedures cost to deliver. They know how much they’ll be reimbursed for them — but they don’t know their own costs. That is the sorry state of affairs in the current health care world!!! To believe that we’re anywhere near the transparency we need to allow consumers to choose is just a castle in the air. Really all you get when you view health care as another consumer good is a world full of pharma advertisements and “physician entrepreneurs” who just happen to own the imaging center they constantly refer you to.
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“I should also note something that I’ve learned through my exposure to health care IT — that if you think your provider knows how much a given procedure costs to deliver, you’re most often wrong. Today’s hospitals DO NOT KNOW how much their procedures cost to deliver. They know how much they’ll be reimbursed for them — but they don’t know their own costs.”
Wow. I’m not surprised, but that’s amazing. No wonder the financial side of medicine is such a mess.
(By the way, while I remember it, medical pricing is fairly flexible, especially after the fact. If somebody you know has some impossible pile of bills, it’s worth telling them to walk into medical billing figuratively hat in hand, and to ask billing to help you figure out how to pay them. It’s entirely possible that they will forgive a big chunk. 1) They often are very nice people. 2) They don’t want you filing bankruptcy. 3) The retail prices for medical services are for suckers.)
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What you’re saying doesn’t refute what Steven Green says. Whether someone comes from a “working family” has nothing to do with whether they can afford health insurance. And the majority of old people do vote Democratic–the skew, AFAIK, is even higher in the 75+ demographic you left out.
A quarter of the uninsured are not citizens, and presumably will not be eligible for health care under any national system.
Two thirds of uninsured, poor parents are eligible for Medicaid but have not applied; presumably they will when they or their kids get sick. Millions more children are eligible for SChip but have not applied.
About 20% of the uninsured have family incomes above $75,000 a year and presumptively could afford health insurance if they chose.
Your case is not typical; much more typical is either an illegal immigrant, someone who hasn’t bothered to apply for the benefits they already qualify for, or people who are playing the lottery.
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Isn’t it the case that for many people, even if they apply for and get medicaid benefits, cannot find a provider in their area who accepts medicaid? (Again this gets back to reimbursement issues and the whole problem of making health care a for-profit concern.) This would explain why so many don’t bother with the paperwork. I am not clear on how people find providers via SChip. Anyone know?
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“Isn’t it the case that for many people, even if they apply for and get medicaid benefits, cannot find a provider in their area who accepts medicaid?”
Doesn’t that suggest that many doctors, medical students, and prospective medical students might find something else to do with their time if Medicaid level reimbursement became the norm?
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I don’t know, Megan. I’m getting these numbers from here “http://www.nchc.org/facts/coverage.shtml Maybe they are wrong, but they have different answers from you.
They say that 80% of the uninsured are citizens. Slightly higher than your number of 75%.
You say that “Two thirds of uninsured, poor parents are eligible for Medicaid but have not applied; presumably they will when they or their kids get sick. Millions more children are eligible for SChip but have not applied.” So, if they are already eligible for gov’t help, then it won’t cost anything to more to cover them under a national health plan.
While it is relatively easy to get socialized medical coverage for your children if your are moderately poor, it is very difficult for moderately poor adults to be covered. If you have a job cleaning houses, you are working poor. You some money in your wallet. Not enough to get Medicaid. But not enough for private medical insurance.
If you are making $75,000 and supporting a family, you don’t have enough to get medical coverage. My neighbors are contractors living in modest homes in NJ. None of them have health insurance. One woman is still paying off the birth of her five year old.
I don’t think that those 47 million people are poor, ignorant, lazy, illegal aliens who can’t figure out how to fill out the paperwork, anymore than I think that the 47 million uninsured people are young, carefree, libertarians.
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Regarding the 25% versus 20% of uninsured being illegal aliens, nobody has knows how many illegal aliens there are in the US. Wikipedia says that estimates range from 7 to 20 million, but I think I’ve seen 30 million mentioned, too. Under the circumstances, it’s impossible to confidently say what percentage of uninsured residents of the US are illegal aliens–it could be anywhere from about one in seven to one in two uninsured residents. On the other hand, as the housing industry tanks the US economy slows down, and some show is made of immigration enforcement, there are reports that some illegal aliens are leaving the US. Certain sectors of the economy (housecleaning, landscaping, restaurants) both have a lot of illegal workers and will suffer disproportionately during an economic slowdown. So, I would expect that during the course of the next recession, there will be fewer uninsured illegal aliens and more uninsured American citizens.
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This is off point, but is a common mistake that I believe needs consistent correction. The 80% number that Laura first mentioned was the percentage of uninsured who are US citizens. That means the other 20% are non-citizens, but not necessarily “illegal”. They may be permanent residents, here on student visas, or here on other types of work visas. Non-citizen does not equal non-legal.
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Very true. I’m married to a legal alien (and loyal subject of Her Majesty), so I shouldn’t have missed that. I would think though, that legal resident aliens such as graduate students and H1Bs would tend to have health insurance, and that if not, it really ought to be a condition of the visa-granting process, which is traditionally supposed to ensure that the foreign visitor does not become a charge to the state. (I know things have changed, but when we were doing letters of invitation for visitor visas several years back, we had to very thoroughly document our assets and income.)
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“Two thirds of uninsured, poor parents are eligible for Medicaid but have not applied; presumably they will when they or their kids get sick. Millions more children are eligible for SChip but have not applied.”
At least some of this has to do with how states handle enrollment and publicity. Believe it or not, many people don’t know about SCHIP. Fewer still would recognize the acronym. There was a time, I believe, when some states deliberately tried to keep thier schip rolls low.
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That was one of the objections to expanding the parameters of eligibility for SCHIP–the fact that so many poorer families are not signed up for programs that they are eligible for.
I was talking to my husband over dinner about the graduate students’ health insurance situation (a lot of them are married with one or two kids). As far as I remember, the stipends are about $1,000 a month, with university-offered insurance for a single person being about $100. University-sponsored insurance for a family (unlimited kids) is $350, but my husband’s informant was getting it for two hundred something for a family of three. Aside from the issue of doctor availability and quality, it sounds like the cheapest solution might be to go with Medicaid for the kids. (The area is pretty low cost, and a lot of graduate students have bought houses. A relative of mine who studies here rents an above-the-garage efficiency for $350.)
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As far as I remember, the stipends are about $1,000 a month, with university-offered insurance for a single person being about $100. University-sponsored insurance for a family (unlimited kids) is $350, but my husband’s informant was getting it for two hundred something for a family of three.
You mean per month, right? At my very wealthy graduate institution, the medical insurance offered by the U was $900 for one year for a single grad student ($1800 for the “good” insurance, which included dental).
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Also, proof of insurance was required for enrollment, so there was no “playing the lottery”.
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Yes, all numbers I gave are by month. For further context, our town (which has lots of students, grad students, and lots of just plain poor people) has a median yearly household income of 26K.
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“That was one of the objections to expanding the parameters of eligibility for SCHIP–the fact that so many poorer families are not signed up for programs that they are eligible for.”
Which is a non-objection, as the debate over expanding eligibility concerns how many kids should be, well, eligible.
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But surely it makes sense to work from the bottom up, rather than ladeling out yet more goodies to the middle class? I know they say that programs for poor people wind up being poor programs, but how do you draw the line between the middle-middle class folk who get to have coverage for their kids and upper middle class folk who get juiced to pay for it? (That second group is you and me and Laura and most of the people who post here–there’s really no “them” that’s going to pay for government health coverage for the children of the bottom 4/5 of the country, just us.) I suppose line-drawing is always a problem.
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If you are making $75,000 and supporting a family, you don’t have enough to get medical coverage. My neighbors are contractors living in modest homes in NJ. None of them have health insurance. One woman is still paying off the birth of her five year old.
Without knowing the details of their budgets, I observe families in this category spending money on discretionary items while claiming their inability to afford health insurance. A modest vacation to Florida, video consoles/games, iPods, multiple TVs, etc. Of course, I also know families raking in around $200k making the same claims.
How much is insurance for a family of four? In NY, we subsidize insurance for all children, I believe. Is the annual cost $4,000, $6,000, $12,000? Part of the problem is state mandates for “Cadillac” coverage that makes it difficult to purchase catastrophic coverage. Also, pre-existing conditions can be a problem.
I know, I know. I’m a mean, heartless conservative. However, I believe it is the personal responsibility of individuals to do everything they can to provide for their necessities like food, shelter, clothing and health care before taxpayers step in to pay for these things.
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“However, I believe it is the personal responsibility of individuals to do everything they can to provide for their necessities like food, shelter, clothing and health care before taxpayers step in to pay for these things.”
See, Tex, I am the opposite (which I know you knew), but I think my belief makes *much* more sense. I think that as human beings, we owe it to everyone to ensure that they have food, clothing, shelter and health care, even if taxpayers have to step in and help provide. Then, let people compete/fight/whatever the capitalist/Republican/whatever term is for the extras in life. Want to go that extra mile and work 80 hours a week so you can have a vacation in Tahiti once a year? Go ahead. Want to work as a lawyer for a corporate firm instead of a nonprofit so you can afford that Lexus instead of a Honda? Be my guest.
People shouldn’t have to work 2 jobs just to put food on their table.
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Well yes, Wendy, we should help those who are needy. I guess I would define the needy as those who have already busted their butts, maybe even working two jobs, to try to provide for themselves.
What makes more sense? Even if it doesn’t exactly fit this discussion, I think the “tragedy of the commons” has some relevance.
The metaphor illustrates how free access and unrestricted demand for a finite resource ultimately structurally dooms the resource through over-exploitation. This occurs because the benefits of exploitation accrue to individuals or groups, each of whom is motivated to maximize use of the resource to the point in which they become reliant on it, while the costs of the exploitation are distributed among all those to whom the resource is available (which may be a wider class of individuals than that which is exploiting it). This, in turn, causes demand for the resource to increase, which causes the problem to snowball to the point in which the resource is exhausted.
http://en.wikipedia.org/wiki/Tragedy_of_the_commons
We spend health care dollars differently when “someone else” is footing the bill. Think of an employee using his company’s expense account versus using his own money. That’s part of the reason I strongly support going back to deductibles rather than having “someone else” paying for my routine maintenance expenditures.
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Wendy,
I think catastrophic health insurance should be mandatory and should come right out of your paycheck, but unless we are dealing with the genuinely incompetent (drug addicts, the developmentally disabled, the severely mentally ill, etc.) a functioning state is going to have to sit back a lot of the time and let reality have an educational effect for the smaller stuff. The problem with our current system is that it is dominated by “other people’s money,” whether from private insurance or government programs. I would argue that this is a big reason for the explosion in costs, as well as the blossoming of “lifestyle” pharmaceuticals (if Bob isn’t paying for his Viagra himself, he’s going to go through a wheelbarrow full of it). The reason medicine is so expensive is that it’s basically free to so many people. Plus, as Jen said, the hospitals have no idea what their costs per procedure are. We need a lot more market and businesslike practices in medicine, not less. (Doctors are famously bad with money in their personal lives, I’ve been hearing.)
Under whatever system we go with, there is always going to be a need to control costs. There has to be, or else health care would consume 99.9% of the gross national product. A health system with a large market-component will rely on the citizen to prioritize their medical needs. Under a non-market system, we can ignore lifesaving new pharmaceutical developments (insuring that fewer will be developed in the future), we can deny procedures to people over a certain age, we can limit the number of hospitals that get to have MRI machines, we can delay cancer surgeries until the people die, etc. That will keep down costs to a bearable level, but I don’t think it will make us a more compassionate nation. Given the American character, I think we would wind up spending twice as much as we currently do on medical care, and we would wind up with a medical system very similar to our public schools, where even though almost everyone gets a public education, they come away with radically different levels of knowledge.
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I think there needs to be a bit more discussion of how health-care winds up being distributed when the state pays for it. Under Soviet-style communism, prices for just about everything were set very low, creating chronic shortages. In that system, money was just about worthless, but people were able to use position and contacts to secure the necessities of everyday life. There was an underground economy, but it ran on favors and barter rather than cash. Likewise I hear that in Canada, people have radically different levels of access to medical care, depending on their level of “connectedness.” I hear, for instance, that instead of waiting dutifully for six months to see a specialist, that a professor can do rather well by approaching a medical school colleague.
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Briefly, I turn the mic over to Mark Kleiman:
+++
Ok, maybe that wasn’t briefly, and all emphases are added.
The whole thing is here.
There’s also Matt Welch, now editor of Reason, who recounts his view of comparative system here. (Short version: US or French system? French, emphatically.) Ok, not there precisely, but that part of his personal archives has gotten bloggered, and the quote is accurate.
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Darn, lost a post!
I wanted to take back “There was an underground economy, but it ran on favors and barter rather than cash.” That was too strong–the Soviet Union had a cash black market, too, but the casual exchange of favors among family, friends, and coworkers was less risky. There was a lot of stealing from work, too, which pulled goods out of the official economy.
I think we need to be really careful never to create a situation where people feel that they are using “other people’s money.” That seems to have been a key ingredient in the housing bubble, and it may well be a big factor in the soaring cost of higher education. Likewise, it’s important not to accidently create price controls. As any middle-class Venezualan can tell you, that’s a recipe for disaster.
Thinking this stuff through, I realize that vouchers for private school are actually rather risky. It’s a hard question, especially since the government already pays for most K-12 education. I would probably be for going slow and starting small, and seeing what happens.
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“But however you come down on that argument, the claim that replacing the current insurance mishmash with a better-integrated payment and decision-making process would mean more rationing, or even more rationing-by-queuing, is the sort of palpable falsehood that people who are perfectly honorable in real life are only too willing to utter in ideological conflict, especially if paid to do so. Under a single-payer system we’d have an idea who was waiting how long for what, while under the current system no such data are available. In all my waiting, I was never in a formal “queue,” and if the cancer had gotten me before the pathologist figured out what it was no one would have counted that death as the result of rationing. But only in wingnut health-policy fantasyland is not measuring a problem the same as not having a problem.”
That’s interesting, although I can’t tell if Kleiman has an actual real world model, or if he’s just thinking this up. In the US we live in, there is such a thing as medical confidentiality, and there’s no way that John Brown and Suzie Smith’s relative location on a queue could be debated politically. If the question came up (and it wouldn’t), the answer would be “Suzie is a priority case.” Barring a good dig in Suzie’s medical records, there’s no way that John Brown would be in a position to dispute that.
The point is worth making, though, that the insurance company works in much the same way that National Health would. Why that is an argument for creating a huge mega insurance company that would be the boss of every doctor in the country, I have no idea.
How does the French thing work, by the way?
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Kleiman means, I think, that in the aggregate we would have a far clearer picture now than we do (“we” in this case being interested members of the public and decision-makers up and down the line) of who waits for what, where, and to a reasonable extent why.
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I think you could come up with that information now, if you wanted to, just as we have buckets of data now on the connection between race and socioeconomic status and poor academic performance in public school children. However, even though the vast majority of American children go to public schools, having that information doesn’t bring us significantly closer to improving the academic performance of poor Black or Latino children. Why that is is a matter for long debate, but it is certainly so. I guarantee you that unless there is radical change in American public schools (and I don’t think there will be), we will be having exactly the same discussions about schools in ten years.
When you walk into an American hospital pediatric office or a maternity ward, generally speaking, you are not the customer but the patient, or patient’s relative. That is a huge linguistic difference. The customer is always right. The patient is pretty much by definition never right, spends a lot of time waiting for things, and is surrounded by experts and machines that go beep. And why should your opinion matter–you don’t have a medical degree, and you’re not even paying the bills, and the hospital is probably losing money on you anyway. I think that more “commercial” medicine is the way out, rather than something to be feared.
If anybody has information on French medicine, please explain how it works. It’s possible that it has a stronger market element than the US system does.
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A health system with a large market-component will rely on the citizen to prioritize their medical needs.
Ah, Amy, that actually cuts both ways. People feel sick. They really want the doctor to DO something for them. And the doctor is only compensated if they take action. And so together the patient and the physician figure out something to do — even if it doesn’t help a bit, or if it’s contraindicated in the long run. (Also note that they’re almost never figuring out how to change diet, or manage stress. Nobody gets reimbursed for that stuff. Plus, frankly, Americans don’t like doing lifestyle changes if they can just take a pill.)
Has everyone forgotten that little tidbit about how, even though we spend a nonillion dollars per capita on health care, we are not actually any healthier? We are already spending almost twice as much as many developed countries. Don’t even get me started on pharmaceutical costs. We as a country bear the pharma R&D expense of the ENTIRE WORLD. And we’re all surprised when that ends up to be expensive!!
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“Ah, Amy, that actually cuts both ways. People feel sick. They really want the doctor to DO something for them.”
That’s true under practically any system. My husband’s grandfather was a doctor in communist Poland, and (if I remember the story correctly), he used to diagnose something like “globus hystericus” in these cases. (Poles tend to be major hypochondriacs.)
“Don’t even get me started on pharmaceutical costs. We as a country bear the pharma R&D expense of the ENTIRE WORLD. And we’re all surprised when that ends up to be expensive!!”
Ah, but don’t we have the most virile middle-aged men with the best hair on the planet? Surely that’s worth something?
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Amy, you are perhaps correct that doctors everywhere have approaches for managing hypochrondriacs. I am less amused by this when it results in people having, say, major surgeries to insert drug-eluting stents when it’s not clear that it actually helps. Scratch that — it’s been proven in clinical trials to be ineffective. Yet it still happens, and in no small part because patients like the idea of taking action, and because it’s reimbursed. I am sure they’ll stop reimbursing it soon, and when they do their will be an outcry, and we’re supposed to all feel terrible that the insurance company is “denying life-saving surgery”. In reality we as individuals don’t always know enough to make these calls. Having the health care system be more consumer-driven goes further and further down this path.
I am of two minds on the whole thing. I’ve heard all the stories about how horrible and depersonalizing obstetrical care was up to about the 70s. And I know that the purchasing power of the average expectant mom is precisely what caused hospitals to change their approaches. Yet the reality is that many, many people in this country go without routine care, and then fall back on “charity care” (read: other-patient-supported care) when their conditions get grave. It’s just a stupid way to run anything. I have to believe there are other ways besides consumer-like purchasing of services to build in feedback mechanisms and adjust to what patients want.
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If you like, you can have mandatory educational videos for these folk: “This procedure has been found to have X% chance of helping you and an Y% chance of harming you. It has been found to be less effective than taking sugar pills, aromatherapy, or going to a voodoo priestess. The American Medical Association strongly advises you not to go through this operation. You still have time. Get out!” If the government isn’t an interested party (with an interest in keeping costs down), it may have a bit more credibility when it launches this kind of educational campaign. (There’s also the real possibility that under universal health, there would be irresistible political pressure to fund various useless procedures. As the poster says, all of us together are stupider than any one of us individually!) I think that ideally, the government should spend more time refereeing, rather than out there on the field.
Also, let’s blame the doctors a bit, too. A relative of mine says that doctors don’t get a really scientific education and they don’t understand research, and they tend to continue with ineffective methods. (So I guess we should thank the evil drug companies for kicking them out of their rut.) My relative said that medicine is taught as a craft rather than as a science.
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Health insurance is the reason I’ll probably never return to the states — I cannot be sure that my autistic daughter, even though she’s an American citizen, would be able to find coverage.
I’ve lived in Canada since 1985 and have yet to see much of these “waiting lists” people harp on. People I’ve known have been able to go right in for hip replacements or heart surgery. When my daughter started having seizures, she was seen by her GP that same day and the neurologist within a week.
And while our drug plans aren’t free (another misconception), the buying power of the provincial plan does help to keep costs controlled for all prescription medication.
No system is perfect but the American systems, which cost so much per capita and still fail to provide broad coverage or widespread preventative care, fail to impress me. Don’t get me wrong — I’m full of admiration for the health care professionals I’ve known on both sides of the border, but I’ll take the Canadian system any day. And I’ll continue to happily pay my share, as well.
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Wow, too many comments to read them all, so sorry if I’m redundant.
My husband is one of these uninsured, and one of my close friends was until very recently. While he’s “relatively healthy” as in no catastrophic illnesses, he’s on two regular medications for depression and restless leg syndrome. We would definitely WANT health insurance, but right now we’re struggling to pay for rent and groceries. One of the issues I have with a “mandate” is that if it’s in the form of we find our own health insurance in basically the same market as now, it does little to help us and more to stress us out.
To the person who was talking about the term “mandate” – it could be different from those other things you describe if the users have to find their own health insurance but then pay a penalty (which would come at the time of taxes, no?) if they can’t prove they’re on one? This would be different from coming out of the taxes as an allocation of what you pay to the government, at least in how it affects those of us on the poor uninsured side. I know my friend who was until recently a legal MA resident was concerned about having to pay a penalty for not having health insurance, but it caused her to make sure that her actual NYC address was documented everywhere. I know if it had been us we would have compared the cost of the penalty plus health insurance to what we pay for his medicine and doctor’s visits without it. Likely even if it had been cheaper if we still didnt see how to come up with it, we would merely have ended up with yet another bill from the government that we couldn’t pay just yet.
Personally, I feel like even the democrats seem to be more concerned with making sure everyone is equally contributing than fixing the problem at its core – we need an overhaul that makes the economic drives coincide with the things that make it cheaper per capita and take the health of the patient as the number one concern. I don’t want anyone’s profit to be on their mind when it comes to my healthcare, and think it’s worthwhile to risk adding some bureaucracy in order to make sure no one’s making decision based on profit instead of the patient’s interest.
At my cushy private institution, in my STEM field, grad student stipends are 25k per year, and insurance for the student is covered at the basic level. For an upgrade to comprehensive, the school pays half the cost of the upgrade. The upgrade ends up costing between 300 and 500 per year. To add a dependent, however, is a lump sum of 700ish in the fall and 1400ish in the spring semester. Which is why we haven’t added my husband as my dependent.
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None of the responses above that I read addressed the elephant in the nationalized health room: Rationed care.
Two countries of note already have national care — England and Canada. A short review of their experiences are in order. Long delays for needed tests and procedures; massively high taxes; involuntary doc-in-box visits involving poorly or inappropriately trained care-givers — few doctors and lots of PAs or med-techs, in other words. And looming on the horizon are age, social position, and value-to-society judgments concerning who gets what care and how quickly they get it.
What, did you think none of those matter under national health? How naive of you. You think you will get the same care as a Senator? Now THAT is a laugh.
I lived national health for 24+ years in the military. Although competent, it is not what it is cracked up to be; picture Medicare all over again in spades. The only thing good about it is it is “free” — yeah, right.
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Amy P, about settling hospital bills:
“1) They often are very nice people. 2) They don’t want you filing bankruptcy. 3) The retail prices for medical services are for suckers.) ”
1) Many systems are using bill collectors. Niceness comments unnecessary.
2) IIRC, the recent bankruptcy bill made it far more difficult to declare bankruptcy due to medical bills.
3) Retail prices are, indeed, for suckers. Nice to bargain with some more clout, which individuals so rarely have.
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1) If you go to the hospital billing office and talk to those in-house people, you may be pleasantly surprised. There may be huge piles of documentation to fill out, but if you genuinely don’t have the resources, it’s possible to get the bill cut down to size. They can see if you don’t have any money. Of course you don’t want to wait and talk to a bill collector!
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Here’s one other piece of information that I just remembered: hospitals sometimes offer a significant discount for immediate lump sum payment. Under some circumstances, it might be worthwhile to take them up on that deal and either take out a loan or put the balance on a credit card, rather than miss out on the discount.
Medical billing is a very weird, opaque process. I don’t suppose anyone here can explain why it is the way it is?
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Amy,
The French system provides a basic policy to all citizens. Then, people can buy a supplemental policy in the private market. Approximately 80% purchases a supplemental policy – it is usually provided through work. I’m not convinced the French system has more competition than the U.S. You may be thinking of the Swiss or Dutch systems. (Switzerland mandates the purchase of a basic policy from non-profit “sickness” funds. The prices are regulated and community rated. The prices vary by Canton and by the age of the person upon entry. Individuals can also purchase supplemental policies from for profit insurance companies.)
I think the age rating is an important feature that is missing in the U.S. Let’s say we have a corporation and a 25 yr old guy working in the mail room and a 55 yr old guy who’s the accounting head. Both will face the same premium, deductible and co-pay. If anything, the 55 yr old will pay a lower out of pocket premium, given his position in the firm.
As a result, the 25 yr old will likely pay (premium, co-pay and deductible) over 100% for his total care (approximately 120%), while the 55 yr old will pay approximately 50% of his total care. (Assuming they each have average utilization for their age.) The 25 yr old is subsidizing the 55 yr old. Now, the goal of insurance is to pool risks, but is it right that a 25 yr old who likely makes much much less, subsidizes the 55 yr old to that extent? What would be wrong with indexing the premiums to age?
HMOs and single payer systems are just not that popular with those who have to use them. Ireland has had national insurance for a long time. Originally it excluded the top 15% of the income distribution and covered only hospitalization (I don’t have my notes, so don’t quote). They were to buy their own insurance. The program has been steadily expanded (I believe it covers everyone now), and additional benefits added. The number choosing to buy private insurance has also steadily expanded. Approximately 40% (as of 1999) now purchase private insurance despite being covered through the national program.
Sweden is seeing increases in demands for private care (there is a proposed private children’s hospital.)
The military health service offers insurance to all retirees and their families. It offers several plans at either zero or an incredibly nominal premium. Approximately 50% of retirees and families choose other insurance even though the premiums are at least 5x higher. And this after the incredible rise in premiums over the past decade, and a major expansion in civilian suppliers.
Medical billing is weird because it is meant to maximize payment, not account for costs. Medical practice changes rapidly (new drugs, new procedures) and much faster than reimbursement systems. That’s not the whole story, but it is part of it. (The billing is not necessarily an accurate description of what was done – whenever medicare tries to control costs by limiting reimbursement for a specific procedure, oddly enough, the procedures change. -Huh, why ever would that be?)
Sorry if that doesn’t answer your question about the French system etc, but there just isn’t space, and this isn’t my blog.
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Very interesting. I think Americans (including myself) tend to have a very vague idea of how things are done in Europe, so it’s nice to hear stuff from the horse’s mouth. I’m still interested in hearing about France.
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http://www.thenhf.com/articles/articles_607/articles_607.htm
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I still like our system. We have an HSA and it works. Tax breaks and Network-negotiated discounts. McCain likes it too, and might expand the tax breaks.
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I turn 49 tomorrow, I don’t want to have the federal government to decide how I live my life. The government already takes nearly 50% of what I make and I’m sick of it. If I get sick and pass on, then so be it. A man can’t even die by his own terms anymore. It’s pathetic. Give me Liberty or give me death. Gerald Ford once said, “A Government that is big enough to provide everything you need, is strong enough take take everything you have”. I don’t WANT it and shouldn’t HAVE to pay for it. My taxes ALREADY go many places that I have no say over. Mark my word, there will be a revolution in this country, I may not see it, but traitors and those who commit treason to the principles of what our founding fathers laid out will eventually be hanging from trees.
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