Does a pay-to-use health-care system discourage use?

[Ziggurat]

When the public interest is served by everyone consuming the relevant healthcare service (such as vaccination), then it seems logical--assuming public interest matters enough--to remove the ambiguity in the incentives and lift the immediate cost.

Vaccinations are a rather special problem, though. Unlike most preventive or diagnostic medical services, they address a problem which has very large externalities. There's also a bit of a free rider problem too, since if most people are vaccinated, the risk of not getting vaccinated drops. That too is rather unique, and shifts the incentive balance strongly towards immediate costs in a well-vaccinated population. And lastly, at least in the US there are additional mechanisms beyond cost which provide incentives for getting vaccinated (you typically can't attend a public school if you don't have the appropriate shots). I'm all in favor of public financing for vaccinations, but the dynamics are just not the same as for almost any other form of health care.

 

[tesscaline]

I am just saying that I don't think that pills are the answer. I find it hard to believe that some 40 odd percent of Americans require ongoing therapeutic care simply for pain. I could be wrong.

The papers you cited didn't seem to say that the prescriptions being considered in the statistic were solely for pain. The second source didn't say that either.

I think that perhaps you misinterpreted the papers a bit? After all, the top selling prescriptions in the second source were lipitor and zocor. Those are cholesterol medications, not pain killers. The only prescription in the top selling list that is an analgesic of any sort is celebrex -- an NSAID (like advil) that is prescribed for any number of issues, but mainly for the treatment of arthritis.

When you consider what percentage of the US population is people age 50 and up, none of that should be surprising in the least.

And as an aside: I have a chronic pain disorder. Saying that "you don't think pills are the answer" makes it sound as if you think I should not take pain medications, despite the fact that my pain index gets as high as 9 on a bad day, and doesn't drop below 6 on a good day. There are a lot of painful conditions that do not have cures (like mine), and all doctors can do is try to help those people live as pain free as possible, so that they can at least function in a basic way. Most of the time, that cannot be accomplished without pain medications. Someone like myself might take your statement to imply that we're all nothing but drug addicts, or people who aren't willing to try anything and everything else instead of pills. I'll give you the benefit of the doubt, though, and assume that you meant to say something that painted with a much smaller brush.

 

[foxholeatheist]

Most frequently prescribed therapeutic class: Analgesics

Hmm... it's not hidden or anything. It's from the first source I cited.

I could be going about this all wrong because I have no experience with mere existence "hurting". I only have experience in severe trauma, often ballistic in origin. To me pain was always just something to endure and "it'll go away" but pain is pretty subjective. If I ever hurt I did something to keep my mind off of it or bite the bullet. When I say "hurt" I mean shrapnel and being thrown from a vehicle. Perhaps my tough guy attitude about pain is all wrong. I am open to that.

I understand that with many common health problems the only treatment is supportive treatment.

There was a guy in my platoon that had constant back pain. I had tried motrin and flexril with no results. I took him in to see the PA and took a urine sample. To make a long story short, this guy had been taking some crazy supplement that had wreaked his kidneys which he mistook for simple back pain. No amount of pain killers or pills would have solved the problem, only treat the symptoms.

However, Americans, despite how awesome we are, have our flaws and one of the major ones is our love of the easy answer. I think ya'll are missing the bulk of what I said (or meant to say), chiefly that Americans would overuse a free health care system because many of us are unwilling to do the hard work. The fact that Bariatric surgery is one of the most common elective surgeries in America is evidence for this.

 

[tesscaline]

Hmm... it's not hidden or anything. It's from the first source I cited.

Most common != All.

Example: 40% of the contents of my closet are dresses. The most common color of dress is black.

From that statement, can you tell me what percent of the contents of my closet are black in color? No. You can't. To jump from 40% of the contents of my closet are dresses to 40% of the contents of my closet are black is rather flawed logic. In reality, the percentage of the contents of my closet that are black might only be 5%.

So goes the jumping from 47% of all americans use a prescription drug last month to 47% of all americans are using prescription pain killers.

I'd also like to point out that in the first source, the inclusive dates for the 47% data is from 2001-2004, whereas the inclusive dates for the "most commonly prescribed therapeutic class: analgesics" is from 2006. So you're lacking a bit of consistency there.

I could be going about this all wrong because I have no experience with mere existence "hurting". I only have experience in severe trauma, often ballistic in origin. To me pain was always just something to endure and "it'll go away" but pain is pretty subjective. If I ever hurt I did something to keep my mind off of it or bite the bullet. When I say "hurt" I mean shrapnel and being thrown from a vehicle. Perhaps my tough guy attitude about pain is all wrong. I am open to that.

I have always had the same mentality towards physical pain. I was always of the mind that it was just something you put up with, and it would eventually go away. Unfortunately, I've found out first hand that that is not always the case. It's not so much that your tough guy attitude is wrong. It's just that it's hard to apply what works for a temporary illness to something that is permanent (as far as can be known anyway) and chronic. So that short (relatively) burst of pain from an injury doesn't go away. It stays. It lingers. It reinserts itself over and over and over into your life, no matter how hard you bite down on that bullet.

Sure, you can "bite the bullet" for a day. Maybe for a week. Maybe even for a month or three. But what about when that pain lasts for years? When the pain is severe and wide spread enough to disrupt both mental and physical processes, and make it so that you cannot (literally) walk properly, or do your own laundry, or whatever it is that makes life enjoyable to you?

I understand that with many common health problems the only treatment is supportive treatment.

There was a guy in my platoon that had constant back pain. I had tried motrin and flexril with no results. I took him in to see the PA and took a urine sample. To make a long story short, this guy had been taking some crazy supplement that had wreaked his kidneys which he mistook for simple back pain. No amount of pain killers or pills would have solved the problem, only treat the symptoms.

I never claimed that pain killers solved a problem. Treating symptoms is sometimes all you can do though. If a pain killer will treat the symptom, and allow someone to get back to life as normal (or close to it), why shouldn't it be prescribed?

However, Americans, despite how awesome we are, have our flaws and one of the major ones is our love of the easy answer. I think ya'll are missing the bulk of what I said (or meant to say), chiefly that Americans would overuse a free health care system because many of us are unwilling to do the hard work. The fact that Bariatric surgery is one of the most common elective surgeries in America is evidence for this.

Bariatric surgery is NOT evidence for that. Bariatric surgery is NOT an easy answer. If you think so, I'm sorry that you feel that way, but arguing from ignorance isn't really the best way to go about discussions here -- someone's gonna call you on it eventually. If you really think that Bariatric surgery is an easy answer, I'd suggest you go talk to RandFan about it, and how "easy" it is.

Yes, some Americans love the easy answer. But does painting with an overly broad brush really address any concerns about the system being "abused"? In my view, most of those who would want to abuse the system already abuse the current system. Making health care into a government provided benefit instead of an employer/personal provided benefit won't change that. And even if more people do "abuse" the system (though why anyone other than a hypochondriac or an addicted drug seeker, or maybe someone with munchausen syndrome would want to see a dr more than necessary, I have no idea, and even those are actual disorders that need treatment), what impact would it have? Would it cost more than we, as a country, already pay? Here is where I would look to other countries with government health programs for examples -- do they have problems with people "abusing" the health care system?

I'd also like to note: Government provided health benefits are not free. They are paid for through tax dollars. You may not have to pay a copay at the dr's office, but you are paying nonetheless.

 

[oggiesnr]

The evidence available from the start of the NHS is that there was a huge amount of hidden medical need because people hadn't been able afford to pay GPs. I see no reason why this shouldn't be the case again if direct charges were imposed for accessing healthcare.

Steve

 

[boloboffin]

And why on earth should you tolerate pain?

Because Jesus did.

 

[DC]

Because Jesus did.

LOL, painkillers are Blashpemy pure ?

 

[foxholeatheist]

Most common != All.

I don't understand this. Does "!" also mean "not" and I just don't know?

Example: 40% of the contents of my closet are dresses. The most common color of dress is black.

From that statement, can you tell me what percent of the contents of my closet are black in color? No. You can't. To jump from 40% of the contents of my closet are dresses to 40% of the contents of my closet are black is rather flawed logic. In reality, the percentage of the contents of my closet that are black might only be 5%.

Eh, It was a hyperbolic guess not meant to be taken literally.

So goes the jumping from 47% of all americans use a prescription drug last month to 47% of all americans are using prescription pain killers.

Again, not meant to be taken literally.

I'd also like to point out that in the first source, the inclusive dates for the 47% data is from 2001-2004, whereas the inclusive dates for the "most commonly prescribed therapeutic class: analgesics" is from 2006. So you're lacking a bit of consistency there.

All the surveys say that analgesics are the most commonly prescribed drugs. I admit, the dates are a bit mixed in the source but it was there when you stated it was not. In fact, it's there three times each for outpatient, HCP office visits, and, emergency room visits. That seems pretty consistent even if there is no percentage in that source for 2006.

I have always had the same mentality towards physical pain. I was always of the mind that it was just something you put up with, and it would eventually go away. Unfortunately, I've found out first hand that that is not always the case. It's not so much that your tough guy attitude is wrong. It's just that it's hard to apply what works for a temporary illness to something that is permanent (as far as can be known anyway) and chronic. So that short (relatively) burst of pain from an injury doesn't go away. It stays. It lingers. It reinserts itself over and over and over into your life, no matter how hard you bite down on that bullet.

Sure, you can "bite the bullet" for a day. Maybe for a week. Maybe even for a month or three. But what about when that pain lasts for years? When the pain is severe and wide spread enough to disrupt both mental and physical processes, and make it so that you cannot (literally) walk properly, or do your own laundry, or whatever it is that makes life enjoyable to you?

I was thrown from an M113 APC in early 2007 and I had problems walking for weeks afterward. I went to see the PA about it and he cautioned me about pain killers, mainly that pain is your body's way of saying that something's wrong. If you dull that you may further injure yourself by using a limb or performing an action that you really shouldn't be doing until it has had time to heal or the source of the problem has been addressed.

Once the source healed (CD in my L5 and hyperextention of the knee) the pain, for the most part, went away.

In some cases, I agree, pain killers would be the best course of treatment, especially if the source of the pain cannot be treated or identified. On of my buddies lost his foot in 2006 and he has terrible phantom pain. He takes oxycotin for it and it helps him deal with it.

Bariatric surgery is NOT evidence for that. Bariatric surgery is NOT an easy answer. If you think so, I'm sorry that you feel that way, but arguing from ignorance isn't really the best way to go about discussions here -- someone's gonna call you on it eventually. If you really think that Bariatric surgery is an easy answer, I'd suggest you go talk to RandFan about it, and how "easy" it is.

I don't know, my father had it done because he was not willing to make the lifestyle changes to address his obesity. I'm sorry for him for believing such an extreme step was the only solution for his problem.

Yes, some Americans love the easy answer. But does painting with an overly broad brush really address any concerns about the system being "abused"? In my view, most of those who would want to abuse the system already abuse the current system. Making health care into a government provided benefit instead of an employer/personal provided benefit won't change that. And even if more people do "abuse" the system (though why anyone other than a hypochondriac or an addicted drug seeker, or maybe someone with munchausen syndrome would want to see a dr more than necessary, I have no idea, and even those are actual disorders that need treatment), what impact would it have? Would it cost more than we, as a country, already pay? Here is where I would look to other countries with government health programs for examples -- do they have problems with people "abusing" the health care system?

I'd also like to note: Government provided health benefits are not free. They are paid for through tax dollars. You may not have to pay a copay at the dr's office, but you are paying nonetheless.

Well, we're talking about an entire nation so indeed, broad brushes are required. I see any National Health Care System as a giant backlogged mess just waiting to happen. I don't mind if folks go see a doctor for every runny nose or every cough as long as it's on their dime. I do mind if I have to pick up the check for it.

Other countries with health care do not have those problems. Switzerland has more guns per capita than the US but far less gun crime per capita. Just because it works for one does not mean it will work for another.

This is all pure speculation from me.

 

[Ziggurat]

I don't understand this. Does "!" also mean "not" and I just don't know?

Yes. It comes from programming, where (unlike written or typeset math and logic) you can only use the characters on a keyboard.

 

[tesscaline]

I don't understand this. Does "!" also mean "not" and I just don't know?

Yes. != means "does not equal".

Eh, It was a hyperbolic guess not meant to be taken literally.



Again, not meant to be taken literally.

If you're citing sources for your statements, it's not a good idea to be hyperbolic about the statistics in those sources.

All the surveys say that analgesics are the most commonly prescribed drugs. I admit, the dates are a bit mixed in the source but it was there when you stated it was not. In fact, it's there three times each for outpatient, HCP office visits, and, emergency room visits. That seems pretty consistent even if there is no percentage in that source for 2006.

Except your second source does not agree that analgesics are the most commonly prescribed drug. Your second source says that cholesterol management medications are the top two prescriptions.

I was thrown from an M113 APC in early 2007 and I had problems walking for weeks afterward. I went to see the PA about it and he cautioned me about pain killers, mainly that pain is your body's way of saying that something's wrong. If you dull that you may further injure yourself by using a limb or performing an action that you really shouldn't be doing until it has had time to heal or the source of the problem has been addressed.

Once the source healed (CD in my L5 and hyperextention of the knee) the pain, for the most part, went away.

In some cases, I agree, pain killers would be the best course of treatment, especially if the source of the pain cannot be treated or identified. On of my buddies lost his foot in 2006 and he has terrible phantom pain. He takes oxycotin for it and it helps him deal with it.

And did the PA explain also that subjecting your body to excessive amounts of pain can actually damage it further without you actively doing anything "wrong"? Did the PA explain that the body's own reactions to pain (i.e. muscles tightening, tissues swelling, etc.) can be problematic as well? How about that certain classes of pain killer also act as anti-inflammatories and actually aid in the healing process (i.e. NSAIDS like Motrin)?

It seems like you're just paranoid about taking pills...

I don't know, my father had it done because he was not willing to make the lifestyle changes to address his obesity. I'm sorry for him for believing such an extreme step was the only solution for his problem.

Bariatric surgery is not a solution. It is a tool to help someone make lifestyle changes. Even in the cases where bariatric surgery help a patient lose weight, they will (generally) gain that weight back if they haven't made appropriate lifestyle changes.

Again, you may wish to speak to RandFan about this subject (or look up the various threads in this forum about obesity) -- He's rather well informed on the matter.

Well, we're talking about an entire nation so indeed, broad brushes are required. I see any National Health Care System as a giant backlogged mess just waiting to happen. I don't mind if folks go see a doctor for every runny nose or every cough as long as it's on their dime. I do mind if I have to pick up the check for it.

Other countries with health care do not have those problems. Switzerland has more guns per capita than the US but far less gun crime per capita. Just because it works for one does not mean it will work for another.

This is all pure speculation from me.

Wow... Okay, more arguing from incredulity. If that's all you can throw out there, this conversation is pointless. Especially when you accompany it with special pleading of "oh, but we're different!" and inappropriate generalizations.

Do you actually have any evidence that if we were to have a government health plan, it would be abused? If not, then what exactly are you basing your "speculation" on?

 

[Darth Rotor]

Do you actually have any evidence that if we were to have a government health plan, it would be abused? If not, then what exactly are you basing your "speculation" on?

Hi. Welfare. Government system. Abused (in some cases.) There is no reason not to believe a similar system, "free health care for all" (no, not really free) would also be abused.

See also insurance fraud. It happens.

There is, I repeat for clarity's sake, no reason to believe such a system would not be abused.

Does that mean nothing should be ventured, in terms of change or reform, for fear of abuse? Probably not. But be wary, and don't rush it.

Look at how long it took to reform rules on gasoline on a national basis, with emissions control as the admirable objective: no lead as the standard. Almost twenty years. And that was fairly simple.

A couple of years ago I heard Newt Gingrich comment on part of the problem with Hillary's attempt when he was house speaker. She wanted it all at once, while the House was willing to give here a program or two for starters.

I repeat my guess on Obama's strategy: he is forcing the issue toward a compromise he envisioned as happening downstream, since his rush it through was bound to raise some objections. IMO, and maybe he is or isn't this smart, this clash was expected, and a more workable deal is the expected second inning of this game.

DR

 

[Policenaut]

We don't have to speculate. It is already being abused in Massachusetts which is the main reason why their 3 year old program is already in debt. Also abuse is the reason why Hawaii's child universal health care program was discontinued after only 7 months. Corruption and abuse is inevitable.

 

[Rolfe]

Hi. Welfare. Government system. Abused (in some cases.) There is no reason not to believe a similar system, "free health care for all" (no, not really free) would also be abused.

See also insurance fraud. It happens.

There is, I repeat for clarity's sake, no reason to believe such a system would not be abused.

I note that all the systems you cite have limited access. Abuse takes the form of people cheating to get something they are not entitled to.

Care to explain how it's possible to abuse a system where everyone is entitled to access?

Does that mean nothing should be ventured, in terms of change or reform, for fear of abuse? Probably not. But be wary, and don't rush it.

Look at how long it took to reform rules on gasoline on a national basis, with emissions control as the admirable objective: no lead as the standard. Almost twenty years. [....]

Do you really think that many of your compatriots can afford to wait that long?
http://www.guardian.co.uk/society/2009/aug/21/healthcare-provision-us-uk

Beth Gabaree has diabetes and a heart condition. Until two years ago they were controlled through ongoing treatment paid for by her husband's work-based health insurance. But he was in a motorbike crash that pulverised his right leg and put him out of work.

That Catch 22 again: no work, no insurance, no treatment. Except in this case it was Beth who went without treatment, in order to put her husband's dire needs first. He receives ongoing specialist care that costs them $500 a go, leaving nothing for her. So she stopped seeing a doctor, and effectively began self-medicating. She cut down from two different insulin drugs to regulate her diabetes to one, and restricted her heart drugs. "I do what I think I need to do to keep four steps out of hospital. I know that's not the right thing, but I can't justify seeing the doctor when my family's already in money trouble."

The problem is that she hasn't kept herself four steps out of hospital. Her health deteriorated and earlier this year she became bedridden. Even then, it took her family several days to persuade her to go to the emergency room because she didn't want to incur the hospital costs. "It was hard enough without that," she says.

Every article someone links has more and more examples, all different. Do you really want to wait 20 years to help these people?


Rolfe.

 

[sugarb]

Well, we're talking about an entire nation so indeed, broad brushes are required. I see any National Health Care System as a giant backlogged mess just waiting to happen. I don't mind if folks go see a doctor for every runny nose or every cough as long as it's on their dime. I do mind if I have to pick up the check for it.

Other countries with health care do not have those problems. Switzerland has more guns per capita than the US but far less gun crime per capita. Just because it works for one does not mean it will work for another.

This is all pure speculation from me.

Hello, foxholeatheist. On the other hand, though, perhaps a national health care system would help alleviate some of the problem with the over-prescribing of painkillers (and I don't see how anyone could not admit that there is a MAJOR problem, in our country, with addictions to prescription drugs).

As an example, I grew up in WV. Small part of the country, right? Fairly low population comparitively to most states. I hope I do this link right:

http://www.medicalnewstoday.com/articles/132549.php

Earlier this year, there was a small pharmacy in a rural part of the state that had, if I'm recalling correctly, the third highest sales of the prescription painkillers in the United States. Because a small clinic was too freely writing prescriptions, with people from many states coming. The investigation revealed 50 or more people at a time waiting to fill the same prescriptions.

If you'll notice in the story I linked to (again, I hope I did the link correctly), you'll notice that, although early on the increase in pain medicine was attributed to WV having a mostly elderly population, the people overdosing are not, by any stretch of the imagination, elderly.

It isn't poverty that is destroying my home state, and the areas where the three states join, here where I live (WV,KY,OH). It is drugs. "Legal" drugs, that unfortunately some physicians don't handle legally. Not to mention the thefts of drugs from honestly sick individuals (which happens on almost a daily basis) and pharmacies.

Does that happen in the military? Or are the medical histories of each person in a database that would prevent doctor shopping and pharmacy jumping?


We already have a backlogged mess of some kind, if obtaining illegal prescriptions is so easy. And it MUST be easy if addicts and/or dealers can work the system. Our local emergency rooms are, at times, throwing people out who come in VERY regularly just for pain pills. One local paper ran a story not long ago about a woman who was an addict, and on the condition of anonymity explained how "seekers" knew how to work the 911 service, abuse ambulance service that we all pay for, knew exactly what to complain about to avoid triage, and try to get pills. She even described how they knew what indicated it wasn't going to be successful, so they knew when to just walk out before they were caught.

So, there is a two-fold problem. Some people legitimately need pain medicine just to perform everyday functions of living. Unfortunately, it seems that MORE people "need" pain medicine to simply feed an ongoing addiction, or to score pills to sell for profit, and something has to be done about that. It puts physicians, and hospitals, as well as emergency medical workers in a tough position. An impossible position, really, given the new trend here in our area of the seekers who, after an unsuccesful attempt with the 911 system, leave the hospital, literally INJURE THEMSELVES, and then initiate a lawsuit against the ambulance company, the hospital, and the doctor who saw through their scheme. Even though they are mostly unsuccessful, it still costs money for our emergency medical systems. Many are reluctant to give pain medicine at all...so the real losers in all of this mess with drug addiction are the people truly in need, the taxpayers funding the ambulance services, and the physicians and hospitals always at risk of being sued. This makes it all more expensive for ALL of us.

Maybe, with a national system, that could get worked out. Or at least the situation could be improved. Maybe.

 

[RandFan]

I don't know, my father had it done because he was not willing to make the lifestyle changes to address his obesity. I'm sorry for him for believing such an extreme step was the only solution for his problem.

I find it interesting that otherwise skeptical people know with absolute certainity the minds of other people.

I understand that the average person is far more capable than he or she knows and that is why it's a good idea to educate people and get them to overcome adversity through hard work and sacrifice and not look for easy answers.

That said, you don't know what I or your father have been through or what we are willing to do. Your argument is post hoc and without foundation. Further we don't know what "willing" means in this specific context as you are really talking about something that you cannot know, the mind of your father.

Is the problem with schizophrenics just that they aren't "willing"? You are talking about the mind. Perhaps your father is capable and unwilling but you don't know that. Had you stated that you believed that he was capable and unwilling then I could understand that opinion. However your absolutist claim is without foundation and flies in the face of facts and the experts who have spent decades studying morbid obesity.

Let me be clear here. Your anecdotal observations and experiences are NOT proof of anything. Fine for an opinion but worthless scientifically. Since we actually have science perhaps we could rely on that, or, we could be like the IDiots and simply follow our intuition and world view.

 

[JoeTheJuggler]

If you have little income, it's a no-brainer that you are going to avoid paying for certain vaccinations for yourself and your children. Humans take chances with health, they tend to only think short-term.

I disagree. I'm low-income and self-employed, so real insurance is beyond my means. However, I am diligent about my vaccinations. (If I get sick, not only do I suffer, I also lose income from missed work.) Similarly, I don't stint on toothbrushes and floss.

It's way more affordable than dentistry!

(Besides that, even when I have to pay for a flu shot at Walgreens--and I don't usually have to because there are nearly always free immunization programs around--it's $10 or so.)

 

[NYCEMT86]

As an EMT in one of the busiest EMS Systems in the nation, I have to say that I am torn on a National Health Care System. I have to agree with Foxhole, I do believe a NHCS would increase the already existing abuse of the 911 system and hospitals.

Currently, we have been overwhelmed with so many more jobs since the Swine Flu outbreak that we are now relying on Private Companies and Volunteers to pick up the slack. EMS in NYC as a whole is the most underpaid and understaffed public service, we possibly couldn't handle an increase in the number of jobs, unless the NHCS puts more money in our hands to hire more EMTs and Medics at a reasonable salary. 911 abusers as it is clog our system and ERs, making it harder for us to get to the people who truly need our help.

Some food for thought;

New York Post Article on Hospital Abuse
FDNY Performance Statistics (July 09)
Is EMS Over or Under-Utilized in the South Bronx: A Retrospective View

 

[Rolfe]

I totally see where you're coming from here. What I don't understand is how this situation exists in the country which spends twice as much as anybody else (per capita) on healthcare.

OK, I sort of understand it a bit. However, the fact is that there's an enormous amount of money going into healthcare in the USA, proportionately far more than in countries which manage to cover all their population and achieve comparable overall clinical outcomes. To say, "we can't cover everyone because we can't afford it," is flying in the face of the evidence.

Consider - when everybody is entitled to care, "abuse" pretty much disappears. It's not abuse to make use of a facility you're entitled to use. Consider also how much of the present abuse is a result of people having no access to a primary care physician. How many of these "abusing" people would still show up at the hospital if they had a GP they could go to who would be able to deal with their health problems before they reached the point where they were showing up at an emergency room?

Rolfe.

 

[JJM 777]

Here in Social-Democratic Scandinavia us better persons cannot understand how the richest nation on the planet can be on such primitive moral level what comes to taking care of its own poorest citizens.

In Finland we have government-funded health insurance for all persons born in the country or legally migrated to the country (e.g. spouses of citizens, even if the migrated citizen is not a citizen yet).

BUT

Some tens years ago they understood to put a 25 EUR fee per consultation, with annual maximum 500 EUR. This 25 EUR fee per hospital visit helped scare away people who earlier came every day complaining about the same imaginary or real problem. The 500 EUR annual maximum liberates the seriously sick persons from bankruptcy. No matter how expensive your treatment is, you never pay more than 500 EUR per year.

 

[KoihimeNakamura]

To be fair, some of the abuses lay in other directions (such as addictions.)