Paying For Health Care

Although I'm a die-hard defender of health care reform, I do have some worries about the cost. I think we can pay for health care, because other countries do it. However, I am worried our system is going to end up costing a lot more; we have too much redundancy built into the system, nobody wants to tell dentists how much they can charge to fill a cavity, special interest groups are protecting their turf right now, and individuals don't want to go on a waiting list for mole removal.

Megan's been writing hand-wringing posts about the cost of health care policy. They're worth a read.

UPDATE: Megan responds to Russell's comment.

32 thoughts on “Paying For Health Care

  1. I tend to believe that only truly effective cost controls available to modern people–that is, people that reasonably will choose to make use of available technology to make their lives as long and as comfortable as possible–is collective bargaining power with the providers out there, the doctors and dentists and hospitals and so forth. That can mean employing them all (Britain NHS approach), or making the government alone responsible for paying them (Canada’s single-payer approach), or something else–but ultimately, something that, one way or another, challenges the effective monopolies which health care providers and insurers have over the great majority of us. The bill looking to pass the Senate does many good things, but it doesn’t do that; instead, it essentially creates a system of mandates, and thus potentially tens of millions of hand-outs to enable individuals to satisfy those mandates by paying what the insurance companies demand. There may be some long-term cost controls built into the proposals, but none that strike me as doing the kind of broad, game-changing work that needs to be done. (More here, if you’re interested.)

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  2. I just got a letter from Blue Cross (a non-profit, apparently), telling us that we may be on the hook for $700 for D’s ER stitches of last month. I think we’ll manage to sort this out in eventually (no one’s answering the phone at the physician group office), but the issue seems to be that although the ER itself is in network, the doctor in ER wasn’t. That’s sort of a stupid system, n’est ce pas? The physician group and Blue Cross eventually came to an agreement, but they did so after our ER visit, so we need to talk them into counting our work under the new agreement.

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  3. I don’t see much of an advantage is switching a private monopoly for a government one. That said, I think that mandating coverage, if that stays in and has teeth, is a game-changer.
    What we’ve seen is adverse selection. First, rising costs encourage the healthier people to chance it without insurance thus raising costs more and causing more people to try it without insurance. Second, more expensive private coverage is pushing more people into the public sector as. At least in PA, if you aren’t covered by your employeer, the state’s CHIP (which only covers children) plan is really the only option that isn’t cost-prohibitive before a six-figure income. (A family of three with one kid and a household income at the median for Pittsburgh would get a subsidy.)

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  4. “although the ER itself is in network, the doctor in ER wasn’t. That’s sort of a stupid system, n’est ce pas? ”
    It’s all a stupid system. The morning after I’d broken my ankle, I was on the phone for 2 hours trying to figure out which provider near me I could see (I was on vacation, though in the same state). I called the main Provider Directory and got a bunch of names, but that was a stupid idea. The better idea was just to call providers and ask them if they took my insurance. So. Stupid.

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  5. “…individuals don’t want to go on a waiting list for mole removal.”
    Or become permanently incontinent because of a delayed bladder surgery like this Canadian woman:

    Or suffer crippling pain for years because of delayed hip replacement like this Canadian woman:
    http://www.wikio.com/video/2276769
    There’s another video that I can’t find right now where a 30-something Canadian woman was basically crippled for a couple of years because of another delayed surgery (spine, I believe). She couldn’t take care of her children or work for two years because she was too far down the wait list.

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  6. The relevant data is how often that happens (i.e. someone ends up incontinent for lack bladder surgery . . . .) in the Canada v the US. In Canada it happens because of a protocol/triage-dependent delay (I don’t know the Canadian system, but UK’s system assigns delays based on reasonable medical evidence). In the US it happens because someone lost a job, or didn’t have money to pay for health insurance, or unwisely chose not to pay for it.

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  7. I think that some of the cost savings in our system can come from pressing the providers to provide more service for less pay (through collective bargaining, perhaps). But, part of it has to come from people accepting that the system that’s available to all is not going to be the “best.” That means waiting times for mole removals, unless known evidence indicates otherwise, or you pay for it yourself.

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  8. A big chunk of my family is Canadian, including my 97 year old great aunt. My cousins were visiting a few months ago and told us that they were shocked at the American scare ads about Canadian health care. They LOVE their system.
    For every scary, and perhaps fake, video about the scary Canadian health system, I can find a video or story about a person who died in America, because they didn’t have any health care insurance.

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  9. Maybe Canadians are just more complacent than Americans. When Canadian leaders wanted to switch Canada to the metric system, Canadians switched. When they tried that in the U.S., everybody was able to ignore it unless they needed it for a job or were in middle school.
    My guess is the crucial difference between us and Canada is the Irish. Canada got the Irish who weren’t pissed-off enough to want to completely leave the British Empire, leaving Canada with a stubbornness deficiency that persists to this day.

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  10. “They LOVE their system.”
    I don’t love ours and I can see a lot of areas for improvement, but I don’t think that doing a last-minute term paper job on America’s healthcare is a good idea. I’ve got Canadian relatives, too, and my feeling is that how well you are served by Canadian healthcare depends a lot on who you are and how well you are able to work the levers of the system. When money is no longer the motivator and there is scarcity (which is pretty much saying the same thing), who you know and how important you are becomes the deciding factor in how quickly you get care. There is inequality, but it is veiled by the egalitarian appearance of the system.

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  11. I’m an American-born naturalized Canadian so I have plenty of stubborn gene and I much prefer our Canadian system. I have family on both ends of the socioeconomic system, in both countries.
    There is no doubt that my rich American family members get superior health care. Hands down.
    However my poor American family members have developed lifetime serious health issues due to not seeing anyone during a period of non-coverage, and another family was bankrupted when the breadwinner was age 59 – not an easy time to start over – due to an out-of-network hospital stay. Whereas my poor Canadian family members, including the transient drunkard, get pretty much the same care I do.
    The system here definitely is imperfect. But we don’t see that as a reason to end socialized medicine – we see it as a reason to improve socialized medicine.
    I could go through my medical history but pretty much my experience is that my primary care (family doctor) is fine, my emergency care is fine, and where the system tends to lag is in hooking up to specialists. So when I was having super-distressing symptoms, I had a MRI that day, no problem. When it turned out not to be a brain tumour, it took 4 months to see a specialist. The weak point is if a non-distressing symptom turns out to be super-serious. However, we work towards improvement.
    That admitted/said…here’s the deal. I’ve never, ever in my life spent a day wondering if I would be covered. My doctor is definitely conservative in ordering tests so as not to overload the system – but when she thinks I need one, I get one. Period.
    I have never, ever, ever had to call a bureaucrat to find out if I could get/afford the care I was getting or which was being recommended. (Although at the fringes of certain kinds of care, the gov’t would stand in.) I would FREAK OUT if a company making a PROFIT were trying to tell me something my DOCTOR thought I should have was NOT covered. I put this in some all-caps to emphasize that I think the American system is *whacked* and people should be screaming. It’s not about complacency.
    I have changed and left jobs with nary a thought towards my coverage. I cannot believe what my American friends and family go through when their employer changes their network and suddenly they have to switch all their doctors. I’ve had the same doctor since I was 14, and she knows my medical history inside out and backwards.
    It would be nice if the US would come up with a better solution so we could copy it.
    It’s true we put up with shabbier surroundings but we have world-class hospitals, doctors, and researchers here, including stem-cell researchers who fled the US. So I don’t really think much of the “oh, Canadians just don’t complain” argument. If I were a poor American I would be up in ARMS, literally.

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  12. “So when I was having super-distressing symptoms, I had a MRI that day, no problem. When it turned out not to be a brain tumour, it took 4 months to see a specialist. The weak point is if a non-distressing symptom turns out to be super-serious. However, we work towards improvement.”
    “That admitted/said…here’s the deal. I’ve never, ever in my life spent a day wondering if I would be covered.”
    But, insofar as you had to wait four months while you were in great distress, you weren’t covered.

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  13. AmyP, there was no 4-month wait while ‘in great distress’ – the MRI was done ‘that day’.
    In any comparison with other OECD countries, the US has the worst and most expensive health-care. I find Megan’s concerns unpersuasive – how is it that other countries cover all their citizens at a fraction of the cost ? The problem as always is not technical but political. The need to make a profit out of everything is a cancer in US society.
    The public option was the best bet for reducing costs. For some inexplicable reason Senator Lieberman decided to kill the public option – he never gave a coherent explanation for opposing it. The bill we have is a poor one, but it’s the best we can get given imbecile Senators like this.

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  14. Yes, thanks Doug. I had the MRI that day. When it turned out not to be a neurological problem but a migraine, it took much longer to get in.
    I wasn’t thrilled, but it was acceptable to me, as the big nasty possibility had been ruled out. Also, I knew that if my symptoms got worse I could either go back to my doctor or go to the ER or a clinic. That’s not the same as not being covered.
    I guess what I didn’t make clear is that yes, Canadians may be more willing to wait for certain things. But there are other things about which we are totally not complacent.
    I do think the point about working the system is a good one, but my observation is that it’s pretty much the same in the US – so a problem in both countries.

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  15. “AmyP, there was no 4-month wait while ‘in great distress’ – the MRI was done ‘that day’.”
    After they figured out it was non-malignant, she didn’t get to see a specialist for another 4 months. That’s as close to no coverage as I’d like to get.

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  16. Around here, getting to see a (any) dermatologist is a wait of at least 2 months, and that’s to see the nurse-practitioner. I made some poor schmuck very happy when I had to cancel E’s appointment for next week.
    OMG, seeing a psychologist in Maine? Not easy. The system was so overloaded that it was nearly impossible to find someone who’d see a new patient.
    I’ve also gone on about this at length before, but I blame the capitalist system that rewards over-specialization instead of primary care for my father’s situation. The nephrologist whom the insurance company deemed his “primary care” provider saw only kidney disease (duh!) and totally missed the bigass prostate cancer that moved to his spine.
    I like the Chinese system* where you pay the doctor when you’re well and pay nothing when you’re sick.
    *I saw a reference to this on some site but never had the time to check up on it so I have no idea of the accuracy of this statement.

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  17. Amy P – it’s so interesting you see that as non-coverage. I really don’t, so maybe that goes with the complacency theory. I have no trouble waiting for something that is going to require time to track down and treat.

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  18. But, we have plenty of 4 month wait non coverage here, too. The difference is that it occurs, unlike in Canada, for nonmedical reasons. And, because it does, one person (I don’t want to call this person rich, ’cause they may also be the well covered or the sqeaky wheel gets their MRI. Others die of treatable disease.
    I’m for rationing basd on medical need. And that bugs a lot of people ‘case it raises hairy questions.

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  19. I think Amy’s concern about “working the levers” is realistic, and find that it definitely plays a role in schooling in the us, both regular scholing in which choice is allowed (Chicago, SF, NY, . . . .).
    What’s the percepion in Canada? JennG — do you believe your care would have been different, if you knew the right people? Who would those people have been? For example, a doctor probably would know ways to code the head pain in order to get faster MRIs.

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  20. I’m for rationing basd on medical need.
    That part apparently comes later. Given that the government’s biggest health care plan, Medicare, “rations” based on trying to pay doctors as little as possible for a procedure and not on whether the procedure is need, I don’t think we’ll get much change on that front. The hope seems to be that if you nickel and dime providers enough, fewer of them will accept the card. That’s the one point where the government and private sector are starting to converge.
    Anyway, given that it is about impossible to be middle class and get coverage without working for the public sector or a giant corporation, I’m relatively happy about the Exchanges and the Mandate part of the current reform. The rest of it, blah.
    (Everybody seems to be mis-reading JennG’s MRI comment, even after the correction, because Canadians correct people so politely.)

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  21. Well BJ – no, definitely not for the MRI. In my case the code was A+ priority. But my doctor is pretty ethical and wouldn’t throw the code to get in early either.
    I’d say that when you walk in with certain symptoms, no matter who you are, you get to the head of the line. If I’d walked off the street into emerg I’d’ve been in the same queue in the same place (or faster since I had to get from my doctor’s office to the hospital. :))
    But yes there are definitely places where working the levers is a factor. Certain kinds of cancer care (getting into experimental studies) come to mind. Also the kind of thing where the diagnostic phase is longer and a quick triage of symptoms doesn’t help (allergists, immune system disorders, back problems, etc.).
    And there’s no doubt sometimes with those kinds of specialists you can get in faster if you know someone or, maybe more importantly, your doctor’s referral network is strong.
    However, I’m not sure I understand how Americans would know which doctor is the best or what would happen if that doctor didn’t work with their insurance. I was kind of floored when my sister, who has amazing insurance in the US, had to get each step of her treatment approved by her insurance company during a very serious pre-term labour experience.
    I couldn’t believe anyone would STOP to call an insurance company in the middle of treatment, and that the insurance company could overrule the doctor’s judgment. Mind you, there was a staff person whose job that was, so it went pretty fast, but it blew. my. mind. I can’t imagine having to wait for approval like that.

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  22. Here’s the thing: we need to think about what kind of experience we want when we go to the doctor, then make that kind of experience happen. I can’t imagine ANYONE wants to have to call insurance companies when they’re in pain or discomfort. They want to just go to the doctor of their choice.
    How can we make that happen? And how much are we willing to pay for that? What is the government’s role in making that happen? (I.e., regulation of costs?)
    I guess I would have liked it if, when I broke my ankle, I was able to call the nearest hospital and go to the ER right away. In fact, that is what I should have done*, but I made the mistake of calling the insurance company first to see what doctor they’d approve, and no one there had a clue where to tell me to go.
    *I ended up going to an urgent care center where they x-rayed my ankle and told me it was broken, but then they sent me to the ER to get a splint put on because apparently, they can’t put on a splint in an urgent care center! WTF? I should have just gone to the ER first.

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  23. I was kind of floored when my sister, who has amazing insurance in the US, had to get each step of her treatment approved by her insurance company….
    Is that really amazing insurance? I’ve heard about that, but only with HMOs. I’ve seen our doctors order very expensive non-emergency things without batting an eye.

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  24. For those who are really interested in a nuanced look at differences between American and Canadian health care, I definitely recommend “The Barbarian Invasion,” a (French) Canadian film from earlier in the decade that is (nominally) about a father and son coming together as the father faces a terminal illness, but is really about American and Canadian health care.
    The father is an avowed Socialist professor in Montreal, facing treatment of a fatal illness in a medical system that recognizes the low chance of success of any intervention, and the son is a “capitalist” working in business in New England, and tries to get him to come to Vermont (or maybe New Hampshire) where he’s agreed to pay out-of-pocket for more aggressive treatments in a much nicer facility.

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  25. So, the Americans are the barbarians? That’s so unfair. Nobody has invaded Canada from the U.S. since 1871 and it’s been even longer since there was an official U.S. invasion.

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  26. “However, I’m not sure I understand how Americans would know which doctor is the best…”
    This is the information age. It should be possible to figure that sort of stuff out. Aside from medical expertise (which is genuinely difficult for a patient to evaluate), it should be possible to get solid information about a practice’s pricing structure, bedside manner, and how much time is devoted to each patient. I think the latter two are actually pretty closely related to medical quality, since taking the time to get all the relevant information out of the patient is really important. About the pricing–I especially liked the part of the Reason video I posted up above where the cash US practice had all their prices for surgeries listed on their website. Pricing transparency is definitely a step in the right direction. My parents negotiate the prices of their planned surgeries in advance and they are very happy with the quality of care they get. In an emergency, you don’t have that luxury, of course, and that’s where I suppose it would be nice to have the insurance company twisting the hospital’s arm for you.
    In real life, when we moved to Texas 2.5 years ago, we queried my husband’s new colleagues for names of doctors. We got a fantastic family doctor out of that process who really takes the time to talk, rather than edging out the door a few minutes after he says hello. Finding dentists that we were happy about took literally 1.5 years and the kids spent 5 months on the waiting list of their current pediatric dentist before they became patients, but she’s won the “Best Pediatric Dentist” in town two different years. The other two dentists we tried just weren’t gentle enough with the kids.

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  27. Personally, I still have no idea whether I wasted my money or not when I signed my newborns up on my dental plan when I knew they weren’t going to have teeth anytime soon.

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  28. Our pediatrician said that you didn’t need to take a kid younger than three to the dentist unless he saw something that gave him pause. So we spent three years contributing to adverse selection in the dental insurance market. I also skip vision insurance despite 100% of the household adults wearing corrective lenses. Since nobody who doesn’t need corrective lenses gets the coverage, it is a bit more expensive than going in to get new glasses every 2 years.

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  29. Dentistry is a funny sort of health care industry, because it’s got so much show biz to it. My last dental appointment in Texas, I was offered (and gratefully accepted) a hot paraffin treatment for my hands. A couple years earlier, I had been bemused by the fact that my dentist’s office in DC suddenly went spa. They started offering back rubs and lavender-scented hot towels to go with procedures, and the waiting room was remodeled to include a very large water feature. How do you code a water feature? I really love both these dentists, but this stuff makes me smile.

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