Our Health Care “System”

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Will Truman

Will Truman is the Editor-in-Chief of Ordinary Times. He is also on Twitter.

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  1. Avatar NewDealer
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    I don’t think I could afford insurance if it cost me 1600 a month. Well I could but almost all of my post-tax income would go towards insurance and rent. I’d need to unhook cable, cancel my weekend times subscription, and such to have some extra spending money for things like groceries.

    Right now my insurance costs 255 dollars a month and has a 2500 dollar deductible but I do get a free physical every year. This ends in December because Aetna decided to stop offering individual plans in California because of Obamacare. They are deciding not to participate in a market (aka the exchanges)!!!!! This should rankle conservatives and libertarians. Though we seem to live in an age where partisan points are more important.

    The best health insurance I’ve had post-school was a health savings account called Healthy SF. This is an SF mandate and generally covers people who do not get health insurance like restaurant workers and long-term temps. So I was able to get refunded for my medical expenses even stuff that I was previously uncovered for like health insurance.Report

    • Avatar NewDealer in reply to NewDealer
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      Dental work rather.Report

    • Avatar Brandon Berg in reply to NewDealer
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      It does rankle us. We just don’t blame Aetna for its response to the fished-up incentives that the government created.Report

      • Avatar NewDealer in reply to Brandon Berg
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        Brandon,

        This is the bit where libertarians seem more pro-business than pro-market. The insurance companies preferred to operate in the dark and not compete with each other.

        The exchange forces competition by creating a one-stop shop for consumers who can compare and contrast coverage. Deciding to pull out of this just shows that the companies do not want a market.Report

      • Avatar Will Truman in reply to Brandon Berg
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        This would be a better point if transparency were the only change. But the exchanges told them how to run their businesses, what plans and services they had to offer, how they had to price offerings, and so on. It’s not anti-market or unmarket at all to say “We don’t want to enter the market under those conditions.”Report

      • Avatar Brandon Berg in reply to Brandon Berg
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        I’m on my phone, so it’s too much of a pain to look up the link for that video of Mandy Patinkin saying the line, but you know the drill.

        The exchanges are not just the government enforcing transparency and creating a one-stop shop where you can compare options. That already exists—ehealthinsurance.com, for example.

        The exchanges are heavily regulated in ways that distort the market and pick winners and losers. If a company chooses not to be a part of it, they’re not doing it to spite you. They’re doing it because they don’t think it’s a good investment.

        Specifically, they and other companies are citing concerns that the rate caps in combination with the coverage mandates will not allow them to operate in certain states without losing money.

        One of the key characteristics of a market economy is that prices and the quality of goods offered for sale are determined by supply and demand, not by government fiat.

        Since you clearly don’t know yourself, maybe you should stop lecturing us on what it means to be pro-market.Report

      • Avatar Shazbot3 in reply to Brandon Berg
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        Is there a real health care or health insurance market anywhere (or at any time in the last 50 years) in the developed world.

        By the standards BB proposes, the answer is “no, there hasn’t been.” And why not? Because it would be crazy and hurtful and really unjust.

        NB: The Singaporean system has lots of governmental interference. Indeed, it might not be Constitutional because if the government can force you to save money for healthcare, it can force you to buy brocoli.Report

      • Avatar Kim in reply to Brandon Berg
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        Will,
        it is when you write the bloody rules yourself, and then pitch a hissy fit when they don’t help you make enough profit.Report

  2. Avatar Angela
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    This was not my experience.

    In the past, I had insurance that covered well baby care, and my sister did not. Our kids were about a year apart in age, so we were going to the same pediatrician for the same type of care. Even though she paid cash at time of service, and they had to deal with paperwork and 6+ months of delay from me for a smaller amount, they wouldn’t give her a break on the price. Calling around to other pediatricians in the area was also not productive: We couldn’t find anyone that would give a cheaper cash price.

    There were (are) clinics that will give charity care, but they’re not dealing with insurance at all, so I don’t thing that’s a comparable situation. They also didn’t deal with a long-term doctor / patient relationship.

    Just recently, in the family, we had an accident that required facial surgery. The surgeon said that these were the prices, he wanted payment up front (credit card or cash), and we had to deal with the insurance company. When the reimbursement was much lower ($6600 vs $1735), we have to pay the difference.

    YMMV.Report

    • Avatar Will Truman in reply to Angela
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      For the record, I was not talking about charity clinics (community health centers). Obviously they will give you discounts as well, but that’s a niche.Report

    • Avatar zic in reply to Angela
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      One of the strange things about the whole health care debate leading up to passage of ACA was the vastly different systems in different states, compounded by different practices by different hospitals/offices/clinics.

      Everybody was talking based on their experiences, which often had nothing to do with the experiences of the next person.

      YMMV indeed.Report

  3. Avatar Francis
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    Among other problems, the cash system doesn’t (a) scale or (b) work for people with chronic conditions or (c) work for really expensive problems. It also requires people to actually have the cash and the time and ability to negotiate effectively.

    But all those things aside, it’s a great system and one that’s widely in use around the world.

    Of course, most people find that list of problems so significant that they want an insurer between them and their medical provider’s financial team.Report

    • Avatar Jim Heffman in reply to Francis
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      Why would you need insurance for a chronic condition?

      I don’t expect State Farm to pay for my oil changes.Report

      • Avatar Will Truman in reply to Jim Heffman
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        You can replace a car easier than you can replace a bad spine.

        I get what you’re saying (what we call insurance is often just “pay for my health care”)… but a key component of insurance is unpredictability. You’re insuring against the expense of having a chronic condition.

        (Errr, though this does assume that you buy insurance prior to getting the chronic condition.)Report

      • Avatar BlaiseP in reply to Jim Heffman
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        Chronic conditions have to be viewed in perspective.

        Obesity leads to all sorts of chronic conditions. What’s the proper course of treatment for Type II diabetes in obese juveniles? Insulin? Or making them lose weight?

        Heart disease and stroke cost us something over 400 billion USD per year. Diabetes, about half of that, about 200 billion USD per year. Most of it completely preventable.

        At some point, we have to quit acting as if these diseases are something we can Treat, with pills and injections. While America gets fatter and fatter, the bills for chronic disease are going up and up, yes, including spinal problems, since these obeasts are confined to wheelchairs and can’t even stand upright a good many of them. Most of this stuff is completely preventable. Until that issue is addressed, chronic health care costs are moot.Report

      • Avatar NoPublic in reply to Jim Heffman
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        BlaiseP

        And constructive language like “obeasts” is just how you want to motivate them.
        Fat shaming is just as valid and effective as slut shaming. Which is to say not at all.
        I’d name you appropriately, but it would violate the commenting policy here.Report

  4. Avatar LeeEsq
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    There are some services that are simply best produced by the government rather than the market. I think that we have ample evidence that the various government provided forms of healthcare, from NHS to single-payer to the Bismarckian system, work a lot better than our system. They are cheaper and provide an overall better quality of care for the majority of people.Report

    • Avatar j r in reply to LeeEsq
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      Those single-payer systems may work better than our system, but as Will pointed out our system is the worst of both worlds. Would a single-payer system outperform an actual functioning free market system? I suspect we will never know.Report

      • Avatar zic in reply to j r
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        Would a single-payer system outperform an actual functioning free market system?

        You’ll have to define what you mean by ‘free market system’ here; one that’s well regulated or one that’s actually free; where insurers get to boot people off when they get sick, etc. (this was happening until ACA passed in the state’s without regulation preventing it).

        And since insurance is mostly provided by employers and so is non-taxed income, there was never a free market; there was a tax-payer subsidy; one I’m well familiar with since I’ve mostly purchased my own due to being self-employed. I cannot thing of a bigger disincentive to entrepreneurs the health insurance costs.Report

      • Avatar LeeEsq in reply to j r
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        Why should we embrace on a free market experiment when we have dozens of proven systems that work to choose from?Report

      • Avatar James K in reply to j r
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        @leeesq Two reasons:
        1) If no one ever tries anything new, no improvements to out existing policy structure are possible. Democracy and secular republics were once dangerous untested ideas, someone has to go first, if we are to progress.

        2) I have no confidence the US government can run something like this properly. I suspect whenever the government denies someone funding for a medical procedure it will become a massive political issue until the government backs down.Report

      • Avatar LeeEsq in reply to j r
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        James K, we run Medicare, which is basically single payer for senior citizen well. There is no reason to think that it can’t be expanded to include everybody.Report

      • Avatar Will Truman in reply to j r
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        LeeEsq: According to the chart here, our government spends more on health care for the elderly than other countries do on their entire population.Report

      • Avatar LeeEsq in reply to j r
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        Will, Medicare doesn’t have the price negotiation powers that other universal healthcare providers do. We also have a lot more elderly people and people in general. Medicare still spends less than the private sector does and gets good results.Report

      • Avatar Will Truman in reply to j r
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        Lee, Medicare and Medicaid can afford to go on the cheap in part because private insurers and individuals pick up the tab. So in addition to the increased leverage, we’d also have less flexibility from doctors and hospitals. And the leverage would be far from absolute, because many would retire or shift to private practice if the alternative were payments less than they get from Medicare now. Not to mention that many of the mercenary docs would make up for lost per-service fees by upping the procedures.

        I’m not saying that these are problems that can’t be fixed. But it’s far from obvious that the government would actually be able to do so in a way that proves to be cheaper than Medicare is now.Report

      • Avatar Kim in reply to j r
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        our “actual functioning free market system” did just fine for years upon years.
        Republicans, Libertarians, fix the fucking problems and we can go back to how we used to do it.

        FIRE in the hole!Report

    • Avatar BlaiseP in reply to LeeEsq
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      If there’s to be any Bismarckian Health Care Sausage prepared, the simplest and most obvious scheme would be to have a market solution with a healthy dollop of socialism thrown in.

      Here’s the Socialist Bit: health care providers are issued something akin to a VISA merchant account. Ordinary people have a health care card tied into a Federated Identity Management scheme. Both cards are required to create a health care transaction. As with VISA or Mastercard or any other banking system of that sort, we’d have the usual problems with fraud, — but if this was done correctly, as we now manage it with credit and debit cards, this part we’d understand.

      A health care provider could have his claims for payment denied and his certs revoked. Medicare is being routinely defrauded because they aren’t running their payment schemes properly, see above. Patient data is part of the federated identity system, managed securely — again, using protocols banks and financial outfits have long since established. Leverage the market based systems for all they’re worth: it really is money moving through these pipes. Getting data from my physician in New Orleans to my physician in Eau Claire should be a matter for those two physicians, with me involved to swipe my card and grant permission.

      Insurers would love it, too. Betcha everyone reading this comment has a VISA card in his pocket, at least a debit card. We don’t think of VISA as a single payer system — but it is.Report

    • Avatar Michael Adams in reply to LeeEsq
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      Well, the statist systems do NOT work as well as ours, much less better. The NHS, for example, cuts off most care at age fifty five. Yes, there are exceptions, like hip replacements, which enough people need to make the noise of refusing them unbearably loud. More esoteric care, second runs of chemotherapy for cancer, neonatal intensive care, just do not exist where the government picks up the tab. The bleat is always heard about their life expectancy and infant mortality rates, compared to ours. The difference is in how they do their statistics, especially in infant mortality. The rest of the world does not count a baby as born alive until he or she has survived outside the womb for a period of days or weeks. Since some babies do die in those first few days, a country that counts every baby who tries to draw a breath as alive will have a lower AVERAGE length of life.

      The comparisons of cancer and MI survival rates show that the US system is vastly superior. This is why most of the world’s people who can afford to do so, bring their sick to these shores. Ninety five percent of the world’s new drugs and treatments are produced in five US hospitals.Our semi-free market allows innovators to recoup their research and development costs here, making us the engine that pulls the world’s medical train.

      I realize that many very nice people have an innocent, even child like faith in government, but, at least in health care, the data do not support the dogma.Report

      • Avatar BlaiseP in reply to Michael Adams
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        That’s not always true, though sometimes it is. Here’s a case in point: the single most profitable operation is a quadruple heart bypass surgery. The Steak Eater’s Operation. It’s always covered by insurance. It requires a large surgical theatre for the heart-lung machine. Because it’s so profitable, many US hospitals built them, so many that Canada now sends its cardiac surgery cases down to the USA because of the overcapacity built into the US system.

        But loads of Americans go to Costa Rica for surgery. Here’s the deal: some guy needs a hip replacement. He’s too old to be covered by employer health insurance and too young for Medicare. So instead of going down the road, he goes to Costa Rica and spends four grand for the operation. Everyone speaks English in the hospitals, it’s a booming business. Lots of Americans retire to Costa Rica these days, it’s positively infested with American blue hairs living like kings for a pittance, with friendly, handsome people to wipe their asses and push their wheelchairs.Report

      • Avatar LeeEsq in reply to Michael Adams
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        This is bull, this is pure bull. Like BlaiseP pointed out above and the NYT times explored recently, there is a lot of overcharing in our system. Surgeries that cost a few thousand elsewhere cost tens of thousands in the United States.

        There is absolutely no evidence that your accusations about NHS are correct. If they were true than we would have a lot information about it because the life expetency rate in the UK would be much lower.Report

      • Avatar Jaybird in reply to Michael Adams
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        Control for class/caste. I wonder what the numbers look like.Report

      • Avatar LeeEsq in reply to Michael Adams
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        I think that Godwin needs to be extended into liberal/libertarian conversations. If the liberal accuses libertarians of “FYIGM”, the liberal looses the debate. If the libertarian uses the word statist or a synonym than the libertarian looses the debate.Report

      • Avatar BlaiseP in reply to Michael Adams
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        All comparisons to any other nation’s health care system fall flat. Wish everyone would quit trying these apples and oranges match ups. USA’s problem is obvious: we got into the employer-provided health insurance paradigm during WW2, when it was the only route to giving workers a raise in an era where wages were fixed by law — and we’ve never been able to get ourselves unwrapped from around that axle.

        Anything is better than what we’ve got now. I’m serious.Report

      • Avatar Will Truman in reply to Michael Adams
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        Despite my skepticism of how well single payer would work in the US, I do agree with the last two sentences right there.Report

      • Avatar greginak in reply to Michael Adams
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        Michael- Do you have any proof of those claims? They sound like the kind of “Stephen Hawkings would never have been kept alive in a NHS style system” level of claim. Are you claiming every uni care system does that? Are you just wishing away every bit of data that doesn’t show the US as being the bestest?Report

      • Avatar Mike Schilling in reply to Michael Adams
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        I’d probably cut off neonatal care for people over 55 too.Report

      • Avatar zic in reply to Michael Adams
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        Our semi-free market allows innovators to recoup their research and development costs here, making us the engine that pulls the world’s medical train.

        And the other side of that coin is that we pay a premium to be the guinea-pig test population for all those drugs.Report

  5. Avatar Scott Fields
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    Will –

    “And I did the things that people say people don’t or can’t do.”

    I really don’t think antibiotic prescriptions and mole removal are the procedures that spring to mind when people claim the medical market is inelastic. Share a story of a person with first degree burns or heart failure passing on medical attention because the price is too high, then you can make this claim.Report

    • Avatar Will Truman in reply to Scott Fields
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      Perhaps not, but I have seen the idea mocked that people can our would call clinics to price check because of the lack of transparency. They don’t even know how much they charge, and all that. Which is actually true, to an extent. It can sometimes be difficult to get prices. But it can be done and people do it.

      I certainly agree that it’s a different story with emergency care. Most health care isn’t emergency care, though.Report

      • Avatar zic in reply to Will Truman
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        I researched this pretty hard about a decade ago.

        Yes, most clinics do not know the price of a service. They have negotiated prices with the plethora of insurers they work with. The actual cost per service exists somewhere; but it’s often not available. In VT, they have to post those fees and make them available; I don’t know of any other state that requires this.

        Fees can vary wildly, and what they include will vary based on the facilities billing/accounting practices. Some places will include a slice of all overhead, from janitorial services to heat. Others won’t. It’s a freakin’ nightmare.

        I just heard a piece on NPR on doctor’s refusing to do circumcisions at a hospital in Alaska; the hospital was charing nearly $3,000 for a procedure they charged about $700 for (numbers from memory, not precise), and a nearby hospital only charged a few hundred for.

        The cost of a procedure, say having a mole removed, may reflect a plethora of things; the new MRI machine in Radiology, the benefits package for the new Chief of Staff. They do not, rest assured, reflect the actual cost for actually removing the mole.Report

      • Avatar Will Truman in reply to Will Truman
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        I have never been able to not get a price. Sometimes they have to call me back, but if the doctor doesn’t know (and the doctor rarely will) then the front desk does. If they don’t know, then Financial does. If it’s the difference between them scheduling something, or not scheduling something, they’ll find out.

        You’re right that there is a disconnect between how much it costs a service to provide and how much they charge the patient. That’s not actually all that unusual across industries. The fluctuations do seem larger, though.

        I meant to mention this in the post, but without price checking, we paid $437 for a bunch of medications that, had we gone to Walmart, would have cost $150 or so. I doubt that the pharmacy we went to (a national chain) paid the supplier 3x more than did Walmart.Report

    • Avatar Brandon Berg in reply to Scott Fields
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      Share a story of a person with first degree burns or heart failure passing on medical attention because the price is too high

      First-degree burns don’t require medical attention, and heart failure is a chronic condition, but I understand what you’re trying to say.

      It’s true that with medical emergencies you can’t really shop around. But antimarketeers often want to jump from this to the claim that shopping around is simply not a viable strategy for controlling health care costs. I don’t know the exact numbers, but I guarantee you that a large majority of medical spending is for non-emergent care. Preventive care, cancer, neurological diseases, diabetes, chronic circulatory conditions, etc. In the emergency column, there are heart attacks and strokes, plus some comparatively rare things like trauma, poisoning, and the occasional dangerous acute infection, and even these often involve a lot of non-emergent follow-up care.Report

      • Avatar Brandon Berg in reply to Brandon Berg
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        A better argument against price shopping as a way to control medical costs is that people won’t do price-shopping for expensive chronic conditions because even with high deductibles, price is irrelevant for anything over the out-of-pocket limit.

        I think what might make sense is having the consumer’s out-of-pocket payment be an uncapped logarithmic function of the actual costs. That way consumers still have some skin in the game even for very expensive treatments.Report

      • Avatar BlaiseP in reply to Brandon Berg
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        I have the definitive argument for price shopping. I’m sitting in a basement in rural Wisconsin, running someone else’s business while he’s on vacation. Most of the people transported are repeat clients. WWCares saves the state of Wisconsin tons of money which would otherwise be spent on nursing home care. Better outcomes all round, people get to stay in their homes, I’ve got six vans moving around the area, one on the way to Rochester MN.

        The billing for all this is preposterous. Medicare, private pay, WWCares, there’s also MTM in the mix, I spend as much or more time managing the billing as anything else. It’s the main reason I’m here. Private pay is trivial. And this is non-emergency transport, wheelchair, drug addicts going to treatment and counselling, there’s not a whole lot of money in this but it’s a logistical nightmare, keeping ahead of all this paperwork.

        It’s tough enough just dealing with the various paying entities we’ve got here. Private insurance would only complicate things: it’s literally not worth the trouble to get integrated with more paying entities, only to have them futz around and pay me if and when they’re good and ready — and God alone knows how much they’re going to pay. It’s a clusterfugg of colossal proportions. Obviously, there’s no way to compete for these runs. I’d love to just throw some of these unprofitable runs (we’re only billing for loaded miles) to another outfit. Noooo, I have to throw them back to the dispatching entity like MTM or WWCares. Conversely, not thirty seconds ago, as I was writing this comment, I just got a harried call from MTM asking if I could take a run — and I can’t do it.

        When the health care market will support price shopping, then we’ll be on the way to saving everyone money and time and every other sort of efficiency will come into play. The current situation is Kafka-esque.Report

      • Avatar LeeEsq in reply to Brandon Berg
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        Brandon, I also think that most people won’t do price shopping because people believe that they are not in a position to judge what treatment is effective or not and tend to defer to experts, usually their doctor or the specialist recommended to them by their doctor.

        If your going out to buy an expensive good, lets say really nice furniture, you tend to know what you want and you could do comparison shopping at different stores. In NYC, you can go to Barneys, ABC, Bloomingdales, and a host of high end stores and compare and contrast. Nobody is going to stop you. Insurance puts limits on this by restricting what doctors they cover and through deductibles for services. When you combine this with the fact that most people aren’t going to know a lot about the most effective treatment for various ailments than you create disencentives for cost comparrison. Most people just want to get better.Report

      • Avatar Scott Fields in reply to Brandon Berg
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        Brandon –

        Thank you for the charitable reading – I was thinking 3rd degree burns and heart attack when I dashed that comment off.

        And I concede that most medical spending is for non-emergent care. But even with non-emergent care, there are issues with transparency and inelasticity.

        Even when the customer is able to accurately determine pricing, there are significant gaps in information that undermine the consumer’s capacity to influence the transaction. If a doctor says those half dozen tests are needed for an accurate diagnosis, how many patients would accept the risk to say otherwise? One could shop for a TV with some confidence that you could judge the quality of the product versus the price, but could one do the same with a dialysis machine, even if you were so inclined to accept the risk of possibly buying an inferior machine?

        And wouldn’t it be fair to say that for pricing to truly have an impact on demand in medicine, customers would have to be willing to do more than just shop around for the best price, but also forgo the purchase if all prices were too high? It may be possible to imagine a cancer patient choosing hospice care over treatment, but it flies in the face of human nature to think the number choosing that route would be meaningful to the market.

        I would agree that there are areas in medicine where the market could be brought to bear in order to better control costs. Will is absolutely right that we have the worst of both worlds in our “system” and we could undoubtedly design something better if we started from scratch. That said, there are components of health care – assymetrical expertise, inelasticity, moral considerations – that make broad market solutions untenable.Report

      • Avatar Will Truman in reply to Brandon Berg
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        Ultimately, we cannot have a real free market system unless we are willing to let people die of fixable things because they don’t have money and/or mismanage their money. Other government intervention flows from the fact that we’re not willing to do that.

        Having said that, there are elements of the market that we can (and, in my opinion, should) implement. Whether pricing for services is one of them or not is an open question.Report

      • Avatar BlaiseP in reply to Brandon Berg
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        The rise in the cost of health care is demonstrably tied to price opacity. It’s gone ape in the absence of meaningful price information.Report

      • Avatar BlaiseP in reply to Brandon Berg
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        As for dying of Fixable Things, Maimonides said

        Galen, in the third section of his book, The Use of the Limbs, says correctly that it would be in vain to expect to see living beings formed of the blood of menstruous women and the semen virile, who will not die, will never feel pain, or will move perpetually, or will shine like the sun. This dictum of Galen is part of the following more general proposition:–Whatever is formed of any matter receives the most perfect form possible in that species of matter: in each individual case the defects are in accordance with the defects of that individual matter. The best and most perfect being that can be formed of the blood and the semen is the species of man, for as far as man’s nature is known, he is living, reasonable, and mortal. It is therefore impossible that man should be free from this species of evil.

        Everyone will die in his own way. Medicine doesn’t Fix People, well, with some aspects of genetic medicine coming into view, that’s debatable. People fix themselves — with proper treatment, I’ll grant you. I mean to say the human body heals itself.

        Saying we’ll die of Fixable Things — yes, I understand what you’re intending to say here. Currently, people spend more on the last two weeks of life than the rest of their lives together. It’s ghastly and painful. Nobody’s going to put me on a respirator when I’m old and feeble. Waking up with that intubation tube down my throat, it’s like that Face Hugger in the Alien movies. Revolting. Whatever it is, it’s not Fixing. Intubate me only if there are good enough odds for me to have a meaningful life when I wake up from the anaesthesia.

        When we can’t Fix Things, the surgeon closes the incision and tells the patient the truth, that he is mortal, that his defects are in accordance with his individual matter. Without that humane perspective, surgery becomes car repair — and we don’t go on repairing what can’t be put back out on the road.Report

      • Avatar zic in reply to Brandon Berg
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        I know a man, early 60’s, no insurance. Owns his own business, but barely squeaks by. He’s got a serious heart condition. Needs a bypass. Probably shouldn’t be doing the physical labor he does. But he’s playing the numbers here; waiting until he qualifies for Medicare because he won’t take ‘charity’ now; and that’s presuming charity would cover his medical costs; it’s not knowable until he applies.

        He can’t afford it, and he won’t ask help but he’ll accept Medicare when he’s old enough. If he makes it that long.

        He hasn’t died yet; but nobody who knows him will be surprised if he does before he reaches the magic age.

        I know another man who’s officially blind now; glaucoma. It was preventable, but he didn’t have the cash necessary two years ago, when he needed it.

        I don’t have to dig very deep into my community to find these stories. If you don’t know any first hand, it’s more likely for lack of looking than lack of existing.Report

      • Avatar Will Truman in reply to Brandon Berg
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        Zic, I’m not sure if that was a response to me, but to be clear, I’m not saying that we don’t let people die of fixable things. I’m saying that we’re not generally okay with it, as a matter of policy. Politicians don’t get elected saying “Let them die so that we can have a market system.”

        (You can argue that they are saying things that result in that, or that they are saying that in code, but they know better than to actually say it. Nobody in power has really suggested that we get rid of EMTALA, which is ground zero for this sort of thing.)Report

      • Avatar zic in reply to Brandon Berg
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        says:

        @will-truman I was responding to Brandon.

        I cannot say this is a trend, it’s anecdotal observation, but enough to make me question if it’s a trend, and were I reporting still, something I’d investigate: many of the people being left behind in our current health-care conundrum are represented by the two men I described; male, self-employed, and mid-50’s or later in age. They’ve always paid out of pocket, and enjoyed relatively good health or been able to suck it up and not complain. Now, life’s catching up with them, they cannot afford insurance, and they’ve been brainwashed into thinking the social safety net is for slackers, and they cannot admit to any sort of slacktitude.

        So they’ll die or continue on until they really are disabled or, finally, old enough that they can accept help in the form of Medicare while maintaining their dignity that they are not moochers on the system.Report

      • Avatar Jim Heffman in reply to Brandon Berg
        Ignored
        says:

        Medicare isn’t “mooching” any more than a defined-benefit pension is.

        (And yes, I’m aware that works on a couple of different levels.)Report

  6. Avatar zic
    Ignored
    says:

    After several years of purchasing an individual, high-deductible plan (meaning a $15,000 deductible, and that still cost nearly $500/month), we’ve had relatively ‘good’ insurance for a year from an employer. Now, my husband’s changed jobs; he’s an ‘assistant professor,’ and the new gig doesn’t include insurance.

    So we’re back to either paying the costs to purchase our previous insurance through cobra, which will be $800/month, or back to the high $15,000 deductible. Interestingly, the cobra’d insurance plan has a $2,000 deductible. The same per/month cost on the individual market will not quite cover a $10,000 deductible.

    But there is one distinct benefit from even a high deductible plan; you get the negotiated rate for medical services, which is often quite a bit cheaper then the non-insured rate.

    Me? I want a single payer plan, I’d happily settle for Canadian style insurance. And all the complaints about long waits and shortages of doctors are so mislead; because there are already long waits and doctor shortages; you just don’t see them if you have one of those premium insurance plans; it’s like getting the VIP pass to Disney; you step to the front of the line. But somebody else is being made to wait longer; some other doctor/nurse team is missing a lunch break.Report

    • Avatar Anne in reply to zic
      Ignored
      says:

      @zic I am also self employed and one of the biggest things I find is that one can’t afford insurance that means anything without throwing my money out a window if I make a claim it is pre-existing conditions which at my age mumble, mumble, is everything. As a woman with, please excuse the TMI. an unusual looking cervix which gets me a painful biopsy every time, if anything, read cancer comes up because I have had all these test, (all negative) it is still preexisting and not covered and if I disclose everything and try to get private coverage I am denied. Knock single payer all you want but it is the only option for someone like me. As it is I am now waiting it out till Obama care kicks in so I can get health insurance again.Report

    • Avatar Lyle in reply to zic
      Ignored
      says:

      The comment suggests a question: given that for negotiating power the more the spending the more power, why don’t insurance companies sell discount cards,that provide the insurance companies rate, but bill the insured for everything at that rate? Such sort of exists for some drug areas, but why not for medical?Report

  7. Avatar Jim Heffman
    Ignored
    says:

    Presumably, even the Pay For Nothing plan will negotiate prices; that means you get charged the insurance rate rather than the base rate, which can result in a significant discount even if the insurance company doesn’t actually pay anyone a dime.

    Which is the key to these “negotiated the price down”, “cash discount” stories. Some providers are willing to say “well if he were insured then we’d only be able to charge him so-much, let’s just act like he was insured and charge him that much”. Other providers are not.

    But nobody wants to point to friendly Doctor So-And-So and say “you’re a greedy bastard” so we blame everything on the insurance companies.Report

    • Avatar Will Truman in reply to Jim Heffman
      Ignored
      says:

      Some do, but some don’t. I don’t know if mine did because, as far as the clinic was concerned, I wasn’t insured at all. In the case of the WSJ, he paid less out of pocket significantly less than he would have if he had paid the insurance rates out of his deductible. Sometimes, at least, what you negotiate yourself is indeed less than they get through insurance.Report

  8. Avatar Russell Saunders
    Ignored
    says:

    Great post.

    Our office will always work with uninsured families to help them access care they can afford.

    And I agree with your last paragraph entirely. We have a total mess of a non-system, the more of which I learn the more my disdain for it grows.Report

    • Russell,

      Mine is more of a general comment about the OP, but I’m making it a response to yours because I seem to recall some blog post, quite a while back, where you (or someone) said that insurers don’t let health care providers charge below the rate negotiated with the insurers. (Alas, I don’t have a cite.)

      Obviously I’m mistaken on some point here because neither you nor Will T. are/is a liar. But where is my error? Are some people permitted to pay less? How often, and in what circumstances? Am I just wholly misremembering whatever it is I don’t have a cite to?Report

  9. Avatar Jaybird
    Ignored
    says:

    Mickey Kaus (yes, yes, goats, etc) reports that his local hospital, Saint John’s, is opening a “VIP Caritas Suites”.

    Sort of a Gold Plated Healthcare option.

    http://www.newstjohns.org/Caritas_Suites.aspx

    This strikes me as something that would strike others as troublesome… as Kaus points out, we have issues with First Class being so much better than Coach. This is, like, *HEALTH CARE*.Report

    • Avatar greginak in reply to Jaybird
      Ignored
      says:

      There has always been a first class option in health care. There were single rooms people could get instead of a shared room or the big name specialist or special clinics or fancier hospitals. This isn’t new.Report

  10. Avatar Kazzy
    Ignored
    says:

    Will,

    How much does the lil’one change your calculators? I assume you keep coverage for her, yes? If so, how so? And does it change how you look at your own health and care, even if you are only adjusting your consideration of hypotheticals and worst-case-scenarios?Report

  11. Avatar Aaron
    Ignored
    says:

    Both will look at the pricing transparency and blame it on the market and absence of market. Liberals will correctly point to this as being a non-issue if we just had single-payer, and conservatives will correctly point out that the lack of transparency is a product of the separation of buyer and consumer.

    The lack of transparency is due not only to the separation of buyer and consumer but also – and much more importantly – because the most costly procedures are obtained by consumers who have little knowledge or information with which to gauge whether they are getting the care they need or what it should cost, under circumstances in which seeking multiple quotes or negotiating for discounts is not realistic.

    A health crisis is comparable in some ways to being arrested for a crime. You need a lawyer, but how do you find one? How do you choose one? Why is one lawyer offering to take your case for $1,200, but another lawyer is saying $25,000 and perhaps more if the case goes to trial? There’s nothing between the consumer and service provider, yet….

    A lawyer who, frankly, was probably overpaid at his original rate told me that he had fewer client complaints about his services after substantially raising his rates, plus the benefit of having customers assume that because he charged more than most lawyers in town he was better than most lawyers in town. The market at work.Report

  12. Avatar Damon
    Ignored
    says:

    “It’s a hodge-podge system that we didn’t develop, but rather backed into due to wage controls and circumstance.”

    Which is why “obama care” isn’t doing to do what it’s supporters claim it will do.Report

  13. Avatar roger
    Ignored
    says:

    Fantatic post, Will.

    I agree that we have the worst of both right now, and, sadly, recent changes are continuing this negative momentum.Report

  14. Avatar LWA
    Ignored
    says:

    The health care “market” is a market where you don’t get to choose to enter or exit; in fact, everyone at some unpredictable point will be forced to enter, except to wildly varying needs. You can’t really plan for your health care needs and as Will pointed out, our societal norms about the sanctity of human life force us to provide health care free at some basic level.Report

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