Rationing Health Care - it's a lie!

[Ziggurat]

If it was decoupled from work and replaced with something totally optional, the selection biases that would kill off efficient pricing would be much worse than they already are. The argument pushes in the other direction--to make insurance mandatory and (regressively) state-subsidised if not fully funded.

As the system stands now, when you sign up for a job, you can CHOOSE whether or not you accept the company health insurance. So selection bias already exists. Why does it appear worse for non-employer health insurance than for employer health insurance? Because of two things: first, employer health insurance is often partly subsidized by the employer (meaning you're effectively getting a pay cut if you opt out), and second, because of massive tax advantages which favor employer-sponsored health care plans over privately purchased plans (thanks, FDR wage freezes!). The second is very easy to change: just level the tax playing field. And the former? Well, tax credits for purchasing health insurance can do that job quite well too. In fact, they can do the job more effectively than employer-sponsored plans can, because they can apply to everyone regardless of employment (or even unemployment). There's no reason that the selection bias problem needs to be any worse by decoupling insurance from work.

 

[Ziggurat]

You can call these isolated examples if you like, but your government was concerned enough about the practice to have an actual enquiry into it, just this year.

Why, look at that: just like with the NHS, the government is investigating complaints about the system not working as intended, with an eye towards fixing them. Huh.

And yes, the problem of rescission can be addressed without going to UHC.

 

[uk_dave]

And yes, the problem of rescission can be addressed without going to UHC.

By the government intervening?

 

[Ziggurat]

By the government intervening?

By the government tightening rules and/or enforcement of existing rules on rescissions. Yes, that's intervention of a sort. But of a very different sort than changing to UHC.

 

[ddt]

http://www.commonwealthfund.org/Con...rage-and-Regulated-Competitive-Insurance.aspx

and interesting article about our 2 systems and the US.

and no its not income related. and its just (almost) minimal coverage there are meanwhile some cheaper insurers.

Thanks - good read!

For comparison, I pay EUR 765/year with a 655 deductible out of my own pocket. On top of that, a percentage over the first 32,000 of income (6.9% for employees, 4.8% for self-employed and pensioners).

 

[Francesca R]

But other systems have been mentioned, e.g. the German system, the Swiss system, the French system which ranks first in the world according to the WHO, and the Dutch system as I've described it the other day here. All non single payer systems.

(I'm on-record somewhere here as believing that the mandatory insurance-based systems such as the Dutch one are even better than the single-payer NHS)

 

[Francesca R]

There's no reason that the selection bias problem needs to be any worse by decoupling insurance from work.

I mean (I think) that removing the tax break--which is what couples it to work effectively--will bring about more opt-outs, and those opt-outs will be healthy folks.

 

[Ziggurat]

I mean (I think) that removing the tax break--which is what couples it to work effectively--will bring about more opt-outs, and those opt-outs will be healthy folks.

But it's not the mere existence of tax breaks that couple it to work, it's the fact that the tax code specifically favors health care purchased through work. And there's no good reason for that. The tax-favored status of employer-provided health insurance is not the result of an effort to decrease selection bias, it's the result of employers trying to get around the crippling effects of depression-era wage freezes. If government wants to encourage the purchasing of health insurance, it makes sense to offer tax advantages. It makes no sense for the tax code to favor employer-provided health insurance over privately purchased health insurance.

 

[ddt]

(I'm on-record somewhere here as believing that the mandatory insurance-based systems such as the Dutch one are even better than the single-payer NHS)

Ideologically, I'd be in favour of a single payer system. However, I think it's vastly more important to have a uniform system in place that ensures that all people have access to a reasonable baseline of health care, whatever their income, age, family status, employment status or whatever else you can think of. Whether that's implemented through a government framework of uniform regulation as in the Netherlands, or as a state health care system as in the UK, is secondary. And if people want to buy extra health care above and beyond that baseline - fine with me.

If there is anything that these threads have highlighted, then it is that the USA doesn't even have a system. It's a patchwork of private insures, ad-hoc rules, lack of government oversight and what-not where people routinely fall through the cracks and get burned. That should ultimately be addressed.

 

[Francesca R]

But it's not the mere existence of tax breaks that couple it to work, it's the fact that the tax code specifically favors health care purchased through work.

'S what I meant.

And there's no good reason for that. The tax-favored status of employer-provided health insurance is not the result of an effort to decrease selection bias, it's the result of employers trying to get around the crippling effects of depression-era wage freezes.

Folklore over here has it that GM and the UAW had intimate say in it in decades gone by.

If government wants to encourage the purchasing of health insurance, it makes sense to offer tax advantages.

Absolutely. All uni-systems in existence have tax advantages. Many of them flat out force you to grab the advantage or the state will do it for you (unless you "disappear")

It makes no sense for the tax code to favor employer-provided health insurance over privately purchased health insurance.

Agreed, but non-universal private insurance (with no subsidy) would crash and burn. I don't think you're disagreeing.

 

[Rolfe]

Going back to the question of whether insured people can rely on getting the care they need, and whether uninsured people will also be looked after acceptably, someone else linked to this article. The quotes below are from the article and the subsequent comments.

You have no idea what it’s like to be called into a sterile conference room with a hospital administrator you’ve never met before and be told that your mother’s insurance policy will only pay for 30 days in ICU. You can't imagine what it's like to be advised that you need to “make some decisions,” like whether your mother should be released “HTD” which is hospital parlance for “home to die,” or if you want to pay out of pocket to keep her in the ICU another week. And when you ask how much that would cost you are given a number so impossibly large that you realize there really are no decisions to make. The decision has been made for you.

My best friend from High School, Joel, died of kidney failure 6 years ago. I was out of touch with him and had no idea he was ill. I get back home and I hear he is about gone. We needed $7000 to keep him alive. I had $2000 in the bank. We started going door to door. he died the next morning.

He used to work in the hospital that turned him away.

My brother lost his job and his health insurance.
He has been diagnosed with COPT.
He won't qualify for public aid for another year. He applied for SS disability a year ago and his lawyer told him it will be another two years. By then - without care - he could be dead.
This is government bureaucrats deciding to let my brother die.

treatment for cancer. It is very expensive. Fortunately, we have Medicare and a good coinsurance from my husband's 40 years as a union employee. Even with that some treatment was denied by the co-insurer. Hopefully, all will turn out ok anyway. I asked someone in the billing department of the oncology department what happens when people without insurance have this disease. She said they are in bad shape, since there is a limited amount of charity care at most hospitals. So,friends, the death panel is in full swing. It's just got a different name....the uninsured.

A friend of mine, married, employed (but no beautiful employer insurance), and mother of a teenaged daughter, was suffering from a severe, debilitating disorder that had her bedridden. She is too poor to afford private insurance (though as a pre-existing condition, it probably wouldn't be covered anyway), and not quite poor enough to qualify for Medicare, so short of literally making her family poorer to qualify her only option was to wait until she was having difficulty breathing so could go to the ER where they can't turn her away.

$500,000+ of open-heart surgery later, they tossed her out of the hospital four days later because she couldn't afford to stay. It's obviously impossible for her to pay this bill, so I can only assume they will have to declare bankruptcy.

Of course, it wouldn't have cost $500,000 if she'd been able to go to the doctor and get a proper diagnosis and surgery a year or two earlier, but--hey--can't afford to pay for that, too bad!

Now, a follow-up surgery is going to be required if she's actually to, you know, go on living. Except she can't get that, because she can't pay for it. And it's not like you can use the "ER loophole" to schedule surgery.

There's your damn death panel.

I was in the same situation three years ago, and I'm born and raised a US citizen. Bedridden, unable to work, about to lose my insurance, slowly wasting away, and Blue Cross (now Anthem) refused to pay for expensive diagnostic tests or continued interim treatment to keep me alive. My options were A) Use my life savings to pay for the tests myself. Or B) Move to Japan where my wife is originally from where they would cover the tests and treatment.

There's also a funny one about Russell Brand trying to get out of a psychiatric hospital in the USA and nobody would take any notice of him, so he told them he wouldn't be able to pay their bill (yeah, right!) and had no insurance, and he was out the door before you could say "co-pay deductible".

Th internet is crawling with these sorts of stories. Are they all lying or exaggerating for political reasons? Then we only have to look within this forum, everybody from Ducky to epepke and a lot of people in between, reporting that they've been sick and unable to pay for what they needed, and in deep money trouble or going without. I was told about one member, years ago, who needed a lung transplant (for CF) that his HMO denied, and he died while fundraising efforts were getting off the ground.

Has there been one single British resident (or even European resident) who has posted similar difficulties in the forum? I know the baseline numbers may be skewed to the US side, but there are enough non-US folks here that you'd expect to hear about something - that is, if the anti-universal-healthcare propaganda was anywhere close to right. In contrast, it's the experiences of US posters here (starting with epepke, which shocked the socks off me) that reinforces my impression that the "horror stories" coming out of the US healthcare systems are true and are representative.

Does anybody really want to defend the positon that the present system is basically OK and it's just a few people who've unfortunately slipped through the net we're hearing about?

Rolfe.

 

[Francesca R]

Going back to the question of whether insured people can rely on getting the care they need [ . . . ]

Even if they got the care they needed in all cases, it's still a hugely inferior arrangement to a UHS, as I tried to point out in another thread:

I was considering this more from the perspective of patient distress.

"We will do whatever it takes to treat you, and there is no cost" [1]

is very different from

"We will do whatever it takes to treat you, and there is no need to worry just yet about the cost which might mean future financial ruin for you" [2]

In particular I wonder what strength of belief in the evils of free-riders getting away with hugely expensive unnecessarily self indulgent yet probably life-saving medical treatment is required so that one thinks that [2] is at least as good as [1] in the moment of need.

 

[ohp]

I thought I'd weigh in on this issue, share some of my personal experiences with the NHS.

A lot has been made of rationing of some of the newer, more expensive therapies and drugs on the NHS. Perhaps it seems distasteful to put a value on the extension of peoples lives, and people might worry that in a system with universal care, then those drugs might be denied them.

It's certainly all about doing the most good with the funds available, and this has benefits for people who are currently healthy.

I'm in a risk group for a number of different diseases, and in terms of bang for buck, it's cost effective for the NHS to monitor my health rather than wait until I'm at deaths door. This means that I get attention from my local health centre in the form of reminder letters to have a regular health check.

Perhaps this all seems like a nanny state - the UK has a number of programmes to keep its population healthy, from mandating that people wear seatbelts, to assistance with stopping smoking. I'm sure that some people would hate it here.

I've been to hospital as an outpatient, and the treatment I received was very thorough, bordering on the obsessive Perhaps I was lucky. A friend of mine has a relative with a strange liver problem, and they're frustrated with the speed at which things are being processed.

I have private health insurance, it's provided by work. I've never claimed on it, but it might be useful if I needed an exotic drug. You can also get health insurance plans that will pay for healthcare in situations where you might want those drugs. Because the NHS picks up most of the healthcare tab, these policies are pretty cheap, as the claims are low.

Early fire brigades used to work on an insurance basis.. if you didn't have insurance, or if you couldn't pay up front, they'd let your house burn to the ground.

Nowadays they insist that houses are built so that they don't burn so easily, and emergency services will attend to those most in danger before they rescue your cat from a tree.

I must confess, I'm not familiar with the way the fire service works in the US. is that done on an insurance basis?

I earn an above average wage, so I'm probably subsidising the healthcare of others, but I find my overall stress levels are lowered where I know that whatever happens to me, I will receive a good basic level of care, free at the point of use.

 

[Ziggurat]

I must confess, I'm not familiar with the way the fire service works in the US. is that done on an insurance basis?

No. Fire departments (which is what they're called over here) are primarily funded by property taxes at the city or county level. They can also get some funding from state and federal grants, but it's mostly just local taxes.

 

[kellyb]

And what would it take for you to realize that there are other ways to reform the system besides single payer?

Ok, well, what about the french system? What's wrong with aiming for something like that?

 

[The Painter]

WHOA! That is about .25% of normal. Care to divulge what company that is?

I think i smell unicorn poo.

It's a very large communications company in New York. My wife has over 20 years in the company. Until 5 years ago it was free.

So put that unicorn poo in your pipe and smoke it.

 

[kellyb]

Oh, and Skeptigirl...
From the whitehouse.gov's new "reality check" site...

http://www.whitehouse.gov/realitycheck/faq#r1

I have heard many people worry that health care will be "rationed" under health reform. I won’t be able to get certain tests or procedures. What if I want those tests and what if they detect something that could save my life?
Health Insurance Reform will end current forms of rationing, not expand it.

First, there is widespread rationing in today’s system. Right now, decisions about what doctor you can see and what treatment you can receive are made by insurance companies, which routinely deny coverage because of cost or the insurance company rules. Health reform will do away with many of those rules that result in rationing today.

Health Insurance Reform will prevent insurance companies from denying coverage because you have a pre-existing condition; prevent them for canceling coverage because you get sick; ban annual and lifetime limits on coverage, which often force people to pay huge sums out of pocket if they develop a serious illness; and prevent discrimination based on gender.

With health insurance reform, we will also put treatment decisions back into the hands of doctors in consultation with their patients.

One of the reasons we spend too much on health care today is that our incentives are perverse: Doctors are paid by the procedure, rather than for quality. We want reform that rewards quality of care not quantity of procedures. Having dozens of procedures doesn’t necessarily make you better. In fact they can make you worse. Right now roughly 100,000 Americans die every year from medical errors, which, in many cases, were the result of treatments that were wrong for them. We want to reduce preventable hospital re-admissions that are frequently caused because patients are not getting the right care in the first place. We want to give doctors the ability to make the best treatment decisions for you and your family.

Has Obama, too, fallen for the "framing" ploy?

 

[Rolfe]

It's a very large communications company in New York. My wife has over 20 years in the company. Until 5 years ago it was free.

So put that unicorn poo in your pipe and smoke it.

Right. So $60 per month is absolutely everything, the total sum that you and your wife put into the healthcare system? And you really think you had it "free" until five years ago?

I mean, you're sure that this large communications company doesn't contribute anything on your behalf (which might otherwise be in your pay packet)?

You're sure that none of the tax money you pay goes to fund Medicare or Medicaid?

You're completely confident that you're not liable for any co-pays or deductibles should you ever use the system?

You've got a saddle and bridle for that unicorn?

I'm just gobsmacked. US posters frequently jump on British posters who describe our healthcare as "free" when we're all perfectly well aware that it's funded from our taxes, and "free" is just short-hand for "free at point of delivery".

But this seems to be a real, live American who honestly thinks that his modest personal contribution to his employer-funded health insurance is the sum total of what he pays (or is liable to pay) into the US healthcare system.



So just go away and add up that $60, and your employer's contribution, and the proportion of your tax dollars that goes to fund Medicare and Medicaid (and the VA), and think about the co-pays and deducibles you're liable for, and then once you've done that, come back and say that you're not paying double what someone of comparable income would be paying in Britain.

This reminds me of the time when I, as an eleven-year-old, couldn't understand the teacher's explanation of the Law of the Conservation of Energy as it applied to driving a big truck, because surely the amount of energy you put into pressing the clutch and turning the steering wheel wasn't enough to move that big heavy weight? (And even then I was only being perverse because I didn't think she'd explained it very well.)



Rolfe.

 

[The Painter]

I mean, you're sure that this large communications company doesn't contribute anything on your behalf (which might otherwise be in your pay packet)?

You're sure that none of the tax money you pay goes to fund Medicare or Medicaid?

You're completely confident that you're not liable for any co-pays or deductibles should you ever use the system?

Are you retarded???

Of course the company pays It is called a benefit, and enticement, to get someone to work for you. Most people , which is sizable, who get insurance through their job pay a small percentage of the total. Yes there is a Medicare tax.I have a $15 co-pay. Happy now??? We still pay $60 per month for insurance.

I was unaware that I had to explain the obvious to you. I will make note of that for future reference.

 

[ddt]

Are you retarded???

Of course the company pays It is called a benefit, and enticement, to get someone to work for you. Most people , which is sizable, who get insurance through their job pay a small percentage of the total. Yes there is a Medicare tax.I have a $15 co-pay. Happy now??? We still pay $60 per month for insurance.

I was unaware that I had to explain the obvious to you. I will make note of that for future reference.

As you mentioned yourself, a couple of years ago, you had a sizeable increase in the amount you had to pay yourself, in fact so sizeable I can't even express it as a percentage (hint: it's from 0 to 60 dollars a month).

You might be interested to know how much your employer pays. One day in the near future you might have to cough up the whole amount, because your employer won't do it anymore. Or you decide to switch to an employer who is not so magnaminous. I hear many employers in the US, especially small and midsize ones, are not so nice to their employees to cough up (nearly all) of the premiums.