Health Insurance Changes

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Mike Dwyer

Mike Dwyer is a former writer and contributor at Ordinary Times.

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182 Responses

  1. Avatar Kazzy says:

    Isn’t that what catastrophic care coverage is?

    The argument I’d make against it is that to whatever extent it encouraged people to avoid routine care, it would augment the need (and expense) of care down the road.

    But I don’t see why having such plans, which (again) I’m pretty sure is exactly how catastrophic care works, available as an option is objectionable.Report

    • Avatar Mo says:

      But isn’t that true of car care as well. Skipping oil changes and basic maintenance leads to higher costs down the line as well.Report

      • Avatar Kazzy says:

        I honestly don’t know. I don’t know enough about the human body or cars.Report

      • Avatar DavidTC says:

        Skipping oil changes and basic maintenance leads to higher costs down the line as well.

        Yes, but car insurance doesn’t pay for that _either_. Car insurance just pays for when a car is damaged by outside forces, not if the engine blows up if you never change the oil.

        A car warranty, OTOH, does cover that result…which is exactly why oil changes _do_ tend to be covered under them. (And it’s also why you can’t get, like, a ten year full warranty.)

        Health insurance is rather like warrantying a random car that someone has owned for decades. Frankly, I’m amazed more of them don’t _mandate_ you send in evidence you do change the oil.

        It is stupid for someone to set up a system where upon major problems are covered, but minor problems which, when uncorrected, lead to major problems, are not.

        Catastrophic care coverage does exist, but it tends to have exceptions and high costs and exactly the sorts of things you’d expect. They’re not that great an insurance policy, simply because it’s a poor way to structure insurance.Report

        • Avatar Patrick says:

          Health insurance is rather like warrantying a random car that someone has owned for decades. Frankly, I’m amazed more of them don’t _mandate_ you send in evidence you do change the oil.

          Point of fact, you do have to do exactly this to get warranty coverage for a used car, if it’s not certified pre-owned. You have to have the service record even of the previous owner.

          Assuming your dealer wants to haggle over the service that is under warranty.Report

          • Avatar DavidTC says:

            I think you missed the analog part of that. I’m sure before they warranty a used car you have to have all sorts of records.

            My point was, considering providing health insurance is exactly like that, I’m surprised they don’t require it for _that_.Report

  2. Avatar greginak says:

    If we are talking about a regular check up then that somewhat misses the issue. We pay for healthcare through what we call insurance. But health insurance has always been far more than that. Having a collective system of paying for HC simply works far far better than each individual paying when they go. First the collective system, even our insurance based system is partially collective, gives you the protection of catastrophic insurance plus other benefits. There is a lot of HC that falls between catastrophe and regular check ups. There are chronic diseases or temporary problems that need to followed for a while. Some things need PT or long term meds. All those things cannot or at least not easily be afforded by people who aren’t well to do.

    Everybody unless they are super lucky enough to live a completely healthy life then die suddenly or die quickly and catastrophically will need more health care then they can afford. Without some sort of collective system we will end up boned at some point. There is no way around that. Since almost all of us will get old and/or have some sort of serious health problem everyone of us will have a pre-exsisting condition at some point. Without a way to share and shift costs the people with the most needs and pre-exsisting conditions won’t be able to get care.

    There was yet anotherReport

  3. Avatar greginak says:

    above response continued.

    FWLIW here is yet another study comparing our HC results to other coutries.
    http://www.businessinsider.com/best-healthcare-systems-in-the-world-2012-6?op=1

    Some sort of national level uni HC of one of three basic types works.Report

  4. Avatar NewDealer says:

    1. I ask this as a lawyer: What is his proof? Where is his evidence?

    2. I currently pay for my own insurance. I have a moderate-high deductible of 2500 per a year. My insurance still gives me one free physical a year.

    3. How do we determine what is routine? And what is not routine? Is it by result? Purpose of the initial visit? Does health insurance only kick in for surgery or major illnesses like cancer? It seems to me that many illnesses including fairly serious ones like the flu can be hand-waived as routine…

    4. We have seemed to gone beyond the point of “elections have consequences” and I am finding this highly alarming. There is a difference between reasonable opposition and just trolling. The GOP seems to have gone way past the stubborn/trolling phase.Report

    • Avatar NewDealer says:

      I will also note that study after study shows that the best care is preventative care. It seems like most of this could be hand-waived as routine. That strikes me as bad policy.

      It is mind-boggling that American conservatives are still fundamentally opposed to universal health care. This is accepted as axiomatic in the rest of the world. Why not here?Report

    • Avatar Roger says:

      ND,

      I continue to be drawn to your comments because you and I see things so differently. Our world views or paradigms are to some extent opposites. But I am sure you are a person with good intentions and a sharp wit.

      Before jumping in, I need to stress that I do not agree with mandating no option of routine care. My argument is only for allowing the choice of routine or more catastrophic care and everywhere in between. Of course, there is the difficult situation of moving after one discovers an illness. This can be handled structurally ( I designed non health insurance programs and products and ran underwriting departments for decades).

      On your question of proof. The proof of what happens when you allow people to consume unlimited quantities and qualities while others pay is not even up for debate. I don’t think any sincere economist questions the effects of this type of situation on driving prices through the stratosphere.

      The answer to your third question again relates not to what the answer is, but WHO should answer the question. In general the consumer is the best person to decide, as long as they are also paying for their decision. This aligns costs and benefits and incentives. I would choose a less expensive policy that provided coverage for large expenses and which provided incentives to pay for cost effective preventative services, but not cost ineffective ones.

      I am no fan of the GOP, but the opposition to Obamacare is not just malicious. In my opinion, after thirty years in insurance, this is exactly the type of program I would build if I wanted to destroy an already FUBAR market. See my recommendations below.

      As to why some of us reject socialized care everywhere, see my other comment below. You can’t socialize care everywhere without killing the complex adaptive creative system which is half the engine of progress in medical care. I can see the argument (selfish, but practical) that we should free ride on others’ markets. However, socialism only works when it can exploit the market creativity of those that aren’t socialists.Report

      • Avatar Kim says:

        ” killing the complex adaptive creative system which is half the engine of progress in medical care”

        I’ve yet to see any evidence offered on this. Frankly, I’m doubtful.Report

        • Avatar Morat20 says:

          From everything I’ve read, the bulk of “the complex adaptive creative system which is half the engine of progress in medical care” is known as “government grants”.

          OTOH, I can understand why it is so appealing to believe the high prices we pay compared to the rest of the civilized world are buying us something.Report

          • Avatar Kim says:

            This was my impression as well. We are JUST starting to leverage the marketplace, in terms of reducing costs (via changing how providers are paid).Report

          • Avatar Glyph says:

            I am no economist, and I am sure people will detect ideological bias herein (I believe the author is…controversial in blogland) but I believe people are thinking of analyses like these:

            http://www.nytimes.com/2006/10/05/business/05scene.html?_r=0

            If this analysis is clearly wrong or incomplete, then Roger’s (and mine) worry would be (I assume) somewhat obviated. Is it?Report

            • Avatar Morat20 says:

              This innovation-rich environment stems from the money spent on American health care and also from the richer and more competitive American universities

              Needs actual numbers there — part one is nebulous, whereas part two (universities) is well documented and flows straight from NIH grants and the like.Report

    • Avatar Brandon Berg says:

      I’ve had three different high-deductible plans, and they all covered annual check-ups. I’m not sure whether they’ve decided that this actually saves money in the long run, or do this because of regulatory requirements.Report

  5. Avatar Alex in DC says:

    Mike,
    I think you are missing the point about the value of regular check ups in terms of preventative care. Without preventative care, costs go up dramtically as minor issues become major issues before detection. Critical to the consideration of health care is the impact of illness and even bad health is on overall productivity – there are enough studies about this that I’m not going to bother to link to them. Health care, specifically preventative, health care, is to the advantage of the employer and I would argue to the community at large for productivity and economic success.
    Car insurance is not compatible. You don’t need to own a car – you certianly dont need to own the current piece of shit you happen you own. Yes in many areas its necessary to get to work, buy groceries – and that’s another conversatin – but car ownership is not a requirement. It is a luxury. You can always buy another car if you don’t bother to maintain the one you have but you can’t buy a new body or good health after things fall apart. And it’s to ten detriment of the community when a person is sick and no longer productive.Report

    • Avatar Jim Heffman says:

      The exact same thing can be said about automobile maintenance. And yet not every state requires regular inspections; and even the ones that do require automobile owners to pay for it themselves, and go to private service providers for the inspection.

      “Car insurance is not compatible. You don’t need to own a car”

      Hey, tell me more about how poor people should suffer massive inconveniences in their ability to allocate their time.Report

      • Avatar Kim says:

        A bike isn’t that much slower than a car in urban situations.Report

      • Avatar DavidTC says:

        The exact same thing can be said about automobile maintenance. And yet not every state requires regular inspections; and even the ones that do require automobile owners to pay for it themselves, and go to private service providers for the inspection.

        Except _you’re not paying for the cost of your health care_.

        You do grasp that neither the state nor car insurance companies fixes people’s cars when they drive them into the ground, right? Car insurance is a very specific kind of insurance that covers damages by external forces, not idiots who don’t change their oil. (And the state doesn’t pay for it _at all_. They don’t even provide free car ‘corpse removal service’, unlike with human corpses. You have to pay to remove your non-working car!)

        Whereas health insurance _does_ pay for the cost of people who are idiots who do not ‘change their oil’. There is no form of health insurance that only covers other people punching you in the face and breaking your nose, or poisoning you, or accidentally driving over your foot, or whatever.

        Additionally, we as society have no problems with cars failing to work, or with someone deciding a car is too expensive to repair.

        And we, as society, have _massive_ problems with people dying because people do not have enough money to pay to ‘repair’ them. Not because of the ‘cost to society’, but because they are _human beings_.Report

        • Avatar Jim Heffman says:

          “Except _you’re not paying for the cost of your health care_.”

          You’re right, although not in the way you think you are.

          If you sum up your yearly premiums, plus out-of-pocket costs for deductibles and co-pays and insured-portion-of-payments? Most *healthy* people don’t come anywhere *near* paying the cost of their health care.

          They pay far, far *beyond* it.

          People with chronic medical conditions, like diabetes, generally come close to breaking even; and that’s mostly due to planning (since they know how much they’ll have to spend, they can budget for it in healthcare spending accounts and such things.) The only people who come out ahead are the ones with serious unanticipated medical issues–and those tend to be singular events.

          In other words, accidents.

          Which is what insurance is supposed to be *for*.

          “You do grasp that neither the state nor car insurance companies fixes people’s cars when they drive them into the ground, right?”

          Yes, but when there’s an accident, the insurance pays to fix the damage to operable vehicles, pays out the market value of inoperable vehicles, and provides some degree of medical care payments (and the amount of that last is a matter of legal requirement.) Even if the accident was caused by poor or nonexistent maintenance of the vehicles involved. There is no “you didn’t get your oil changed so we don’t have to pay”.

          Which means that when there’s an *accident*, the insurance *does* pay to fix or replace your car.

          Which is what insurance is supposed to be *for*.

          “There is no form of health insurance that only covers other people punching you in the face and breaking your nose, or poisoning you, or accidentally driving over your foot, or whatever.”

          That’s hardly surprising when you consider that ACA made that kind of insurance illegal.

          “And we, as society, have _massive_ problems with people dying because people do not have enough money to pay to ‘repair’ them.”

          Let’s see your tax recepit for donations to the local charity hospital, then. Oh hey, you don’t have one? Looks like you don’t care about people dying because they don’t have enough money.Report

          • Avatar DavidTC says:

            They pay far, far *beyond* it.

            Except, of course, that wasn’t my point at all.

            For someone with health insurance, failing to maintain their own body does not directly cost them money. (At least, once you subtract the actual effort of maintaining it.) When their body fails, they do not pay for it.

            For someone with car insurance, failing to maintain their own car costs them money, period. When their car fails, they _do_ pay for it. No one is going to cover any of that.

            It might also conceivably cost the insurance company money also, but that’s a fairly uncommon circumstance.

            Which is what insurance is supposed to be *for*.

            The really odd thing is, you’re exactly right. Insurance is only supposed to be things people can’t plan for.

            Which is why having insurance for _health care_ is an incredibly fucking stupid system.

            You see, _everyone_ has medical expenses, period. This isn’t like car insurance, where you can go your entire life without costing the insurance company money.(1)

            If we actually want to cover everyone’s medical expenses, let’s just fucking cover them and stop screwing around. Have the government set cost-of-living adjusted prices, and hospitals just bill them. This current setup is complete nonsense.

            Let’s see your tax recepit for donations to the local charity hospital, then. Oh hey, you don’t have one? Looks like you don’t care about people dying because they don’t have enough money.

            Uh, I actually _have_ done the equivalent of donating to charity.

            I don’t have any insurance because they won’t sell it to me, and I pay for the goddamn absurdly inflated prices they charged me.

            Over my lifetime, I have, in fact, probably given over $30,000 in this form of ‘charity’ over-inflated bills, directly benefiting poor people who cannot pay for their health care. (And also helping asshats who are allowed to have health insurance that negotiates their hospital bills as low as possible, and yet feel like it’s _my_ fucking job to donate to charity.) Please note that’s not pretend ‘$30,000’ medical bills that insurance ‘pays’ by sending $1700, that is actually _two year’s income after taxes_.

            I’m the only person in this entire goddamn system who not only is paying for my own health care, but half of everyone else’s. (Oh, and before you talk about how healthy people pay a lot in insurance…yeah, and you’re paying to _insurance companies_ so they can swim naked in a money pit. I’m paying it to _hospitals_ so they can charge other people less.)

            More importantly, I didn’t say _I_ cared about people dying because they don’t have enough money. I said _society_ cared. Society has, in fact, passed laws to stop this.

            And, oddly, I am getting a premonition here. This is the point in conversation where the person I am talking to commonly makes a statement. A statement about whether or not society _should_ care people dying because they are too poor to heave health care.

            You could respond either way, I honestly don’t know. Really, I don’t know, so don’t be offended if you’re about to say the opposite, the odds are about 50/50. But let me let me preemptively respond if you state society should not care about poor people dying:

            Congratulations. I entirely understand your position. There is no need to discuss it. in fact, what you need to start doing is tell people that _in advance_ so that people can just skip the entire boring discussion. Tell them, right off the bat, what you think should happen with people who cannot pay their medical bills.

            1) Incidentally, _car insurance_ shouldn’t exist, either. At least, not collision. Mandated insurance is the stupidest model of covering the costs of something that ever existed. If we want that setup we should just put large fines on traffic violations and use that funding to cover the costs of repair to non-at-fault drivers. (And, of course, people could get comprehensive insurance to cover those fines and repair costs when at fault.)Report

  6. Avatar Ferry says:

    A big factor would be that the insurance industry has proven itself to be a bad actor with regards to doing everything in it’s power to prevent paying out for necessary care. Having standard health insurance coverage shift to catastrophic care would give incentive to define what qualifies as “catastrophic” upwards to avoid payout on as much as possible. Hell, if you start paying out on coverage late enough patients might die before they can incur huge expenses!Report

  7. Avatar NewDealer says:

    You have labeled yourself a progressive conservative in the past. At what point do you oppose the conservative order of things. How do you feel about the food stamp debacle?

    http://dish.andrewsullivan.com/2013/07/15/the-gop-exposed-ctd/

    At what point can we say that the GOP is merely just opposed to any program that helps the non-wealthy? Note in the link above Rod Dreher and liberal Mike Kinsley are aghast that the GOP has waged a blitzkreig against food stamps.Report

  8. Avatar Shazbot5 says:

    Car insurance companies do often reward behavior that saves them dollars in the long run. For example, Allstate has a safe driver bonus that lowers your deductible if you don’t get in an accident for such and such a period. When you are less likely to get in an accident, Allstate wins. (Allstate does not win when you get an oil change, because they do not cover you for damage to your car that comes from not changing the oil.)

    By analogy, if health insurers cover routine checkups and tests and primary care visits and visits to specialists when you have a referral from the primary, this can save the insurer money in the longrun.

    Moreover, we as a society want people to get preventative and regular care: screenings, tests, checkups, etc. By requiring insurers to cover these things, we see a societal good of a level much greater than by encouraging (or requiring or subsidizing) people to get oil changes. Covering preventative care is more like requiring seatbelts to be installed in cars.Report

    • Avatar Jim Heffman says:

      “Allstate has a safe driver bonus that lowers your deductible ”

      Actually they charge more than the market rate, and after you’ve been a customer for a few years you drop back down to market rate.Report

  9. Avatar LeeEsq says:

    Mike, as explained above, a lot of liberals are very weary of the ability of the private sector to provide quality healthcare to the bulk of the population. Health insurance companies have long histories of doing anything they can to deny care in the name of profits. If healthcare was provided on a free market basis rather than through insurance, most of us would believe that everything but the most ordinary care would be too expensive for most people. Most liberals wanted a more statist healthcare reform than the ACA but accepted the ACA as the best possible reform possible under our political system. Healthcare is an area where socialism really does work.Report

    • Avatar DavidTC says:

      Healthcare is an area where socialism really does work.

      I agree with the entirely of your post except this sentence. Mainly because the word ‘socialism’ doesn’t really apply here.

      Socialism is when the government owns or operates the means of production.

      Firstly, the US government does not own healthcare, even under the ACA. The only thing they’re actually owning is an exchange to buy health care on, which is basically the equivalent of owning the ‘market square’ where sellers set up stalls each morning to sell goods. That is certainly not ‘socialism’.

      However, let’s pretend we’re in England, where the government does own the hospitals and clinics. Or that we’re talking about the VA. It’s still not socialism.

      The thing is…the UK government is _not_ selling health care. Yes, they have a specific tax for it, but it’s a mandatory tax, not a ‘purchase’.

      The government providing health care _for free_ is no more socialism than the government providing police service for free is socialism. The government _selling_ health care would be ‘socialism’.

      Socialism is when the government owns a business, or operates as business, and buys and sells things. Or even if private individuals technically own a corporation, but the government is so much in control that it functionally owns it.

      ‘Socialism’ is not a word meaning ‘The government has decided to add a service that it provides the people for free’.

      Granted, provide _enough_ services, and goods, for free, and that’s _communism_. But socialism isn’t ‘communism-lite’. It’s a specific form of economy activity, where the government is participating in the private economy. Not when an entire section of the economy is removed from private hands which is just…normal government behavior. (How many private roads are there, a dozen in the entire country? And private mail carriers are just outright illegal.)Report

      • Avatar Kim says:

        There are multiple private roads within 5 miles of here.
        FedEx, UPS, and others carry mail. Just because 1st class mail carrying is illegal doesn’t mean others don’t do parcel post.Report

        • Avatar DavidTC says:

          There are multiple private roads within 5 miles of here.

          I obviously meant private toll roads…roads that people have constructed for others to travel on, supported by charging them for it.

          FedEx, UPS, and others carry mail. Just because 1st class mail carrying is illegal doesn’t mean others don’t do parcel post.

          No. Parcel post actually means ‘parcels sent via the post’, so by definition FedEx and UPS don’t do that. In fact, ‘Parcel Post’ is actually what the Post Office _calls_ that, or did until very recently.

          And, yes, private _mail_ carriers are illegal. Neither FedEx or UPS carry ‘mail’. They carry only ‘packages’ or ‘parcels’, depending on what you want to call them.

          mail=letters and envelopes. These are ‘mailed’.
          parcels=boxes and whatnot. These are ‘shipped’.

          The confusion arises because ‘mail’ is not only ‘letters and envelopes’, but what many people call anything travelling via the post office ‘mail’. Including parcels. So you can, indeed, ‘mail’ a parcel via the post office in common parlance. (The word that they probably should be using is ‘post’, but ‘post’ and ‘mail’ are very confused terms in English. An argument can be made for either ‘post’ or ‘mail’.)

          The fact there is some verb confusion about ‘mail’ does not mean packages sent that way are _actually_ ‘mail’, although that also is debatable. However, it’s certainly not ‘mail’ when carried by some random company instead of the post office.

          OTOH, private _mail_ isn’t illegal. Plenty of corporations have internal private mail, and it’s obviously legal for people to personally deliver letters to each other. What is illegal is a third party charging to do so, except for the specific exception of ‘couriers’ for time sensitive information.Report

  10. Avatar Roger says:

    Shaz, ND, Ferry, Lee, Alex, Kazzy and Greg

    If it is less costly to include preventative care or include an annual physical, then is in the best interest of the insurer to encourage it. Like ND, I have a high deductible policy. When I shopped for it, I remember a chart of competing plans with different catastrophic limits, allowances for routine or preventative care and prices. I chose the one that best fit my needs. note that any company that offered more preventative care and lower prices had two advantages.

    My first point is that you don’t need a law to encourage a company to do something which lowers claims. Competition would be sufficient. After all, Allstate didn’t introduce their Safe Driver Bonus due to a law, they did it to encourage safer driving (and fewer claims) and to attract and retain better customers against competitors. Another example is Deductible Rewards (aka Disappearing Deductible), where various companies reward their safest drivers with lower deductibles over time. The idea built into both of these is a win win relationship or alignment of interests and behavior between the company and the customer. Note also that both of these policy features encourage customers to treat care as a catastrophe plan more than a routine care.

    The point of a higher deductible (catastrophic care) health policy is to similarly align interests. It encourages the consumer to think wisely about how they spend money, because they pay for routine expenses, and share the cost of more serious expenses. Thus the consumer is incentivized to pursue efficiency. Failure to align interests would encourage massive waste, inefficiency and encourage rampant overuse by all the low grade “hypochondriacs” out there and all the health providers touting benefits of surgery and pills.

    I know some of you guys think health providers are a particularly evil segment of already evil capitalist pigs, and that politicians and bureaucrats would do a better job of creating and supplying health care. The better alternative is competition. The health care market is FUBAR, and misguided interference is making a bad thing even worse.

    I do not believe consumers should be forced to buy catastrophic care or forced to waive preventative care. They should be allowed to.Report

    • Avatar Kazzy says:

      Roger,

      I’m far from an expert on this, so it is possible I’m entirely wrong. Also, when I said that I would “argue against it”, I meant that I would argue any attempt to mandate it: I’d prefer people have the choice.

      One of the problems with our current health insurance system is the entanglement with employment. Odds are that the insurer I have in my 20s will be different than the one I have in my 30s and 40s and 50s and by the time I’m in my 60s and 70s, I’ll likely be on the government’s dime (provided the status quo holds). So insurers aren’t necessarily incentivized to see me as a 50-year-customer, but maybe only a 5- or 10-year-customer. So, they don’t necessarily care if I seek $10K worth of care in my 20s to avoid $50K worth of care in my 60’s; they likely won’t realize the savings but will bear all the costs.

      This entanglement is a real issue for other reasons as well and, as I’m sure you know, came about for some very unfortunate reasons. I’d rather see health insurance move more towards a free market system, where someone could presumably have the same insurer their entire life despite shifting jobs and/or locations. This would incentivize insurers to think long term and hopefully improve the system. I don’t think you could go full-blown free-market, as you’d need certain protections for consumers to avoid getting their coverage dropped as soon as they suffer a real injury or illness (e.g., insurers would be prevented from saying, “We know you paid $10K in premiums every year for the past 40 years but you have cancer now and that shit’s expensive so we’re just going to go ahead and terminate your coverage/opt not to renew.”). Exactly how you’d write laws for that, I’m not sure, but I think that sort of regulation would be necessary for a well-functioning system.

      I’m also sympathetic to the idea of having a public option. Warts and all, I look to our current schooling model as an example: You can take the free public option which has X benefits and Y drawbacks or you can buy any of these private options which have A benefits and B drawbacks (with the reality being that A>X and B<Y).

      Now… please don't agree with me… I do need to go food shopping today.Report

      • Avatar Eric Mesa says:

        I think you hit the nail on the head and that’s what sucks about that fact that we didn’t end up with a true public option. Even in countries like England or Canada you have the option to buy private insurance if you feel the public one is too slow or not up to par.Report

        • Avatar Roger says:

          I agree that we should have a universal coverage option. Here is how I have previously argued it could be structured…

          1) I would recommend exploring ways to establish catastrophic care for extremely serious and expensive medical conditions. I would allow people to opt out of this with some very onerous requirements. This would be paid for via payroll taxes unless the fool opted out.

          2) I would recommend people buy their own insurance that meets their needs for routine, non catastrophic care. I would choose a high deductible and low premiums and few frills. Others can get low deductibles, high premiums and all the frills they would like. I would allow any company to sell any policy that people will buy as long as the company is honest and has proper reserves.

          3). I would encourage experimentation with guaranteed insurability and portability, so that people would not be harmed on their routine care premiums if their health status changed.

          4). I would subsidize the poor and elderly and possibly the sickly so that they could purchase the underlying coverage policy and pay their deductibles. Catastrophe coverage would be free or cheap as they do not work much or at all.

          I would add choice, competition, experimentation and all that wherever possible, and if this doesn’t work, I would just follow Singapore’s modelReport

          • Avatar LeeEsq says:

            Why should the public, government-run program only cover the catastrophic and extremely serious? If there is a government program, it should cover the routine and non-catastrophic as well. One way you prevent illnesses from becoming castastrophic is to nip them in the bud if possible. People would get more necessary, routine care if they could do so without getting hit in the pocket book or penalized by their bosses for taking time off work to go to the doctor or take their kids to the doctor.Report

            • Avatar Roger says:

              First of all, if you read my recommendation closely, my program doesn’t just cover extreme health issues. The more destitute would also get subsidies to buy coverage for routine care.

              To the extent your logic on preventative care is correct (and in some cases it surely is and others it surely is not), this can be handled via competition and choice. Any company offering truly cost effective preventative medicine would have superior prices and benefits to one which is either too stingy or too generous.Report

      • Avatar Kim says:

        This would incentivize insurers to think long term and hopefully improve the system.

        … part of the problem is that the market on information vis insurance is pretty horrid. Know how often your insurance company has classified a miscarriage as an elective abortion (and thus not covered anything??)Report

      • Avatar Roger says:

        Sorry Kazzy, but as usual I agree with you. You are non partisan and full of common sense.

        Seems like “I agree with Kazzy” should be a programmed macro on my IPad.Report

      • Avatar Morat20 says:

        Anecdote: My father had a bone spur in one of his vertebra. It placed pressure on his spinal cord, caused random pains and numbness in his arms.

        His doctor heavily suspected that was the problem. The specialist he saw heavily suspected that was the problem. His insurance company required he undergo 6 months of ‘physical therapy’ before paying for a CAT scan.

        His therapist AND his specialist were blunt: Nothing in his case suggested physical therapy would help at ALL. But odds are, when it came time to handle his yearly benefits at work, either he or his company would select a different insurer. And six months of physical therapy was a LOT cheaper than a CAT scan that would require his insurer to pay for expensive surgery. (I won’t name the insurance company, but you’ve heard of it. It’s a rather large one)

        It took him over a year to get that CAT scan, during which his condition worsened. It was ultimately fixed, but he has permanent numb spots and reduced mobility in one hand due to it.

        Which is (1) why I don’t really trust health insurance companies to provide care (I admit, my realization that health insurance exists to make the insurers money not the policy-holders healthy doesn’t help my opinion of them) and (2) find “You have to wait for CAT scans in Canada! NO SOCIALIZED MEDICINE!” so hilarious.

        You have to wait here too. And sometimes you can’t ever — EVER — get one, no matter how much it’s needed.. In Canada, at least, they triage the stupid things.Report

        • Avatar Kim says:

          I had an insurance company fail to cover phexophenadine because it was overprescribed. This despite the fact that our allergist/PCP were willing to explain that this was medically necessary (… at the level of “do this or we’ll be recommending frequent hospitalizations” — given that involuntary hospitalization had already occurred, this seemed frighteningly plausible).

          Hospitalizations/ERvisits cost a ton more than $300/month for pills.Report

    • Avatar LeeEsq says:

      Roger, at this point can’t we just use the evidence available from other countries rather than try for some market-based solution that has never been attempted before because we are devoted to the free market or something like that.Report

      • Avatar Roger says:

        Good point, Lee. But I must build on the idea…

        First, markets have also been tried in a few million different categories, and, when properly structured tend to work amazingly well (note emphasis on “properly structured”). Thus the debate isn’t so much on markets yes or no, it is about how to properly structure them.

        Second, you are assuming the solution. Before healh care can be mandated it must be created. Markets are experimental, competitive cooperative, creative systems. In socialized countries, they borrow a solution created primarily via free market processes. Part of the experimentation is on cost efficiency. Thus the remaining free markets are doing much of the heavy lifting (though this is not necessarily true of pure research, which can operate outside of markets).

        In other words, socialized markets free ride or “exploit” the positive externalities of capitalism. That is all well and good, as long as there are still enough free markets somewhere to drive the engine of progress.

        See my recommendations above on balanced institutions which provide catastrophic care for all and which also promotes more free market creativity and efficiency.Report

        • Avatar LeeEsq says:

          I’m not buying this. I think that we have enough evidence from our own experience with Medicare to show that single-payer can work in this country. I’d even argue that the VA is a sign that we can pull of NHS if it was desirable. I’d prefer NHS over single-payer but most liberals seem to prefer Medicare for All as the solution. The problem is that doing either of these things is politically impossible but they can work.Report

          • Avatar Roger says:

            You didn’t address my objection at all. You can socialize some of the world and still free ride off the creative problem solving power of properly structured markets. This is not true though if you socialize or destroy all or almost all markets.

            In other words, you need to be real careful about killing the goose that lays the golden eggs.

            Do you understand –and agree — with how properly designed markets test and create progress? If not, we are probably talking past each other. You are assuming the solution exists.

            I seem to run into this odd assumption constantly in debates with the left. They assume progress or believe it always comes from some wise and benevolent Solon.Report

            • Avatar Kim says:

              Roger,
              Yes, dangnabit, if you’re talking to NIH folks, you’re getting the assumption of progress. Same thing with DARPA folks (reinvent the world!).

              But Manual J isn’t becoming standard because of markets. Actually, let’s use that as a starting point. How do you design a marketplace where Manual J would become standard? What are the shortcomings of our current marketplace that it hasn’t become standard without government intervention?
              I’d rather talk about homebuilding than Health Insurance, because my argument on health insurance boils down to “poor information marketplace”. And that’s bloody boring.Report

        • Avatar Kim says:

          What in particular have these markets created that the socialized countries have borrowed?

          NMRI == MRI? Branding?Report

          • Avatar Roger says:

            Take a look at what medical care existed in 1700. Take a look at lifespans and death rates.

            The twin engines of almost all progress in health care and almost every other field has been properly structured science and markets. (Note careful use of “Almost”). The fuel of course is human ingenuity.

            Your question is like fish asking what all this funny talk about “water” is. Everything in health care, from the syringes to the pencils to the pills, to the power outlets and advanced machines needs to be created, tested and combined into a reaonably efficient and effective solution set. You cannot assume what we have today. It had to be created.Report

            • Avatar Kim says:

              We don’t have people piss in a cup these days to tell if they’re diabetic. I’m pretty sure that was government research.

              I mean, if you want to talk cost savings, you can probably get into consolidating providers. That’s fair. But it’s not invention. I can’t think of much more than that, and I am actually trying. Oh, wait. Memory foam. Not that it really helped with bedsores that much, but… [I am pretty sure the tech got developed outside of grants.]Report

            • Avatar Morat20 says:

              lol. The bulk of modern health care arose from government spending.

              Trauma medicine – everything in the ambulance to the emergency room? Came from government funded research and development for battlefield medicine. Plastic surgery? Government funded research for post-battle reconstruction of debilitating injuries. Prosthetics? War. Burns? War.

              Now, drugs? Oh look, government again — the pharmaceutical companies spend the bulk of their money on marketing and changing a single molecule in an antacid to keep it under patent. The vast bulk of research seems to, again, come from government grants.Report

              • Avatar Kim says:

                re: drugs. Detailed Citations available from the US patent office.Report

              • Avatar Jim Heffman says:

                “The bulk of modern health care arose from government spending.”

                This is like saying that smartphones exist because of government spending.

                Yes, it is true that smartphones use semiconductor microprocessors, which were the result of research into improved missile-guidance systems, which were necessary to make ballistic missiles sufficiently accurate to serve as a nuclear deterrent, the need for which arose from government policy decisions. But that doesn’t mean some guys in the Pentagon back in 1950 said “you know what we need? A little glass rectangle so people can play Angry Birds on the train. R&D, get on that.”Report

              • Avatar Mike Schilling says:

                It’s true. All government could do was fund technology that allows knowledge to be collected and shared with unprecedented ease and power. It took the free market to turn that into YouTube comment pages.Report

              • Avatar Morat20 says:

                The ambulance you ride in, and the drugs and methods used by EMTs and doctors at the ER? Taken directly from pointed, goal-oriented research by the military.

                Because — get this — it turns out soldiers often get very traumatic injuries, and the military was keen on them surviving to get to a field hospital, and then surviving after getting there.

                Plastic surgery? The first reconstructions — the very FIRST plastic surgery — was done on soldiers burnt, shot, broken, or maimed in combat. Same with prosthetics. (Gulf War 2.0 gave us a LOT of advances in prosthetics and battlefield/trauma medicine, thanks to all those IEDs. All government funded).

                University research — which does the lion’s share of drug development, genetic research, therapy, and the like? Paid for by government grants, not private money.

                Government money is not only the linchpin of general medical research, but poured into practical applications.

                The proper analogy: Government built a robust smartphone. Private industry wrote angry birds to play on it, slapped on a browser, and claimed they invented the whole thing.

                Then charged you twice what people pay in other countries, and told you it was because of all the research to make the first smartphone.Report

              • Avatar Jim Heffman says:

                “Government built a robust smartphone. ”

                what

                There was no government project that develope the iPhone, unless I’m badly mistaken about the history of Apple Computer.

                “well the government did this thing that was sort of similar and so I can–” stop. That something similar to the smartphone existed at some point in the past, as part of someone’s concept, does not mean that Steve Jobs was thinking of exactly that thing when he worked out what he wanted the iPhone to be.Report

              • Avatar BlaiseP says:

                Don’t be like that. It makes you look silly, Heffman. Radio telephony began in the US military.Report

              • Avatar Kim says:

                Steve Jobs?
                try startrek.Report

              • Avatar BlaiseP says:

                It was Hedy Lamarr who gave us the basis for what would become radio telephony.Report

              • Avatar Mike Schilling says:

                Star Trek? Try Dick Tracy.Report

              • Avatar Glyph says:

                Who’s “Dick Tracy”?Report

              • Avatar Morat20 says:

                I said:
                The proper analogy: Government built a robust smartphone”

                I’m not sure what’s confusing about that sentence, or whether you just decided not to read it in favor of making some stuff up in your head, but let me spell it out for you.

                “To take your analogy about smartphones and change it to be appropriate to the reality of government involvement in the field of medicine, we would have to say the government invented a robust smartphone — pretty much the first one — albeit one aimed at purely military applications. This technology, having been created, was snapped up by the non-military marketplace wherein someone slapped a browser on it, added Angry Birds, and declared they’d invented the world’s first smartphone rather than taking a ton of military R&D, prototyping, and money and tweaking it for civilian use”.

                How you managed to miss the freaking primary clause right on front with the word ANALOGY IN IT, is beyond me.Report

              • Avatar Jim Heffman says:

                The point is that it’s stupid to use “the government built a smartphone” as your analogy, because someone actually DID build smartphones and it WASN’T the government.

                I didn’t bring up smartphones as an analogy, I brought them up as an ACTUAL THING.Report

              • Avatar Morat20 says:

                It was your analogy.Report

              • Avatar greginak says:

                I”m not quite following your argument Jim. Let me plug in my Garmin GPS to see if that can help me follow your thoughts on gov funded research and how it has benefited us.Report

              • Avatar Jim Heffman says:

                “pharmaceutical companies spend the bulk of their money on marketing and changing a single molecule in an antacid to keep it under patent.”

                Yes, many of the successful drug-development efforts (with “successful” defined as “you can go buy it from the pharmacy”) involve minor tweaks like this.

                This is because major drug-development research very often ends up going nowhere at all. And what *does* have successful results is generally downchecked by the FDA because it isn’t better than what’s already available.

                Government- or university-sponsored research into basic chemistry does not constitute “making new drugs”. Very often they discover an interesting chemical interaction that possibly has some pharmaceutical benefit…once someone figures out how to deal with nasty side effects like shutting down the autonomous nervous system, or attacking bone marrow more vigorously than cancer cells, or causing such severe phlebitis that the patient gets gangrene.Report

              • Avatar Kim says:

                we’re out of chemicals, anyhow. Anybody smart is moving R&D out of America… or lobbying to do more biotech.Report

              • Avatar Roger says:

                Morat,

                First, note my carefully chosen words. There are major two engines of progress — science and markets. You argue that government can be a source of funding for science. I do not dispute this, though I am skeptical of how important it is or should best be overall. Let’s just agree though and move on… Governments can act as a middle man to contribute our tax dollars toward scientific research. A lot of the real advance in health care comes from science and foundational knowledge of biochemistry and anatomy.

                The other major role governments can play is as a major consumer. They can represent millions of soldiers. Or they can purchase/ negotiate Medicare for millions of consumers. Again the government is acting as a middle man, representing consumers and purchasing from market based producers of health care solutions.

                Once the government becomes the sole consumer, and also uses coercion to manage the production, you basically have fascism on its way to full blown socialism. The track record on both is pretty embarrassing.Report

              • Avatar Chris says:

                There are major two engines of progress — science and markets.

                One wonders how these things came about, then.Report

              • Avatar Roger says:

                I would be glad to elaborate or share my ideas if you are really interested. Seriously.

                I find the topic to be the most interesting subject in the world. To understand progress, one must first have a reasonable definition and a workable framework for the term. Interestingly I find that few do.

                And that is a shame, wouldn’t you say?Report

              • Avatar Chris says:

                Sure, I’d love to hear it. I know going in that I’m going to disagree, but that doesn’t mean it won’t make me think.Report

              • Avatar Kazzy says:

                “To understand progress, one must first have a reasonable definition and a workable framework for the term.”

                Going even further, must we not identify and articulate our goals? Otherwise, progressing towards what exactly?Report

              • Avatar Roger says:

                Once again. I agree, Kazzy. And since we have multiple goals and some contradict each other, progress can be quite tricky to say the least.Report

              • Avatar Kazzy says:

                Whenevr I get into conversations about how we can fix education, be it in my classroom or nationwide, I always ask, “What are we trying to accomplish?” This throws far too many people for loop.Report

              • Avatar Mike Schilling says:

                You left out religion.

                Seriously, there has been a spate of books written recently “proving” that the West leads in science and technology because Christianity (or Protestantism, depending on the author) uniquely fosters the idea of immutable natural laws, which is the basis of the scientific method. And I believe this every bit as much as I believe that the key to continued scientific progress is to trust its future to deep, long-term thinkers like hedge fund managers.Report

              • Avatar BlaiseP says:

                Oh, Mike, you poor deluded sap. Everything is easy. Haven’t your managers told you as much, dozens of times? And yet you persist in your error-prone ways, continuing to believe reality can’t always be mated with theory as neatly as you have been told — by people who know better.Report

              • Avatar Roger says:

                I agree with you on this Mike. These have little to do with progress. Science and liberalism did not emerge out of Christianity.Report

    • Avatar Kim says:

      Roger,
      I consider death by spreadsheet to be evil.
      I know folks who have written code that actively discriminates against HIV positive folks.
      These are not hypotheticals.Report

    • Roger,

      I often see things very differently from the way you do, and I’m not sure I agree with everything you say here (assuming, of course, I understand what you’re saying, which I might not be). Perhaps my (probable) disagreement is that I’m not sure that in the U.S., with all its veto points and with the way the insurance market is presently structured (with the vested, rent-seeking interests in it), is susceptible to the “proper structuring” that would be necessary. So, alas, I’m prepared to make the structure worse, with richer people having to pay more and maybe some people getting worse care than before, in order to spread the wealth, when it comes to access to affordable health care.

      That which I’m supposedly willing to accept (making the already FUBAR market even more FUBAR), of course, I would find less acceptable if/when I’m the one who has to pay the higher prices or get worse health care.

      Still, you’re rocking this thread and your comments are very provocative.Report

      • Avatar Roger says:

        I am not pretending my vision is currently politically feasible. I believe the first step in moving in the right direction is to establish a foundation which recognizes what the right direction may be and how we may begin moving slowly and experimentally in that (or those) direction(s). Compromises may be necessary along with millions of baby steps and course corrections.

        I would be happy to leave better health care for our descendants, and I would prefer not to exploit anyone while doing so. I believe well functioning markets are a necessary ingredient for the future.Report

  11. Avatar dhex says:

    the issue is one of semantic confusion – health insurance, despite having the word “insurance” right there, is not like other kinds of insurance.

    whether this confusion is intentional or not is for others to contend over.Report

    • Avatar Mo says:

      This is true. Health insurance is really a health payment plan.Report

    • The evidence suggests that it was unintentional. An IRS ruling just after WWII established that providing health insurance did not count as taxable compensation.

      After that, it was off to the races. Employers realized that they could provide more and more real compensation by growing health insurance bigger and bigger — because any new dollar that was going to health insurance didn’t get taxed, and any new dollar that was going to the paycheck did.

      Think of it this way: If employers didn’t have to pay taxes when they bought us groceries, a lot more employers would pay our salaries in part with groceries. Those groceries wouldn’t be of our choosing, they’d be too expensive, they’d quite often be terrible (and the portions would be HUGE!), and we’d have no effective way to complain.

      That’s what our health care system is.Report

      • Avatar NewDealer says:

        As Lee pointed out above, some variant of socialized healthcare works in almost every other country. And I think you are too honest for the typical right-wing propaganda that these people come to the U.S. for secret medical service and/or that it will be a step on the road to tyranny*.

        It seems to me that on healthcare, the US is following the Winston Churchill School of American Observation. “Americans will do the right thing, after trying everything else first.”
        For once in my life, I would like this not to be the case especially on a grave and serious issue. Of course “right thing” is subjective.

        *I’ve always been deeply curious about the psychology of how elements of the right-wing use freedom to usually mean business stuff and nothing else. I don’t think you are part of this group.Report

        • Avatar dhex says:

          sadly i had a whole post laying out why things are as they are but it got eaten, so i’ll attempt to pith it – the flipside of the grocery store metaphor, from a consumer pov, is that everyone wants the best and most expensive cuts, but doesn’t want to pay for them and likely couldn’t pay for them were things more like the grey market apple cart down the street.

          no one really knows what the aca will mean in practice beyond providers and docs will get less money and larger provider systems will become insurance companies or at least partner for managed care solutions to close the money drain and offset the (presumed) lubeless date night planned for them as re-admission rates get squeezed. oh and customer service and concierge styling will now be a big deal as part of your payouts will be based upon hcahps scores.

          we’ll see more boutique but reasonable concierge programs targeted at yunguns like the one medical group/mymd efforts in nyc and other large cities. this is actually a good thing for the under 35 crowd, by and large.

          docs are going to be largely unhappy, due to a mismatch between expectations and reality. ever see a room full of people go through the five stages of grief unsynchronized? (you likely have, being a law school grad) specialists in particular. providers are unhappy. insurance companies are going to be unhappy-ish, but they’re already regarded as hitlersatan so who cares about them.

          the expectation is that the insurance exchanges will do virtually nothing to control provider costs due to health insurance not being insurance (as mentioned above) and not being portable. nor will it do much for everyone else’s costs.

          everyone will be further tied to their employers, so yay i guess.

          i do not see the flow of foreign self-payers to major institutions in america stopping anytime soon. also they’re now going to be prime recruitment fodder – even more than they are now – because they pay up front, there’s no battles with insurance companies, and they spring for private rooms and private duty nurses, etc, while using a lot of high end care.

          i know a few docs who were convinced the aca was designed to fail to make way for medicare expansion. i think they’re paranoid, but likely right. much like “get the gubmint out of my medicare” is delightfully oversimplified, the “single payer will fix everything” people are also delightfully simple. again, everyone wants the choicest cuts, but no one wants to pay for it.

          i know a few research docs who are convinced this will slow the rate of medical breakthroughs, etc. i am less concerned about that, but it is possible.

          the good news is that targeted healthcare marketing will be more valuable than ever before. that’s mostly good news for me, though.Report

          • Avatar Kim says:

            There’s a ton of waste on billing. Singlepayer fixes a lot of that.

            “the expectation is that the insurance exchanges will do virtually nothing to control provider costs due to health insurance not being insurance”

            … umm, bullshit. What we’re seeing now is health insurance learning how to control readmits (okay, they’re slow, but they are actually doing it!). This is how it works: the person who doesn’t see his PCP within a week of getting out of the hospital? He gets on a list, and folks start calling him (reminding him to take medicine, getting him an appointment). It saves on readmits.

            This is current tech, not some future fairytale.
            My workplace has implemented this.

            Health care consolidation was coming with or without ACA (though ACA will speed it up).

            Electronic Health Records will improve care, and minimize costs.Report

            • Avatar dhex says:

              what’s going to control readmits for individual providers, ultimately, is learning to find the right kind of patient in a way that doesn’t get them boned by the feds. the dude with fixable problems but not too many (or preferably none at all) nonfixable issues. all the diabeetus people can go find another provider doorstep to darken, etc.

              all the reminders are cute and all that but also cost money (those pte/fte positions and/or vendors ain’t gonna pay for themselves) that wasn’t being spent by a lot of places. should they see savings down the line? probably? it will not be a stunning victory for the most part. it’s definitely best practices, and smart practices have been doing it for years, but there’s no magic bullet against people who have mountain dew’d themselves into shitblivion.

              and consumer costs, well…yeeeaaaaaaaaah.

              insurance companies have been shaving on re-admits for years, and especially for anything related to an extended stay. a way of doing this from a single payer pov would be like when medicare payout rates were regionalized in the middle of the last decade. which is pretty hilarious but, again, everyone wants filet mignon on a chuck budget, and that’s one way to do it.

              consolidation was coming, probably. this will definitely speed it.Report

              • Avatar dhex says:

                anyway, even shorter version: i would love employer decoupling and actual cross country free market exchanges. i would also love a unicorn, mostly because you could kill other horses with it and i’m kind of afraid of horses.

                obamacare will do nothing to address my crippling eqinophobia, btw.Report

              • Avatar Kim says:

                2/3rds of people kill themselves, on a “take this pill at x time or you’ll die” monthlong experiment.

                If hospitals get caught “trying to find the right patient” they’ll get burned just as badly as insurance companies do when they screw over HIV positive patients.Report

              • Avatar dhex says:

                well obviously you do it so you don’t get caught.

                they’re gonna get boned if the guy with a chronic condition gets cleared for a knee replacement and picks up an infection or messes up the implant, even if it’s not their fault. or only partially their fault. etc. so why not game the system as much as possible? it’s not like medicare is particularly generous – nyc hospital gets paid the same as a hospital near canada, despite having vastly different costs and patient bases to deal with.

                so in short something something something gordon gecko something something.Report

              • Avatar Kim says:

                I think better treatments (specifically ones that require less expensive care) are going to pay off more than “finding the right patient.” For now, at any rate [does the knee replacement need to be done in a hospital? Can we have a “clean clinic” for those sorts of surgeries (where you aren’t breathing hospital air?)]Report

              • Avatar dhex says:

                both would pay off, as they’re related strategies – keeping costs down while maximizing revenue.Report

        • Avatar Mike Schilling says:

          I’ve always been deeply curious about the psychology of how elements of the right-wing use freedom to usually mean business stuff and nothing else.

          That’s ridiculous. It means guns too.Report

        • “It seems to me that on healthcare, the US is following the Winston Churchill School of American Observation. ‘Americans will do the right thing, after trying everything else first.’ For once in my life, I would like this not to be the case especially on a grave and serious issue. Of course “right thing” is subjective”

          If we assume the right thing is government-sponsored universal health care, then maybe it would be nice if the U.S. finally did it. I’d support it.

          But the reason Americans “do not do the right thing” hasn’t much to do with Americans’ depravity or whatever can be peculiarly laid at the mantle of “Americans” I think much of what has happened has to do with federalism, veto points in the political system, regional norms and practices, the large geographic size and population, and just plain old accidents and unexpected consequences from history.

          I know that wasn’t exactly the spirit of you comment, but I think it’s healthy to keep these points in mind as points that are at least debatable.Report

      • Avatar Chris says:

        Add that sometimes you’d pick up your food and find that, even though you have an employer-based food program, you have to pay for it because the grocery store has denied your food claim.Report

  12. Avatar Kim says:

    Mike,
    “Catastrophic” insurance would be something I’d support…
    if ANYONE ever bothered having enough on hand to deal
    with their other catastrophic insurance problems.

    A responsible homeowner has at least $10,000 in the bank,
    reserved for emergencies related to the house. He also does not
    allow furnaces/ac’s/roofs to go beyond the normal expiration date.

    How many folks do you know who do this?

    Catastrophic medical care (where it isn’t just a high deductible —
    $2000 or so is payable) doesn’t work for people who can’t budget.

    And that’s most people. The guy with Angina doesn’t hit the
    hospital until he’s got a heart attack. And that’s $50,000 minimum.

    And, you know what? if he’s on catastrophic medical care, well…
    He’s probably not going to pay the $500 it costs to get a
    nurse to remind him to take his pills. And then he’s back in the hospital
    again.Report

  13. Avatar Kim says:

    ALSO: Catastrophic medical care is also known as “affordable for the poor” …
    at least to people who actually think about things.

    Thing is? The poor are going to walk into the hospital with a virulent melanoma
    that they could have gotten excised while it was still benign. They’re going to walk
    in with their feet rotting off (where some decent preventative care might have saved the foot).

    How do I know this? I know people who haven’t been able to afford decent medical care (in college, yes?). A guy who never went to see the doctor when his hands and feet had suffered multiple broken bones. A guy who worked an 8 hour shift on an ankle that got so bad they had to cut the boot off by the end. A guy who didn’t get cavities fixed, and eventually needed to have teeth extracted. A guy performing home surgery on himself (removing a toenail embedded in his toe).Report

    • Avatar Kim says:

      One more: getting a bit of allergy medication prevents mandatory hospitalization with assisted breathing.Report

    • Avatar Morat20 says:

      Pro tip: ” removing a toenail embedded in his toe” — don’t do this. It always just makes it worse.Report

      • Avatar Kim says:

        It needed removal to drain the pus. The doc looked at it later and said he probably couldn’t have done a better job.

        I tend to advise against home surgery on yourself. Even if you have read the relevant Army Manuals from Vietnam.Report

        • Avatar Morat20 says:

          I’m prone to ingrown toenails. I know both the urge to “fix it myself” and the results.

          Ingrown near the tip of the toe? Doable. Ingrown at the base? GO SEE YOUR PODIATRIST. Suck it up, it’s two fairly painful injections then it’s clean sailing.Report

          • Avatar Kim says:

            … oh, this wasn’t ingrown. Or at least that wasn’t the proximate issue. The proximate issue was having an oxygen tank dropped on the toe, with subsequent breakage of toenail, and then walking on it for a couple of days (driving it deeper into the toe).

            (are those injections the kind with adrenalin in them?)Report

            • Avatar Morat20 says:

              Nah, standard nerve block with..I dunno, lidocaine? Never asked. You get two, top and bottom at the base of the toe on whatever side it’s ingrown in. Maybe four, but I think just two. Been awhile.

              It’s painful insofar as, you know, feet are sensitive, the contents burn as they go in, and they rock the needle back and forth to cover the whole nerve while injecting. (At least that’s my highly layman’s version, based on what the doc has told me and what it felt like).

              Then they wait 10 minutes, drape your foot (most people really don’t want to see) and go at your toe with what would make excellent torture implements. Slice a line down the nail on the ingrown edge, scrape it from from the skin, and then remove it all the way to the root.

              If there’s an infection, they drain it, dig out any bits of nail left in it, and then wrap it. Give you some soaking instructions, antibiotics to apply (generally just a few drops topically after soaking and cleaning), and you come back a week or two later to have the nailbed killed if you’re prone to it reoccuring. (Which requires another set of injections, but the stuff to kill the nailbed can’t be done if there’s an infection for reasons I’ve never been clear on. It’s apparently a Bad Idea).

              They only kill the outside edge, so your toenail isn’t quite so wide and so doesn’t get pressed into your foot.Report

              • Avatar Kim says:

                The lidocaine shots they use for dental surgery (cavities etc) have adrenalin in them…Report

              • Avatar Morat20 says:

                Do they? I don’t generally ask beyond “Will this make it not hurt” and “Oh dear God, what is that thing, why does it have all those spikes?”

                Having just had a lost filling replaced, I would like to note that modern dentistry is barbaric and basically still in 1890 with slightly better tools and far better anesthetics.

                I look forward to the day when dentists have options beyond, effectively, “cut out the rot and slap a prosthetic on there”.Report

              • Avatar Morat20 says:

                Not to badmouth dentists. They do fabulous jobs, and teeth don’t exactly heal. It’s just that dental tech really hasn’t advanced like the rest of medicine, which is I think a statement about the difficulty of dentistry and the unusual nature of teeth than a slam on dentists.

                That cold plasma stuff looks awesome — in human trials, last I heard — and there’s been encouraging news on both enamel regrowth and flat-out stem-cell fueled tooth regrowth (whole tooth or that pulply middle mess of nerves stuff).Report

              • Avatar Kim says:

                Yup. If you look around, you can generally find someone who does laser surgery, which doesn’t require anesthesia Or drills.Report

  14. Avatar Francis says:

    By analogy, if you skip a few oil changes and your engine seizes up, you can throw the car away. Your heart seizes up, by contrast, and you’re dead or very expensively sick.

    To be more accurate, you’re asking a version of the question: What is the rate at which people (largely poor) will decline needed medical services when charged co-pays? Alternatively, What is the adverse health effect of high-deductible insurance policies?

    Oddly enough, when I typed “effect of co-pays on medical care” and “adverse health effect of high-deductible insurance policies” into Google, long lists of articles popped up. So, instead of using intuition — which for all of us is a terrible idea — why not do some research and get back to us?Report

  15. Well, the comparison between cars and human bodies is a bit strained. A person can live a perfectly happy (if somewhat more inconvenient) life without a functioning car, whereas a happy life with a poorly-functioning body is a much taller order.

    And Mr. Cuccinelli seems to be begging the question a bit. Intended by whom? And why does original intention have to dictate what something may change to accomplish?

    In point of fact, I don’t actually have a terrible time imagining a reformed system where preventive care was subsidized for those who lack the ability to pay, and everyone else paid out of pocket until they reached a threshold, at which time automatic subsidized healthcare would kick in. However, that supposes that people would take seriously their need for preventive care and would shoulder the costs themselves, rather than ignoring it and then ending up with preventable calamities that might have been obviated by regular check-ups. (Strokes because years of hypertension were missed, let’s say, or heart attacks because they never got their cholesterol monitored.) Whether or not this system would save money or just toss more people in the catastrophic coverage pool is not an answer I’m qualified to give.Report

  16. Avatar Tod Kelly says:

    I can’t answer for the left, but I’ll answer as a guy who’s set up health plans:

    Health insurance isn’t the same as car insurance. It uses completely different mechanisms. Comparing the two is something pundits who don’t know about insurance do. For example, it’s ridiculous to talk about car maintenance vs. body maintenance, because car insurance doesn’t pay for when your car inevitably breaks down. Why is it worth an insurance company’s bother to pay for your oil changes if your engine wears out because you didn’t change the oil? They won’t have to pay you a dime.

    I thought one of the side benefits of HRCC’s passing was that I was never going to have hear dopey “But car insurance…” lines again.Report

    • Avatar Jaybird says:

      I was always under the impression that insurance was a bet with a bookie. I bet that such-and-such was going to happen to me. The bookie would look at his actuarial table and bet that it wouldn’t. Rates were vaguely related to the actuarial tables (in real time, if possible) and, as such, the house would always win… but, hey, variance right? Variance is why you’d make the bet in the first place.

      If Health Insurance doesn’t work like this, I don’t see how the bookie can stay solvent.Report

      • Avatar BlaiseP says:

        Not really. Insurance arose alongside venture capitalism.Report

      • Avatar greginak says:

        Unless you are lucky enough to be killed quickly and almost instantly everybody will need significant HC as some point. Most of us will at several points. It’s not a bet, it’s an almost certainty, unless you have one of those cool blimp accidents or something where you go out in a burst of flames.Report

        • Avatar Jaybird says:

          I’m not talking about what *I* need. I’m talking about the solvency of the bookie.Report

          • Avatar BlaiseP says:

            The bookie is a terrible comparison. Every bookie has backers with deeper pockets than his own. He’s paying reinsurance to the mobsters. A numbers racket is quite profitable: the bookie’s backers won’t kill him if the bookie has to occasionally pay out on a large-ish bet. That keeps the whales coming back to lose their money.

            Here’s the problem: the actuarial tables in health insurance are all rigged in ways a bookie couldn’t get away with, not for a second. Anyone can look at the Vegas line to work out the terms of their sports bets. But with health insurance, these weasels will tell you to your face, wringing their hands, “Oh, it’s just you, I can’t give you odds on you getting sick. Maybe on a thousand people I could but since it’s just you, I have to charge you six times more than I would for someone in a life pool of a thousand.” And that’s exactly the difference, Jaybird. Health insurance in the USA is a goddamn racket, an unregulated banking system where these fucks expect a monthly deposit and will determine if and when they’ll ever pay out on the “bet”, which isn’t a bet at all. Actuaries aren’t bookies.Report

          • Avatar greginak says:

            Hmmm i wonder if any counties have managed to find a way to pay for all our inevitable healthcare problems. I’d really wonder how they manage that, if it were actually possible to do that. I’d guess that countries with solid mixed free market economies could probably generate enough wealth to pay for HC along with using some some cost controls. But then again i like sci fi. We’ll certainly be flying personal jet packs before anything like that happens.Report

            • Avatar BlaiseP says:

              From what I’ve seen, most of a person’s medical expenses are incurred in the last two weeks of life.Report

              • Avatar greginak says:

                Yes that is often true. Chronic illnesses often cost big time over the long term as due the care most elderly people need especially if their health is poor.Report

              • Avatar Jaybird says:

                Surely opium would be cheaper.

                Is this one of those things where there are enough folks who get treatment and then bounce back for a year or three in decent health to make it important for everybody involved to invest this much?

                If that’s not the case, this is downright immoral.Report

              • Avatar greginak says:

                Its both. The docs, with my approval, kept my mom high on morphine in the last couple days of her life. She had terminal cancer and nothing could be done, so we agreed good drugs were best. It’s hard to figure with old folks whether more treatment will lead to a bit more good life or just more and more treatment and pain.Report

              • Avatar BlaiseP says:

                As the end nears, the figuring becomes easier. Signing a Do Not Resuscitate Order will cut out most of the worst of it.Report

              • Avatar dhex says:

                sorry to hear about your mother greginak.

                radiolab has a very good piece on this issue:
                http://www.radiolab.org/blogs/radiolab-blog/2013/jan/15/bitter-end/

                i’ve never met a doc with a no code tat personally but i wouldn’t be too surprised.Report

              • Avatar BlaiseP says:

                It is immoral, after a fashion. Remember that little idiot Sarah Palin talking about Death Panels? They do exist, you know. Everyone’s who’s been party to the wrenching decisions surrounding the end of life for a loved one knows they exist. They’re held in bleak hospital conference rooms. There’s a box of tissues in the middle of the table and they’re used. Doctors, nursing staff, family members, everyone in that room is weighing someone’s life in the balances.

                I wish I could take Sarah Palin by the hair and pull her into one of those conference rooms and nail her hands to the table and make her sit through what I went through, what a good many people here have been through. There are worse things than dying. Dying, ecch, everyone has to die. But suffering? Suffering’s a different story. When I lost my Dad, all I felt was relief and it bothered me greatly. I’d done my grieving already.Report

              • Avatar greginak says:

                Yup..both my parents died of cancer so by the time they died, it was a lot of relief and release of pain. More of the same with my wifes grandmother, her body was mostly okay but she had so much dementia she was always confused, upset, paranoid and rattled. Life was no longer good and she wasn’t even herself.Report

              • Avatar BlaiseP says:

                It really is confusing, though. Why am I not weeping? Tell you when I did go to pieces though: when my Mom and I were going through his chest of drawers. Holding his pairs of socks in my hand, putting them into a bag. My Mom wanted me to have them.

                Every time I hear one of these GOP bastards rattling away about Obamacare I feel the urge to murder him. I really do. Obamacare is only a good first step. It needs work, lots of work. But if we’re ever to reduce suffering and cure disease and generally act like a respectable nation which gives a shit about its citizens, the GOP are not helping matters at all.Report

      • Avatar Roger says:

        Jaybird,

        Oddly, you seem to be assuming objective utility.

        Insurance is spending money to reduce risk. If you do not need to reduce risk, you can save the money by not buying it. In general it is a win win. I get less risk and reduce the chance of catastrophic loss in exchange for premium paid. Both our positions are improved.Report

      • Avatar Morat20 says:

        Health insurance is, well, like a mortgage.

        A bank with a decent actuary, some historical data, and a large enough client pool can tell you exactly what rate to charge customers so the bank always makes a steady profit. It doesn’t matter that some borrowers end up defaulting — again, decent actuary.

        So health insurance basically says “This is how much money, on average, we will spend per year per patient”. The bigger and more diverse the pool, the better the prediction. So if they need a billion dollars a year to cover their patients, they charge a billion dollars a year split over their patients, plus a little extra. Easy-peasy.

        Problem comes in, of course, is there’s a zillion ways to game the system. Starting with not covering people for life — so you have an incentive to cover them when they’re healthy and young, and to kick them off when they get sick or old. (Of course, an old sick man was once a healthy young man — so your healthy young years are subsidizing your own sick, old years — but health insurance in America is year-to-year, not lifetime).

        Or, quite common, charge them for insurance and then when they get sick, find a reason to deny them coverage or kick them off. Years of premiums, no actual expenditures.

        In the end, health insurance is straightfoward to price. It’s nothing different than any other actuarial problem, and all the stuff about underlying conditions and obesity and the like don’t really matter in the aggregate.

        The problems arise because we, as a society, refuse to deny health care — especially emergency care — on the basis of lack of funds, which causes some seriously perverse incentives (especially given who picks up the tab). We also refuse to actually admit that, and pretend it’s somehow cheaper to wait until they’re dying to pay for it.

        Add in a profit motive, and it creates really perverse incentives. Offer coverage to those who don’t need it. Deny it to those who do.

        Health insurance is very, very simple — if your goal is paying for the necessary healthcare needs of a society. It is very complex, very expensive, and very easily gamed if your goal is to sell health insurance but not provide health care.Report

        • Avatar Roger says:

          Morat,

          These are all easy-peasy solutions in a reasonably well functioning free market.

          I would not buy a contract (such as life insurance) which allowed the company to cancel it for any reason such as my getting sick or one year closer to old age. I would not buy a nursing care policy which contractually allowed the company to cancel it when I turned 80. Similarly I would not buy health insurance which contractually allowed the company to cancel after I got sick.

          Policy is not set on extreme hyperbolic anecdotes. The trick is frankly getting old. The left distorts companies as evil beasts (often based upon incentives they created despite warnings to the contrary) so they can step in and socialize the thing for the power of their master planning bosses. Humanity suffers, politicians get laid. Lather rinse repeat.Report

          • Avatar Morat20 says:

            I can’t determine if you’re not actually an American, or have never actually sought insurance on the individual market, or if you’re so blinded by idealogy you’re immune to facts.

            Guess what? Recession is illegal. They did it anyways. Over and over and over. Denial of care – they slow walked people into the grave, rather than cover it. lawsuits are useless once you’re dead. “You wouldn’t buy” — Roger, you don’t have a CHOICE. It’s not like, pre-ACA, there were “good” individual polices and scams and people just naturally flocked to the latter out of stupidity.

            “I wouldn’t buy a policy that X” means “I don’t have coverage at all”. Enjoy your medical bankruptcy, like god knows how many tens of thousands of other Americans this year. Or dying of cancer while your insurance argues each and every treatment, until you die and they bill your heirs — because the last thing they want is to treat you, because god forbid that’d cost them money.Report

            • Avatar LeeEsq says:

              One big difference between health insurance and car insurance is that car insurance companies are relatively sure that people are going to do everything they can to avoid accidents. Probably. Health insurance companies know that people get sick even if they do everything possible to stay healthy. In order to make money they have to find a way to collect premiums while providing minimal coverage or ideally no coverage.Report

              • Avatar Kim says:

                This is just dunderheaded. The actual problem is that too many Americans are just too poor to afford properly priced insurance.

                People do a LOT to make sure they don’t have to go to the doctor.Report

              • Avatar Roger says:

                Consider life insurance as an alternative model.

                Lee, health insurance companies do not have to collect premiums and deny coverage to make money. If they are doing so, there is either a problem with the contracts or the enforcement of contracts.

                No market, let alone insurance market, is perfect. However deliberate abuse is probably rare even in the messed up health insurance. Presenting this as the norm is a pretty extreme accusation. At a minimum it requires solid, non anecdotal, statistical evidence.Report

              • Avatar Kim says:

                http://consumerist.com/2007/09/24/blue-cross-blue-shield-calls-miscarriage-elective-abortion-denies-claim/

                Callcenter’s claiming that this is standard.

                n.b.: not trying to say that all insurance abuse customers. Perhaps all private insurance companies (aka not through employers)… maybe I could substantiate that, with their tendency to take money and only deny coverage once you’ve got a problem.Report

              • Avatar LeeEsq says:

                The abuses of health insurance companies are well-documented and have been so for years.

                Roger, again I ask this question. Why are you so focused on a free market solution to healthcare? We know what works based on our programs like the VA, Medicare, and Medicaid and what other countries do. Why not just scale Medicare up to cover everybody and allow the purchase of supplmental insurance or free market purchase of things like cosmetic surgery. Whats with this obsession with having a free market solution just because we are America and thats what we do?Report

              • Avatar Morat20 says:

                Every time I’ve asked that question — “Why should we go with an utter free market approach to a problem that screams of problems (like the fact that we don’t run credit checks at the ER) with a free market approach, rather than try one of the dozen or so other systems used world wide that deliver superior results for half the price or less”

                I get basically three responses. “No they don’t! CANADA HAS WAITING TIMES”. “Americans are too fat for that to work”. “America is different”.

                That’s the three trains of thought I routinely encounter. All of them are pretty lame, so I can’t imagine that’s the real driver.Report

              • Avatar Kim says:

                Roger’s given another one: “they’re freeloading off of us”
                (which I’d be more inclined to grant if someone would tell me something that the freemarket did, and not our research labs — my example: memory foam, failed horribly)Report

              • Avatar LeeEsq says:

                Its capitalism as religious doctrine rather than as an economic system.Report

              • Avatar LeeEsq says:

                Another one I encounter is that America can’t do what other countries do with healthcare because than we won’t be America. We need our own system even if its really crappy.Report

              • Avatar Chris says:

                The responses I see are these:

                1) Those systems are really worse, despite objective data to the contrary.
                2) Those systems only work because the population is so ethnically homogenous.
                3) Our system is necessary for those systems to function as well as they do, because our system produces medical innovations and there’s don.t

                (1) and (3) are false, and (2) requires causal and empirical explanations that are rarely provided, and never seen provided at any level of sophistication.Report

              • Avatar Roger says:

                Morat,

                I am clearly suggesting a mixed approach which includes universal coverage with market elements. Absent that, like I said, I am good with Singapore’s proven model.

                I completely support your right to join a British or French or whatever style plan with anyone else feeling it is a good idea. As long as you allow me to opt out and try my system with those preferring it. Let’s see how they perform and evolve. My guess is we can learn things, good and bad from both. Then let’s let people choose which model they go to.

                Agreed?Report

              • Avatar Morat20 says:

                You mean like the ACA?

                You do realize Singapore’s system has compulsory savings, right? From payroll deductions.

                Their setup is, basically, compulsory Medicare-For-All with a scaling co-pay and deductible (to prevent over utilization).

                It’s less free market than the ACA. Perhaps you meant the German system?Report

              • Avatar Roger says:

                Chris,

                Just to clarify, the argument is that socialized systems free ride off the creative problem solving ability of markets. Not just markets in the US. When there are no more markets, then it will be up to bureaucrats to discover costs, innovate on efficiency and technology and allocate scarce resources.

                I do agree that much of progress in health care comes about via scientific knowledge, which does not require markets, just science.

                You cannot convince me that bureaucrats would perform better at allocating resources than reasonable markets, and I cannot convince you of the opposite. In the end rhetoric doesn’t matter though. Reality does all the sums for us. Let’s try both and see how they do. It is a big country.Report

              • Avatar Roger says:

                Morat,

                Yes. My above recommendation is much more extreme than Obamacare as well. It would provide universal coverage with opt outs and consumer choice, and markets for non-catastrophic care for those that can afford it.

                As I have said several times before, Obamacare takes perverse markets and makes them even more perverse. It is a really, really silly way to fix health care insurance.Report

              • Avatar Chris says:

                Roger, I’m probably not much more of a fan of bureaucrats than you are, but I am a fan of the way in which socialized systems allocate their resources. It’s not perfect, but it’s better than any market-based system, both in terms of efficiency and quality of outcomes.

                And I do not think that those socialized systems are parasitic on the innovations of market-based systems, in large part because the bulk of the innovation in medicine takes place outside of the market, even in the U.S. It’s true that the final stages of bringing these innovations to the public is in large part carried out by market entities (namely, pharmaceutical companies), but a big part of why they are necessary, and why those final stages cost so much, is that the incentives of those companies in a market, and the purpose of having those innovations in the first place, are so completely misaligned.Report

              • Avatar LeeEsq says:

                Chris, 2 isn’t even true any more. The countries with socialized healthcare might have been relatively ethnically homogeneous when they created their system but they aren’t anymore. The systems still work fine. Most European countries always had minority populations as well, the Jews and the Roma. The dynamics weren’t quite the same as they were in the United States but even in the most liberal countries, both minorities were viewed as kind of being strangers.Report

              • Avatar Roger says:

                Really good comment, Chris. Thanks for sharing your perspective, it does influence my view on the topic. You and Morat have both stressed the importance of science and general knowledge to health care. I agree with this.Report

              • Avatar Morat20 says:

                Roger: You are aware that the ACA represented an attempt to adopt US conservative health-care approaches?

                The liberal model a public option (Medicare-for-All), or something akin to the German model (which shares a lot with the Singapore model).

                In short, the ACA may be a “silly way” to handle health insurance, but you can flat out blame free market enthusiasts for that.Report

            • Avatar Roger says:

              I am an American who has bought insurance his whole adult life and has designed, underwritten and priced somewhere well north of ten million policies. I may no longer be one of the foremost experts on insurance, but certainly I am worthy of discussing it with you, no?

              My point, with all due respect, is that in a properly functioning market nobody would ever buy a contract which allowed a company to take the premium and run. I am well aware that health insurance is not a properly functioning market. I can share with you how it could become one, if you are interested.

              It does not include disingenuously accusing all companies of routinely cancelling coverage for the sick. I am sure some company at some time cancelled a policy unfairly. The proper remedy is of course legal action with penalties for contractual violation.

              I am also well aware that there are disputes over what is and is not covered. Fraud is rampant and in some cases even organized on the consumer side. Companies need to be skeptical of claims as failure to do so penalizes all other customers in higher premiums. However Companies have been known to take this to an extreme, and again there are well known remedies for this behavior in properly functioning markets, which is my recommendation.

              Morat, please drop the hyperbolic every company screws every customer every time it can shtick. You know it isn’t anywhere close to the truth, and if not, I am wasting my time by chatting with you.Report

              • Avatar Kim says:

                “Fraud is rampant and in some cases even organized on the consumer side. ”

                … what do you call it when the company encourages and publicizes the need for fraud???

                I mean, seriously, everyone knows that if you have a preexisting condition, you can’t get private health insurance. What they don’t tell you, is that lying on the forms means that the company takes all your money and won’t treat you anyway.

                I continue to maintain that the health insurance industry suffers from an information deficit that may or may not be easy to fix. (I think it’s difficult, but at least its better than contracting!)Report

          • Avatar LeeEsq says:

            Roger, these are all easy-peasy solutions with single-payer to and we have evidence that single-payer works. We have this evidence in the United States, we call it medicare. People on medicare seem to really like it and get pissy when any changes to it are announced. We have no evidence that your free market solution would work. Why can’t we do what we know works?Report

          • “I would not buy a contract (such as life insurance) which allowed the company to cancel it for any reason such as my getting sick or one year closer to old age. I would not buy a nursing care policy which contractually allowed the company to cancel it when I turned 80. Similarly I would not buy health insurance which contractually allowed the company to cancel after I got sick.”

            With due respect for the point you made just after the one I quoted above (the warning against making policy based on anecdotes), I think the fear is that under pre-ACA system, the policies that non-sophisticated purchasers of health insurance on the “open” market* had were in practice contracts where the company could (or at least would, with little process for less-than-costly appeal) abrogate its agreement.

            Maybe that fear was more informed by anecdotes than by what actually did or could happen. But I do think much of the maligning of health insurers and much of the clamor for the types of reform that the ACA tries to accomplish comes from a sense that the non-sophisticated customer has little ability to understand beforehand what will be covered and how quickly, and so they want something where those terms are prescribed by law in a way that presumably prevents the insurer from abrogating its responsibilities. Whether the prescriptions work as their supporters suppose they do, or whether they make things worse in other ways, are of course discussable questions.

            *I realize, of course, that the pre-ACA system was what it was in part due to government intervention, or at least the set of incentives the government had created. Therefore, it wasn’t purely open, and I don’t mean to bait your ideas as suggesting a whole-hog return to the pre-ACA days as if there was nothing wrong with them.Report

            • Avatar Roger says:

              I agree in many ways, Pierre.

              Certainly there have been abuses. We are talking the real world here. At some time or another some companies have done bad things.

              Certainly people are greatly confused and widely misinformed on such a complex topic.

              And certainly those who could gain by discrediting the insurers are incentivized to spread half truths of terror: “Do not trust them. They are evil. All they do is try to make a profit by selling policies and denying claims. Instead trust me.” (despite the fact they just lied through their teeth).

              I trust neither. I trust competition and transparent, well functioning markets. I suggest we create them.Report

              • Avatar BlaiseP says:

                Were you interested in such things, you would be singing a very different tune. I can tell you, straight up, without the slightest hint of irony, not one health insurance firm in this nation can be trusted. You have an unhappy tendency to call people liars, people who have no reason to lie to you. I’ve been at this problem through five franchises of Blue Cross / Blue Shield and the central Association. I don’t think they’re evil: they paid my invoices. But they didn’t pay the claimants before they’d found every excuse not to pay. They’re not so much immoral as amoral. They don’t pay because they don’t have to pay. They fuck with physicians and drive them crazy. They fuck with hospitals and drive them crazy. They fuck with patients and drive them crazy, too.

                The market hasn’t fixed this problem and it won’t, not while the insurance giants have anything to say about it. And they do. They’re the most powerful lobby in Washington DC, far and away. I’m not telling you anything you don’t know. They’re beyond regulation.Report

              • Roger,

                Thanks for your response. I should say that I have mistrust of markets more because I tend to suspect they’re fragile. But I confess that I have only a vague understanding of them.Report

    • Avatar Jim Heffman says:

      “I thought one of the side benefits of HRCC’s passing was that I was never going to have hear dopey “But car insurance…” lines again.”

      Which is kind of funny, because the ACA solution to the problem of people not having health insurance was to make it illegal to not have health insurance, which is the same solution that states found the problem of people not having car insurance.Report

    • Avatar Roger says:

      Tod,

      Your comment is of course correct in many respects. There is a degree of contextual jujitsu on the car insurance/ car maintenance thing. A better example is minor covered scratches or window repairs. Of course the window chip argument doesn’t work for this politician though because most companies have indeed found it is wiser to pay for small cracks proactively before they turn into major windshield replacements. Miracle of miracle, markets actually discovered this absent government mandate.Report

      • Avatar Kim says:

        I’m just really, really unclear about what counts as “minor problems”

        I mean, really. Is it eye doctor appointments? Is it Flu Shots? How about blood tests? Sprained ankles? Broken ankles? Broken noses? Allergy shots?Report

        • Avatar LeeEsq says:

          Thats another reason why having “routine” car being paid for out of pocket is a really bad idea. What gets defined as routine. To me, routine is simply the annual physical or the twice a year cleaning at your dentist or the annual eye exam. Others might have a more extensive defintion of routine.Report

  17. Avatar Creon Critic says:

    Here’s one disconnect I see. The left and liberals tend to take the idea that health care is a human right very seriously. So I’d tend to agree with the way one human rights convention puts it, “recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. Libertarians and conservatives have a less expansive view of economic and social rights, may not even recognize them or frame them as rights at all, and are far less willing to mobilize the state in ensuring adequate provision of these rights.

    For the left, it easily follows that the car insurance comparison and catastrophic care only proposals are inapt and insufficient. Access to routine health care being linked to you’re ability to do anything else you want to do in life (unlike car insurance), and the out of pocket expense being a clear barrier to access to this right. An obstacle to care that can be easily done away with, with an obvious solution being shifting the costs (and perhaps more importantly the risks) to entities that can shoulder the burden.Report

    • Avatar Kim says:

      I’m not even going that far. I’m just really skeptical that removing allergy tests/shots is going to help fix health care in this country.Report

    • Avatar BlaiseP says:

      If I may be allowed to restate the Liberal case in somewhat less simplistic terms, we view health care not so much as a right but as a statistical problem best solved by including everyone in the Life Pool. The agency of government can maximise the life pool, thus exposing actual risk according to the Law of Large Numbers.

      Insofar as routine health care can be shown to save money over time, it’s worth the investment. A stitch in time saves nine, etc. American Liberals acknowledge all this will cost money — we’re not Communists, demanding the State take over health care. We also acknowledge certain members of the life pool will consume far more of those dollars than others: people with ongoing conditions, the mentally-ill, autistic children and the like. Health care is a finite resource and health care dollars even more so.

      But the current system is doing a wretched job of allocating those resources. The health insurance industry, my neck of the woods, where I’ve done a decade of consulting, is horribly inefficient. Market pressures don’t apply to them: they do everything in their power to avoid paying claims and they’re a powerful lobby in Washington. Many of the rulesets I’ve built over time do nothing but find excuses for not paying claims.

      There is a middle way here, one the Conservatives and some of the more reasonable Libertarians might find useful: find a way to apply market pressure to this problem by exposing these insurance firms to meaningful actuarial data. That would push them all in the right direction. Get the employers out of the health insurance racket. They have no business in there: they’re all being played for suckers anyway and they’re not happy about this state of affairs, either.

      Liberals don’t view health care as a human right so much as we believe the problem has not succumbed to market forces.Report

      • Avatar Kim says:

        “Liberals don’t view health care as a human right so much as we believe the problem has not succumbed to market forces.”
        … which doesn’t mean you can’t build a better mousetrap. We liberals are just skeptical.Report

        • Avatar BlaiseP says:

          Huh? A better mousetrap? Are you going to improve on the Law of Large Numbers? Every bookie in the nation knows the line on Green Bay Packers at San Francisco. But nobody can tell you how much it will cost to perform a routine non-perforated appendectomy. Tell you who can give you prices on procedures: plastic surgeons, because their procedures aren’t covered by insurance. A breast aug costs about 6500 USD. Out of pocket.

          We know how to fix this. We’ve known since the Renaissance how to calculate odds. All we need is the data and we won’t get it because the health insurers jealously guard their own data as trade secrets.Report

      • Avatar Creon Critic says:

        BlaiseP,

        Insofar as routine health care can be shown to save money over time, it’s worth the investment.

        I don’t know that I’d put it in return on investment terms. What’s the return on investment in having eye care and glasses if and when you need them? The elderly’s ability to read fine print or a student’s ability to see the blackboard – how do you quantify that? And how to you quantify intervention in a timely manner? I suppose quality adjusted life years is one method (note, I do not do public health professionally, so there may be some really obvious quant measure I’m just unaware of). But I don’t see the root reason as ROI based, and inasmuch as the Democratic Party represents the left and liberal position, various state platforms articulate the human rights based approach to health care and health care policy.

        Altogether, it is probably six of one, half a dozen of the other. To me the ROI thing is just icing on the cake, but it isn’t the core of the reasoning. And I’m confident the further leftwards you go on the spectrum, the consequentialist-utilitarian arguments do less of the work than the human rights social justice based arguments.Report

        • Avatar BlaiseP says:

          I do see your point. But improved vision is demonstrably cost-efficient: can’t read things without glasses. Of course, you could get someone else to read for you — which wastes other people’s time — and time is money. Nobody’s time is free. It’s not much different than cost justification for corporate spending on technology or facilities.

          Mostly, I’m talking about the inverse problem: exposing true costs. A non-perforated appendectomy might get complicated in surgery, I don’t propose to put fixed costs on every procedure. Here’s where it gets interesting: physicians and hospitals know the system is fucked up. Their prices are all over the map because their receivables are long: they don’t know how much they will be paid for a given procedure. Or when. Or even IF.

          The overhead costs for clerical assistants is mind-boggling: every insurance firm has different codes — you might as well be speaking Swahili to Aetna and Mandarin to Blue Cross. Just standardising the process of getting paid will massively reduce overhead. There’s a useful initiative called HIPAA, which was supposed to make insurance portable. It’s been sorta-successful in some ways and something of a botch in others. Believe me when I say physicians and hospitals have dozens of ways of reducing overhead and improving quality of care. As a society, we’re not listening to them. Their voices are being drowned out by the health insurance racket, arguably the most-profitable industry in America today.

          Let’s all put aside these nebulous and unhelpful concepts about Rights for the moment. The most right-wing Congressman wouldn’t give up his excellent health care coverage without a fight. Your mileage may vary but from what I’ve seen, the consequentialist/utilitarian argument is found right across the political spectrum. We’re spending more on health care and by every measure, we’re not getting better results. The one voice we’re not hearing in this debate, the most important voice of all — is the front line physician. I’ve talked to dozens of these physicians, they’re deeply angry with the current state of affairs. They will tell you anecdotes which will curl your hair and turn it grey overnight.Report

  18. Avatar Jesse Ewiak says:

    On a side note. Hey, look everybody, see what happens when a state actually tries to implement a policy instead of trying to destroy it!

    http://www.nytimes.com/2013/07/17/health/health-plan-cost-for-new-yorkers-set-to-fall-50.html?src=twr

    “Individuals buying health insurance on their own will see their premiums tumble next year in New York State as changes under the federal health care law take effect, state officials are to announce on Wednesday.

    State insurance regulators say they have approved rates for 2014 that are at least 50 percent lower on average than those currently available in New York. Beginning in October, individuals in New York City who now pay $1,000 a month or more for coverage will be able to shop for health insurance for as little as $308 monthly. With federal subsidies, the cost will be even lower.”Report