Our terrible health insurance

[ChocolateReignRemix]

That harmless little word 'subsidizing' is exactly what jacked the premiums on so many people to begin with. Even those on here with excellent insurance and low costs are seeing it taken out elsewhere in their paycheck. Not to mention the government tends to add twice the cost and half the efficiency to everything from energy to education, and is a poor admin of the existing healthcare they already oversee.

 

There are indeed solutions to the medical access and cost issue. But you're not going to see them coming from the least efficient and least accountable among us.

 

That is debatable.  There is some controversy over whether Medicare has lower admin costs than private insurance, which often comes down to how admin costs are defined.  There is little evidence that Medicare is significantly worse.  Medicare also generally has high customer satisfaction and compares very well with private insurance.  Those two factors combined make it difficult to argue that government involvement in healthcare adds twice the cost or additional poor administration.

 

Medicaid is a but trickier because it is managed at the state level.  Some states get high marks and others not so much.

 

I haven't seen the private sector come up with any better solutions so far, and I have been working on this issue ever since the mid-90s when I was studying healthcare economics.

 

it just seems strange that other nations have figured it out yet we are so convinced that what they do is a terrible place to start looking for solutions.

[maize]

Or let people pick what is covered. For example, I would be happy to eliminate mental health coverage.

Would you also be happy to eliminate cancer coverage?

 

Why pick just mental health coverage out of all the potentially deadly physiological illnesses out there?

 

If you're perfectly willing to bet on no-one you care for ever having an illness that impacts the brain how about illnesses that impact other body systems? Perhaps you would cheerfully eliminate coverage for illnesses and disorders that affect the heart? The kidneys? The digestive system?

 

I can't think of any organ more important than the brain so your willingness to ignore coverage for that is quite puzzling.

[MistyMountain]

The government does not run at twice the cost and half the efficiency for things like energy and education. Private companies and charities are not super efficient. I worked for charities that wasted tons of money just trying to get money. If you look on sites that discuss how much they take in and how much of it goes to the cause it is not efficient at all. Private education does not even have to accept all kids and it is not run super efficiently. All other industrialized nations have universal coverage and it costs MUCH less and is run efficiently.

Edited July 27, 2017 by MistyMountain

[Twolittleboys]

Oh we can cut out defense budget and make it work. I bet Japan and Germany would just love that - sorry guys, we wanted to mirror you and spend less on defense and more on healthcare. Have fun maintaining your own militaries again. Sayonara NATO and foreign bases.

 

That's about the only way to do it without increasing the fee burden, we will have to shift it from one tax designation to another or costs will far exceed what you see in NHS and such. I suppose I'm fine leaving a bunch of places to fend for themselves on some level, but the consequences won't be pretty if that much of a power vacuum is created in the name of US healthcare. It's a lot more fair for our populations, though.

Not that I can speak for Germany - but that would be okay for me. I mean that is one instance in which I think you really should put the health of your own country's people first.

 

I am not talking about a total cut (which would never happen anyway) but I am sure there is quite a bit of military spending that could be postponed/eliminated. And I am sure European countries would be willing to up the spending a bit if it was deemed necessary for safety. I don't think a limited reduction of the military budget would lead to a huge power vacuum.

[MistyMountain]

We spend more on the military then the rest of the world combined. It is the largest part of our budget and is much higher then universal coverage or the safety net. We are targeted because of our interventionist foreign policy and our actions. Spending less on the military and changing foreign policy will make us safer.

[goldberry]

I definitely DO care. I just think that we can improve the situation without dumping private health insurance entirely. I am in favor of expanding Medicaid to all low-income citizens and subsidizing the reimbursement of deductibles and out-of-pocket costs for moderate income folks. I would support raising taxes for that purpose. I would start with a junk food tax since poor diet causes a lot of health problems and unlike cigarettes and alcohol, there is no "sin tax" on it.

 

Crimson, thanks for replying.  And I do believe you care about this issue. I also understand why your personal experience would make you wary.  I hope you do consider how single-payer systems in other countries still has supplemental insurance available and there is no reason to think we would not have that here as well.  It is just that some of us don't believe the proposals in discussion can address the core issue, which is cost of care.  How do you address cost of care without a negotiating base? Or without eliminating middlemen?  Costs are random and out of control.  I don't believe the free market approach works with healthcare, because of the whole need-for-life-or-death aspect.  I'm not seeing something that truly addresses that part without including single payer.

Edited July 27, 2017 by goldberry

[Monica_in_Switzerland]

This discussion of whether single-payer will cost more or less than what is already 1/6 of the U.S. economy fails to mention that the reason insurance costs are so high is NOT due to the actual cost of medical services, but due to the fact that insurance companies, many hospitals, drug companies, etc are all FOR PROFIT BUSINESSES. Having a for-profit health care system is an abomination.

 

 

I completely agree with this.  

 

As an American-moved-to-Switzerland, I look back at the US insurance system and am just appalled.  We (Switzerland) have private insurance which is not tied to employer.  It is mandatory, and all insurance companies must give basic health insurance to everyone, regardless of pre-existing conditions.  Certain income brackets receive vouchers to offset the cost of insurance.  You can purchase various top-off plans as well, though we have NEVER used any of my DH's or any of the kids' top-off plans (I wasn't eligible due to pre-ex cond.).  But the key is that all the companies must be completely transparent and not for profit!  In fact, we got back about $50 last year per family member because the company was under budget for the year.   :hurray:

We pay about $1000/month for a family of 6, plus a deductible of $500 per adult and I think 10% of all bills.  

 

Back when the ACA was being negotiated, the Swiss system was on the table as a valid option.  I will never understand why it was taken off and replaced.  Obviously it's easier to administer to 11m people than 300m people, but at the very least, the "not for profit" should be a GIVEN when re-vamping health care!!!  

[Audrey]

Vermont is really close to universal coverage now. We have about 97% of people covered. Still hoping we implement single payer at some point. Our new governor has been contacting other governors about a New England Health Care Coalition and I hope they work together to figure something out.

 

Oh! That's exciting!  That's kind of how it happened here.  SK was the leader and then other provinces wanted in and then... we have our system in place for all. 

 

Truly and most sincerely, I wish you the very best of luck moving that forward!  Go VT!

[Carol in Cal.]

Wait, so you are saying you researched the criteria for CIs in single payer countries well enough that you know all of their criteria?  Or are you going off of a summery put together by someone else?

Wait, so you are saying that you question her research into something that directly effects her family, though it doesn't directly effect yours?  Really, these constant insulting posts implying that anyone who disagrees with you must be lying are quite tedious and don't add to the conversation at all.

[ChocolateReignRemix]

Wait, so you are saying that you question her research into something that directly effects her family, though it doesn't directly effect yours?  Really, these constant insulting posts implying that anyone who disagrees with you must be lying are quite tedious and don't add to the conversation at all.

 

I do.  It seems odd someone would be researching how CIs are covered under the multiple different health care systems between Canada and Europe. 

 

I honestly don't know how CIs are covered, but based on what I do know about Europe, it seems unusual they are handled that much differently here than there.

 

Thanks for your response though.  I will give it the appropriate level of concern.

[Supertechmom]

This discussion of whether single-payer will cost more or less than what is already 1/6 of the U.S. economy fails to mention that the reason insurance costs are so high is NOT due to the actual cost of medical services, but due to the fact that insurance companies, many hospitals, drug companies, etc are all FOR PROFIT BUSINESSES. Having a for-profit health care system is an abomination.

 

I do agree that it is an abomination but it is not that cut and dried in our current system.

 

All hospitals for profit and non profit have to make money.    I work for a nonprofit hosptial and trust me everything is still about the bottom line. They still have to make money. They still have to pay really  well to attract good people.  I worked for a small nonprofit hospital that was sold to a profit business because they were going to close.   It isn't entirely because of for profits business model.  

 

I do think for profit insurance companies are hurting us.  I also think the gov's policy of deducting and withholding payment from hospitals without regard to actual cost of doing business is hurtful as well.

 

 Hospitals spend a small fortune on entire departments created solely for the purpose of ensuring all those ever changing regulations regarding infections, pressure injury, COPD, pneumonia, Surgical site infections, vaccination rates, diabetes, and readmission are coded correctly, charted correctly to ensure compliance so they can earn their money back or not get it deducted.   And let's add in coders, utilization reviewers and we haven't even touched the insurance dept. I'm guessing easily 100 people just to ensure compliance so the hospital can get paid.  While it is necessary to have oversight, that's a whole lot of salaries that could go to nursing so we could do a better job of taking care of you on the floor or more community programs to help improve your health.  But instead, it is spent on ensuring everyone is jumping through all the hoops that are constantly being added.  And the gov stands up and says they reduced cost.  No, they just found a reason not to pay for services. They saved money and small rural non profit hospitals go under.  Non profits aren't making it in some places. 

 

So it is not as cut and dry as remove for profit out of the equation.  I don't think we can overhaul what we have.  I think we are going to have to remove it completely and create a different system. 

[Twolittleboys]

So it is not as cut and dry as remove for profit out of the equation.  I don't think we can overhaul what we have.  I think we are going to have to remove it completely and create a different system.

I so agree with this! Actually, I think this is a great chance to go and come up with a great system from scratch. Look at experts, look at demographics, look at other countries, look at the political reality and come up with a decent plan that will at least cover the basics for all the people. And then fine-tune as time goes on.

[displace]

I do agree that it is an abomination but it is not that cut and dried in our current system.

 

All hospitals for profit and non profit have to make money. I work for a nonprofit hosptial and trust me everything is still about the bottom line. They still have to make money. They still have to pay really well to attract good people. I worked for a small nonprofit hospital that was sold to a profit business because they were going to close. It isn't entirely because of for profits business model.

 

I do think for profit insurance companies are hurting us. I also think the gov's policy of deducting and withholding payment from hospitals without regard to actual cost of doing business is hurtful as well.

 

Hospitals spend a small fortune on entire departments created solely for the purpose of ensuring all those ever changing regulations regarding infections, pressure injury, COPD, pneumonia, Surgical site infections, vaccination rates, diabetes, and readmission are coded correctly, charted correctly to ensure compliance so they can earn their money back or not get it deducted. And let's add in coders, utilization reviewers and we haven't even touched the insurance dept. I'm guessing easily 100 people just to ensure compliance so the hospital can get paid. While it is necessary to have oversight, that's a whole lot of salaries that could go to nursing so we could do a better job of taking care of you on the floor or more community programs to help improve your health. But instead, it is spent on ensuring everyone is jumping through all the hoops that are constantly being added. And the gov stands up and says they reduced cost. No, they just found a reason not to pay for services. They saved money and small rural non profit hospitals go under. Non profits aren't making it in some places.

 

So it is not as cut and dry as remove for profit out of the equation. I don't think we can overhaul what we have. I think we are going to have to remove it completely and create a different system.

Imagine if there was enough workforce that the hospital didn't have to overspend on a good work force? Clearly the need for qualified health care workers in all fields is high in almost every place in the country (except the few states that have enough supply).

 

What if the government supported education in these fields so people did not have to exclude careers based on finances, and smart people who want to help could do so?

 

Oh, but will we discuss education support wrt healthcare? They are interrelated, but there's poor support for it all.

 

To bring up a junk food tax, it made me think of brief travels everywhere. We probably spend some of the least amount of our % income on food vs a lot of other countries. Visiting restaurants was cost prohibitive for us while traveling. Even fast food was mostly out of range because it was so much more expensive, especially in developed countries. I'm glad food can be more affordable, but should fast food be cheaper than fresh fruits and vegetables? Our diet is so poor and we know it leads to so many health problems. But if a bag of chips costs the same as one apple, it seems sad. Soda is cheaper than milk. I know this is controversial but it's so interrelated. I wish ... a lot of things.

[AmandaVT]

I definitely DO care. I just think that we can improve the situation without dumping private health insurance entirely. I am in favor of expanding Medicaid to all low-income citizens and subsidizing the reimbursement of deductibles and out-of-pocket costs for moderate income folks. I would support raising taxes for that purpose. I would start with a junk food tax since poor diet causes a lot of health problems and unlike cigarettes and alcohol, there is no "sin tax" on it.

 

A few changes right off the bat could help the middle income people. Currently, we make just a smidge over the gross income limit to qualify for tax subsidies. And by a smidge, I mean under $1000/year over. So we have to pay almost $2000/month for our premiums with net income. That brings our take home waay under what would qualify us for Medicaid and even food stamps here. But, we don't qualify for either because our income is just high enough to not receive any help AND we have to pay our premiums after taxes are taken out. 

 

Changes:

 

1. Let people purchasing from the exchange use pre-tax income like everyone with an employer health plan

 

2. Have the subsidies step down, rather than drop off completely. If we made just $1000/YEAR less, we'd receive a $1000/MONTH subsidy.

 

I feel like the people in the middle are in a really tough spot, as far as health insurance goes.

[ChocolateReignRemix]

A few changes right off the bat could help the middle income people. Currently, we make just a smidge over the gross income limit to qualify for tax subsidies. And by a smidge, I mean under $1000/year over. So we have to pay almost $2000/month for our premiums with net income. That brings our take home waay under what would qualify us for Medicaid and even food stamps here. But, we don't qualify for either because our income is just high enough to not receive any help AND we have to pay our premiums after taxes are taken out. 

 

Changes:

 

1. Let people purchasing from the exchange use pre-tax income like everyone with an employer health plan

 

2. Have the subsidies step down, rather than drop off completely. If we made just $1000/YEAR less, we'd receive a $1000/MONTH subsidy.

 

I feel like the people in the middle are in a really tough spot, as far as health insurance goes.

 

Which is one of, if not the biggest, failings of the ACA.  Unfortunately I believe that if what you suggested would have been included (and variations of it were discussed) it would not have passed.  Why? Because it would have worked even better.

[snowbeltmom]

 

 

Back when the ACA was being negotiated, the Swiss system was on the table as a valid option.  I will never understand why it was taken off and replaced.  Obviously it's easier to administer to 11m people than 300m people, but at the very least, the "not for profit" should be a GIVEN when re-vamping health care!!!  

My guess is that the insurance lobbyists had something to do with it being taken off the table.

[TravelingChris]

First of all, let's discuss so-called non-profits.  In my state, we have a giant BC/BS and on paper, it is a non-profit.  All that simply means is that there are no owners or shareholders receiving the profits.  It doesn't mean they don't make extra---- in my state, they sure do and loads of extra.  In fact, our state's BC/BS was noted as a talking point by President Obama as to how bad the insurance is with basically no competition and a fairly corrupt non-profit before ACA.  Nothing has changed and I believe the last non BC/BS exchange insurance has stopped or is stopping offering policies in most of the state, if not all.  

 

We also have two hospitals here in town.  One is non-profit and the other one is owned by doctors so it is profit.  I haven't seen any difference at all in prices and we have used both hospitals at various times including ERs at both and inpatient at the profit one.  Depending on the procedures or illness, one is better than the other.  My current primary care doctor is able to see us in either hospital --- one reason we chose to go with a concierge doctor is to have our regular doctor be able to coordinate our care if we are hospitalized.  He doesn't use hospitalists but rather visits his patients himself.  

 

As to the government handling medical care- we have Tricare as our primary insurance and where I live that is handled by Humana. My prescriptions are handled by Express Scripts.  My daughter's medical care is going to be handled by some other company since she is in New Zealand right now and then when she returns it will be the same as us.  Her biologic medicine for asthma is not handled by Express Scripts but by Humana.  I believe that most if not all Medicare claims are also handled by a contract with some profit making insurance company.  I, for one, would be greatly appreciative of any program to expand association insurance like the Christian ones that are currently available because my son refuses to get insurance as long as someone is making a profit on it. He considers it gambling on people's health and immoral.  As to not tying it to work, my two other children are making decisions about their careers and the married one, about her husband's, based on health care availability and insurance.  My youngest already made a career choice based on it and now will have to work in large companies in order to not bankrupt the company.  Her medications are in the thousands every month.

[Carol in Cal.]

Yes, unless we go after the cost side, nothing is going to work.

 

Physician take home pay is really, really high:  http://www.businessinsider.com/how-much-money-do-doctors-make-2016-4

 

and not because malpractice insurance is so expensive:  http://www.huffingtonpost.com/david-belk/medical-malpractice-costs_b_4171189.html

 

But malpractice lawyers don't make nearly as much as doctors:  http://work.chron.com/much-medical-malpractice-lawyers-make-21136.html

 

Drug companies are raking it in, with cost increases almost an order of magnitude higher than normal inflation:  http://www.cbsnews.com/news/whats-behind-the-sharp-rise-in-prescription-drug-prices/

 

And defensive medicine costs everyone.

 

Insurance companies have had mixed results, with the more generous and broad coverage plans losing while others gained:  http://www.latimes.com/business/hiltzik/la-fi-hiltzik-obamacare-profits-20160427-snap-htmlstory.html

 

Bottom line:  It pays to ration care, it pays to have a monopoly, it pays (bigtime) to be a doctor, and nothing we have done legislatively or are proposing to do legislatively has much effect on any of those things.

[Crimson Wife]

Wait, so you are saying you researched the criteria for CIs in single payer countries well enough that you know all of their criteria?  Or are you going off of a summery put together by someone else?

 

In the UK, the child has to have a loss at 90+ decibels across the full frequency spectrum. My daughter does not. I'm not going by 2ndhand information but the published guidance of the (UK) National Institute for Health and Care Excellence.

 

The FDA actually has similar criteria but here in the U.S., surgeons can perform the operation outside of FDA recommendations based on their own professional opinion and insurers may still pay (like ours did).

[ChocolateReignRemix]

In the UK, the child has to have a loss at 90+ decibels across the full frequency spectrum. My daughter does not. I'm not going by 2ndhand information but the published guidance of the (UK) National Institute for Health and Care Excellence.

 

The FDA actually has similar criteria but here in the U.S., surgeons can perform the operation outside of FDA recommendations based on their own professional opinion and insurers may still pay (like ours did).

 

But you said the UK and other single payer plans.  That is why I questioned that statement.

[Crimson Wife]

A couple of issues with "sin taxes" on junk food.  

 

Let's tax the cheapest food per calorie to pay for...health care for the poor.  Disproportionately tax poor people to fund healthcare for poor people.   :blink:

 

If these sorts of taxes "succeed", revenue from them drops.  Ask states who pinned their state budgets to cigarette taxes how THAT'S working for them these days.  

 

It's a myth that poor people eat more junk food than rich people.

 

Everyone who eats junk food (and that includes me in moderation) should pay a "sin tax" to help reduce the externalization of costs of unhealthy food.

[regentrude]

It's a myth that poor people eat more junk food than rich people.

 

The article you linked actually does not talk about junk food but about fast food in restaurants. Not the same thing. Obviously, poor people do not consume a lot of restaurant food. OTOH, "grocery" stores in food deserts contain almost exclusively junk.

Edited July 27, 2017 by regentrude

[Crimson Wife]

But you said the UK and other single payer plans.  That is why I questioned that statement.

 

I'm on groups for parents with deaf kids and there are CONSTANTLY British moms lamenting that they cannot get a cochlear implant for their child because of 1-2 frequencies that are not quite bad enough under the NHS criteria. Whereas here in the U.S. if they had good private insurance like ours, they could totally have the operation done. Yes, we spend more per capita. But those who have coverage get better care.

[ChocolateReignRemix]

It's a myth that poor people eat more junk food than rich people.

 

Everyone who eats junk food (and that includes me in moderation) should pay a "sin tax" to help reduce the externalization of costs of unhealthy food.

 

Actually the article you linked only studied fast food, not "junk" food overall.

[ChocolateReignRemix]

I'm on groups for parents with deaf kids and there are CONSTANTLY British moms lamenting that they cannot get a cochlear implant for their child because of 1-2 frequencies that are not quite bad enough under the NHS criteria. Whereas here in the U.S. if they had good private insurance like ours, they could totally have the operation done. Yes, we spend more per capita. But those who have coverage get better care.

 

1.) The UK is not the only single payer nation.  That is what I was questioning as you lumped all single payer systems together when they are all quite different.

 

2.)  That is debatable.  We have worse overall health outcomes as a nation, and you are assuming that all coverage is equal, which it is not.  Many people in the U.S. with "coverage" do not have quality coverage, or cannot access what coverage they do have easily due to deductibles. 

[TravelingChris]

In our state, we had a similar chart of who makes the most or how much people make.  Doctors overall did not make more than many other professions.  I don't have an issue with well educated and well-experienced people making money.   What I saw in Belgium was that doctors did make more money than average.  There was a doctor living next to us and we were living in a big relatively fancy house and he had a Merc iike we did but we had a really old one and he had a new one.  Talking with my internal medicine doctor there, I learned that he regularly vacationed in places like the Keys.  For the amount of education and the level of expertise needed, I have no issues with them earning good salaries.  OTOH, the insurance company heads earn astronomical salaries- not salaries anywhere in line with physicians.  As I saw it, most of the physicians earned fairly normal salaries.  

[LucyStoner]

It's a myth that poor people eat more junk food than rich people.

 

Everyone who eats junk food (and that includes me in moderation) should pay a "sin tax" to help reduce the externalization of costs of unhealthy food.

Uh, I'm not a person with much to learn about poverty and food habits. Poor people on average consume the largest amounts of sugary drinks, unhealthy fats and empty calorie grocery products.

 

There's a lot to document this, all readily available. Consumption patterns, type 2 diabetes rates, percent of total daily calories consumed from added sugar. It's a matter of cost, comfort, convenience and access. Sugar is also habit forming and besides being the cheapest way to fill up and stave off hunger, it is also a pleasure that people without much else in their means can afford.

 

I am *from* deep generational poverty and spent most all of my working years running or raising millions of dollars for programs that focus on families and individuals in deep poverty. I know of what I speak. Your one example doesn't reflect the larger picture.

 

Who is eating sugar sandwiches for dinner tonight? It's not my kids. It's not your kids. It's not the kids of my Seattle tech money affluent neighbors. It's the kid whose mom is digging change out of the couch to find enough money for a loaf of the bread that sells for 99 cents. And no, when that mother goes to buy her groceries she should not be taxed more than I am for the smoked salmon, eggs, fruit and $$$ whole wheat bread with no added sugar my sons will be eating for breakfast tomorrow. No one should be, IMO, taxed on their groceries anyways.

 

Taxing people's food as "a sin" just reduces the amount of resources they have to buy food. Which is not something poor families can afford.

Edited July 27, 2017 by LucyStoner

[itsheresomewhere]

Uh, I'm not a person with much to learn about poverty and food habits. Poor people on average consume the largest amounts of sugary drinks, unhealthy fats and empty calorie grocery products.

 

There's a lot to document this, all readily available. Consumption patterns, type 2 diabetes rates, percent of total daily calories consumed from added sugar. It's a matter of cost, comfort, convenience and access. Sugar is also habit forming and besides being the cheapest way to fill up and stave off hunger, it is also a pleasure that people without much else in their means can afford.

 

I am *from* deep generational poverty and spent most all of my working years running or raising millions of dollars for programs that focus on families and individuals in deep poverty. I know of what I speak. Your one example doesn't reflect the larger picture.

 

Who is eating sugar sandwiches for dinner tonight? It's not my kids. It's not your kids. It's not the kids of my Seattle tech money affluent neighbors. It's the kid whose mom is digging change out of the couch to find enough money for a loaf of the bread that sells for 99 cents. And no, when that mother goes to buy her groceries she should not be taxed more than I am for the smoked salmon, eggs and $$$ whole wheat bread with no added sugar my sons will be eating for breakfast tomorrow. No one should be, IMO, taxed on their groceries anyways.

 

Taxing people's food as "a sin" just reduces the amount of resources they have to buy food. Which is not something poor families can afford.

I agree. Not to mention those who have just enough to rent a tiny place without a kitchen or if lucky enough, share a hot plate with another room. Without those "junk foods", they would not have as much food if they tax them. Plus, then we get to debate what is "junk food" as some will see it as all packaged food, some see it as anything that has sugar, and some see it as cookies. Instead of taxing, I still hope that we could just get enough people to listen and get fresh food to those who do not have access to it. And not charge them a premium for it. Edited July 27, 2017 by itsheresomewhere

[displace]

Yes, unless we go after the cost side, nothing is going to work.

 

Physician take home pay is really, really high: http://www.businessinsider.com/how-much-money-do-doctors-make-2016-4

 

and not because malpractice insurance is so expensive: http://www.huffingtonpost.com/david-belk/medical-malpractice-costs_b_4171189.html

 

But malpractice lawyers don't make nearly as much as doctors: http://work.chron.com/much-medical-malpractice-lawyers-make-21136.html

 

Drug companies are raking it in, with cost increases almost an order of magnitude higher than normal inflation: http://www.cbsnews.com/news/whats-behind-the-sharp-rise-in-prescription-drug-prices/

 

And defensive medicine costs everyone.

 

Insurance companies have had mixed results, with the more generous and broad coverage plans losing while others gained: http://www.latimes.com/business/hiltzik/la-fi-hiltzik-obamacare-profits-20160427-snap-htmlstory.html

 

Bottom line: It pays to ration care, it pays to have a monopoly, it pays (bigtime) to be a doctor, and nothing we have done legislatively or are proposing to do legislatively has much effect on any of those things.

I love to bring up The Physicians Foundation Survey when discussing physician satisfaction. Physicians are compensated well. Why is that?

 

1 - The Average debt of physicians just out of medical school is almost $200,000, not including undergraduate debts. The first 3-5 years of their practice, the salaries are $50,000. https://studentloanhero.com/featured/ultimate-student-loan-repayment-guide-for-doctors/

So, you have a 30 year old physician who is now finally earning a doctor salary, with those averages listed for wages usually closer to people who have been in practice a number of years. Specialists make a lot more, which influences some doctors to forgo primary care. For a cartoon descriptor: http://www.bestmedicaldegrees.com/salary-of-doctors/ This is simplified, but shows lifetime negatives financially of becoming a physician, putting off work for a long time, combined with so much debt, not investing, etc.

 

2 - Hours worked is a consideration in salary. The average physician works 60 hours a week (this is after the first 3-5 years, where they work an average of 80 hours a week). Working an average of 60 hours a week for the rest of your career is a deal breaker for many people.

 

3 - Supply and demand. By 2025, there is an expected deficit of physicians ranging from 60,000 - 95,000. https://www.aamc.org/download/458082/data/2016_complexities_of_supply_and_demand_projections.pdf

This is where I bring up the Physicians Foundation Survey (synopsis - http://www.physiciansfoundation.org/news/the-physicians-foundation-2016-physician-survey/) (full report - http://www.physiciansfoundation.org/uploads/default/Biennial_Physician_Survey_2016.pdf)

 

There are lots of other considerations in medicine but I didn't get stats. Consider delaying fertility until your 30's (and then possibly having infertility), inability to call in sick whien working, not enough coverage and stress to treat patients because you're the only person available, dealing with paperwork, being on call at all hours of the night and weekends, stress of treating people properly, deciding what treatment is possible based on what insurance is available, not being able to see your children because you work so many hours a week, being stuck financially and having no other options.

 

This survey is taken every two years. Highlights from the most recent survey - about 50% of physicians feel burnt out, also about 50% have negative morale. Again, 50% would NOT recommend being a physician to their children, 80% are overextended in their work load, about 50% plan to limit patient care (cutting down on hours, switching careers, etc). Okay, so maybe the last survey was an off year? Since I've been following the surveys, the results are generally pretty similar, with high numbers hoping to quit work, regret for going into the field (usually at least 20-30% who would never choose the field if given a second chance), etc.

 

Of course not all physicians feel this way, but salary can sometimes "convince" a physician to stay in practice when they don't really want to. Our country is pretty low as far as numbers of physicians compared to developed countries.

 

What do we do?

 

In countries with socialized medicine, the physicians make a lot less. But! They don't have debt or have less educational debt. They don't work so many hours. They have a good QOL, etc.

Edited July 28, 2017 by displace

[winterbaby]

It's a myth that poor people eat more junk food than rich people.

 

Everyone who eats junk food (and that includes me in moderation) should pay a "sin tax" to help reduce the externalization of costs of unhealthy food.

 

Taxes that are nominally the same for everyone fall harder on poor people because they have less money to spare.

[winterbaby]

The article you linked actually does not talk about junk food but about fast food in restaurants. Not the same thing. Obviously, poor people do not consume a lot of restaurant food. OTOH, "grocery" stores in food deserts contain almost exclusively junk.

 

Having spent time in such areas I don't think that is quite accurate. True, almost everything will be packaged/processed. That is not the same as "junk food" as I think it is commonly understood. Canned ravioli, ramen, and the like do not make for the greatest diet but they are not in the same category as potato chips. In any case the answer to the food supply in such areas is not to decrease the affordability of whatever there is.

[Frances]

Imagine if there was enough workforce that the hospital didn't have to overspend on a good work force? Clearly the need for qualified health care workers in all fields is high in almost every place in the country (except the few states that have enough supply).

 

What if the government supported education in these fields so people did not have to exclude careers based on finances, and smart people who want to help could do so?

 

Oh, but will we discuss education support wrt healthcare? They are interrelated, but there's poor support for it all.

 

To bring up a junk food tax, it made me think of brief travels everywhere. We probably spend some of the least amount of our % income on food vs a lot of other countries. Visiting restaurants was cost prohibitive for us while traveling. Even fast food was mostly out of range because it was so much more expensive, especially in developed countries. I'm glad food can be more affordable, but should fast food be cheaper than fresh fruits and vegetables? Our diet is so poor and we know it leads to so many health problems. But if a bag of chips costs the same as one apple, it seems sad. Soda is cheaper than milk. I know this is controversial but it's so interrelated. I wish ... a lot of things.

Most of the healthcare shortages are due to a lack of training slots, not people unwilling or unable to pay for the training. While the government certainly could do more to lower the costs, most healthcare related degrees have very good return on investment and places with shortages often offer loan reimbursement for new staff and tuition reimbursement for existing staff. The lack of training spots for qualified applicants not only makes healthcare more expensive, but shortchanges individuals, especially our young people, who can't pursue their chosen career.

[Laura Corin]

In the UK, the child has to have a loss at 90+ decibels across the full frequency spectrum. My daughter does not. I'm not going by 2ndhand information but the published guidance of the (UK) National Institute for Health and Care Excellence.

 

The FDA actually has similar criteria but here in the U.S., surgeons can perform the operation outside of FDA recommendations based on their own professional opinion and insurers may still pay (like ours did).

 

Thank you for explaining.  It must be very hard for patients on the borderline.

 

As I understand it, UK residents will get implants free at the point of need if they meet FDA/NHS recommendations.  US residents will get implants at this level of hearing loss if they have insurance but will still have co-pays/other out-of-pocket expenses; if not, not.

 

If patients do not meet the NHS/FDA criteria, in the US they may have implants paid for if they have very good insurance.  In the UK, they may have implants paid if they have top up insurance (this private provider mentions insurance, so I'm assuming that this is the case https://www.hcahealthcare.co.uk/treatments/a-z-of-services-and-treatments/cochlear-implants/)

 

In both countries, patients who can raise the money can have the operation done privately.  Here is the contact page from the same provider for self-pay: https://hcaselfpay.co.uk/

 

If you are happy to pay enough tax that all US residents, regardless of income or wealth, can have the operation if recommended by FDA guidelines, them I am totally happy with your additionally paying more for better treatment.

Edited July 28, 2017 by Laura Corin

[Laura Corin]

Oh we can cut out defense budget and make it work. I bet Japan and Germany would just love that - sorry guys, we wanted to mirror you and spend less on defense and more on healthcare. Have fun maintaining your own militaries again. Sayonara NATO and foreign bases.

 

That's about the only way to do it without increasing the fee burden, we will have to shift it from one tax designation to another or costs will far exceed what you see in NHS and such. I suppose I'm fine leaving a bunch of places to fend for themselves on some level, but the consequences won't be pretty if that much of a power vacuum is created in the name of US healthcare. It's a lot more fair for our populations, though.

 

For information, the UK far exceeds the 2% of GDP recommended for NATO support.  NHS and NATO funding in one country.  Here's Fox on the subject:

 

http://www.foxnews.com/world/2014/06/03/glance-at-military-spending-in-nato-european-members.html

[elegantlion]

Blessed are the poor for they shall have health care and who would begrudge the poor

 

Blessed are the lower middle class...wait, no, they make too much for government aid of any kind, blessed  good luck to the lower middle class trying to find insurance that doesn't suck a larger portion of your income than your mortgage/rent, especially those in states that did not expand coverage. 

 

Blessed are the uninsured, wait we're not supposed to have those are we? But wait, yes, we do. I oddly know a number of people IRL who either are uninsured adult students, don't get coverage through their job because of being a part-time employee or own their own business. These are not lazy slobs who flood the ERs for colds, these are responsible adults who are thankfully fairly healthy and do self-pay for non-emergency care. Blessed   Tired are the uninsured, tired of it all [so much not brought up in this thread, so I'll leave it out]. 

[Katy]

My guess is that the insurance lobbyists had something to do with it being taken off the table.

 

I suspect the economy is the reason it was taken off the table.  I've worked for 3 insurance companies.  The companies don't make much profit from the insurance itself - insurance profits are regulated by states.  Insurance companies make most of their money from investing their reserves in the markets. 

 

I could go off on a long tangent about how the FED is artificially inflating the markets and providing free profits to insurance and financial companies right now, but I won't.

 

The most concrete example I can give is the market crash that happened after 9/11.  Congress forced insurance companies to increase their cash reserves at the time, pulling a huge amount of money out of the markets, and because even then computer trading was a factor, the effect of that withdrawal meant other people pulled out of the market as well.  This continued until the 2008 crisis.

 

My point is, the reason we don't have single payer in the USA is that when you get down to it, it won't happen until there is a major economic reset something akin to the great depression. Because pulling ALL insurance reserves out of the market will cause a great depression.   Expanding medicaid and making it easier and faster for people to get on it when they lose private health insurance would reduce issues with people who desperately need care and wouldn't effect the economy in such a negative way.

 

 

 

 

As an aside, every fall when DH's insurance options come out we look at what we have in our HSA and we plan our next year's budget on having enough in the HSA to completely cover the family out of pocket maximum.  So far, even when one of us is on very expensive medication, we've been able to afford that. Not everyone can.  I for one wish they would get rid of the Cadillac tax.  DH's employer used to provide very good, "platinum level" plans with low copays for office visits and co-insurance for more expensive procedures. When the ACA went into effect, the first year we were penalized with a tax for having a Cadillac plan. The next year all of the good plans were no longer an option and we had to switch to a health savings account plan with a high deductible. Which totally stinks.

[Frances]

I didn't think the Cadillac tax had taken effect yet?

[Josh Blade]

I cannot imagine the decrease in stress levels for the average person, just walking in somewhere and being treated, and not sorting through bills and negotiating and arguing for the next 6 months to a year or more afterward.  I hear about it, but I cannot imagine it.  

 

Not even getting into the financials of how much of a pain insurance can be, literally just having to deal with insurance companies is gigantic pain and waste of time.

We have insurance through my wife's school this year. You have to be enrolled in school to sign up for it. My wife had several doctors and specialists visits, a CT scan, and an out patient surgery this year. We paid our $500 deductible (lowest deductible we've ever had) to the hospital for the CT scan. We paid an additional $1100 for the 20% copay to the hospital at the time of surgery.

Then we started getting bills from the various doctors and specialists that showed us owing the full amount. So we call the doctors to figure out why they didn't bill the insurance. They tell us the insurance company says we aren't enrolled with them. Call the insurance company to find out that you have to verify student enrollment for them to process any claims (on a plan that you had to be enrolled as a student to sign up - and premiums have to be paid in advance 6 months at a time). My wife then had to call all of her doctors back and tell them that they would be able to refile the insurance in 2-3 weeks after the insurance company processed her enrollment verification (which she took care of her responsibilities for the next day on campus).

A month later we start getting doctors bills again showing we owe the full amount. More phone calls and they are all telling us the insurance says we have to pay them for the deductible (which at this point we've already paid 3 times over to the hospital). Well the hospital still hasn't submitted their insurance claims for the CT (4 months old at this point) or the surgery (2 months old), so from the insurance's perspective we haven't paid anything. My wife literally spent an hour trying to explain to a woman that we had already paid $1600 and should only have 20% coinsurance on the remaining bills.

So this resulted in calls to the hospital to ask why they haven't processed these claims yet and calls to all of the other doctors awaiting payment to explain the situation to them to get them to hold off for another few weeks on payment.

The Hospital finally submits their claims. The CT claim where we paid our deductible is denied. Several calls to the hospital and the insurance company later and it turns out the hospital didn't put 'In Care of Student Center' on the address of the insurance company, so it went to the insurance's dental department (lolwut) instead and got denied. I'm not entirely sure why they even need the physical address from our insurance card when everything is electronic, but it's apparently important.

The CT finally gets billed to the insurance properly and the insurance company tells us that the money for the deductible has to be paid first come first serve with their claims, so we'll have to pay the deductible to the doctors who have been waiting for months at this point on their money since they filed their claims first and we'll get a refund from the insurance company on the deductible we already paid.

Queue up another round of calls to doctors offices explaining that now we're waiting on a refund of our deductible from the insurance company to pay them.

This is where we currently are in our saga when we ultimately owe about another $250 in coinsurance and my wife has had to spend about 20 hours on the phone over 2.5 months to get it all straightened out. In half of the steps I outlined above, there is also a billing company that is working on behalf of the doctors' offices that gets the initial call and they have literally no idea about anything and redirect you to the doctor's office.

That's all just for my wife. We pretty regularly get bills for 10 dollars or less on essential health benefits for our kid's well checks that should be completely covered like vaccinations where the insurance partial pays the cost. I'm pretty sure it's not really legal what they are doing with those, but it's such a hassle to deal with insurance companies that it's easier to just pay the 8 dollars.

TLDR: I would gladly even pay more in taxes than my current average annual medical expenses if it meant we could just go to the doctor when we need to without months of hassle trying to get everyone paid properly later.

[kewb]

The Cadillac tax is supposed to go into effect in 2020. Your dh's employer chose to get rid of the platinum plan to save money and still be able to provide benefits.

My dh worked for a company that did an analysis of what services employees were using. The majority were not using platinum level services so they changed to plan that cost less and provided what most of their employees were using.

Edited July 28, 2017 by kewb

[Bootsie]

First of all, let's discuss so-called non-profits.  In my state, we have a giant BC/BS and on paper, it is a non-profit.  All that simply means is that there are no owners or shareholders receiving the profits.  It doesn't mean they don't make extra---- in my state, they sure do and loads of extra.  In fact, our state's BC/BS was noted as a talking point by President Obama as to how bad the insurance is with basically no competition and a fairly corrupt non-profit before ACA.  Nothing has changed and I believe the last non BC/BS exchange insurance has stopped or is stopping offering policies in most of the state, if not all.  

 

If BC/BS is making loads of extra, and there are no shareholders to receive the extra, who is receiving the extra?

 

In addition to not providing shareholders with a return on investment, a non-profit does not pay taxes.  That is a further cost reduction.  A puzzle to me is that much of the health care in the US was done by non-profits in the past.  More and more have been becoming for profit in recent years.  In the banking system we see the opposite trend.  Credit Unions are non-profits.  Up to thirty years ago they were a very small part of our financial institution landscape in the US; they have been growing rapidly in recent years and the for-profits are complaining that the credit unions have lower expenses because they don't pay taxes.  

[Alice]

Having dealt with Army medicine, it would be trading one headache for another. Instead of fighting over bills, it would be fighting to get access to care when some bureaucrat decides they know better than patients in consultation with doctors. :thumbdown:

 

 

This is already the way it is now with insurance. I'm constantly being told by insurance companies as a doctor to prescribe a different medication or order a different test or that a therapy I recommend isn't covered, etc. It's just different bureaucrats. My frustration is that it's different for every company and seemingly without any scientific rhyme or reason. So I can prescribe Drug X for Little Johnny because their insurance covers it. It's a good drug. But for Little Bobby I have to go to Drug Y or have Bobby's parents pay hundreds of dollars a month out of pocket. Is it because Bobby's insurance company somehow knows that Drug Y is a better drug? No, it's because they have a deal with the pharmaceutical company and have it on formulary. Sometimes it really doesn't matter and Y is as good as X. But often, it is not and I have to either prescribe an inferior drug or tell the parents that I think it's warranted to pay out of pocket. Neither is a great solution. 

 

It's a broken system. 

[Carol in Cal.]

If BC/BS is making loads of extra, and there are no shareholders to receive the extra, who is receiving the extra?

 

In addition to not providing shareholders with a return on investment, a non-profit does not pay taxes.  That is a further cost reduction.  A puzzle to me is that much of the health care in the US was done by non-profits in the past.  More and more have been becoming for profit in recent years.  In the banking system we see the opposite trend.  Credit Unions are non-profits.  Up to thirty years ago they were a very small part of our financial institution landscape in the US; they have been growing rapidly in recent years and the for-profits are complaining that the credit unions have lower expenses because they don't pay taxes.  

 

I agree that nonprofits are better but that both have to make money.

Speaking of which, there is a local hospital that used to be VERY good, better in some ways than the renowned med school hospital 30 miles up the road.  It was bought by Columbia Healthcare, a for profit system.  As it happened, I gave birth there right before the purchase, and had gall bladder surgery there about two months after the purchase.  BY THEN, already, they had cut their nursing staff about 1/4-1/3, and the difference in care was palpable. 

 

As in, I was supposed to be able to use a hospital breast pump, and somehow the order got ignored, and I asked no less than 4 people for it before I finally got it.  What would happen is, I would push the 'nurse' button, someone who didn't know much English and didn't know the hospital would come in and ask what I wanted, I would tell her, she would say, "You have to talk to the nurse."  I would say, "OK, how do I call her?"  She would leave, and I would wait an hour and then try again. 

 

As in, pain meds were not delivered on schedule.

 

As in, the actual nurse came in, figured out the situation at a glance, got me the machine, and apologized for not being able to be more attentive, but that he had twice as many patients as had been normal and was running around rather than really caring for people.  (Which I had not complained about to him.)

 

It was interesting to read the inside scoop about this on the union bulletin boards.  Suddenly there were lots of instructions about how to identify an unsafe patient designation in the moment, and exactly at what point you had taken responsibility for a patient, and how not to do so if you didn't think it was safe.  It was clearly a very tough transition.

 

 

 

 

Edited July 28, 2017 by Carol in Cal.

[Carol in Cal.]

The Cadillac tax is supposed to go into effect in 2020.

 

I hate the Cadillac tax because it disincentivizes employers from providing excellent medical insurance to their employees, which as a matter of policy is entirely counterproductive.

 

[Bootsie]

I suspect the economy is the reason it was taken off the table.  I've worked for 3 insurance companies.  The companies don't make much profit from the insurance itself - insurance profits are regulated by states.  Insurance companies make most of their money from investing their reserves in the markets. 

 

I could go off on a long tangent about how the FED is artificially inflating the markets and providing free profits to insurance and financial companies right now, but I won't.

 

The most concrete example I can give is the market crash that happened after 9/11.  Congress forced insurance companies to increase their cash reserves at the time, pulling a huge amount of money out of the markets, and because even then computer trading was a factor, the effect of that withdrawal meant other people pulled out of the market as well.  This continued until the 2008 crisis.

 

My point is, the reason we don't have single payer in the USA is that when you get down to it, it won't happen until there is a major economic reset something akin to the great depression. Because pulling ALL insurance reserves out of the market will cause a great depression.   

What types of insurance companies were required to increase their cash reserves?  Property and Casualty or health insurance?  Was there a particular act that led to this?  Can you provide any additional info--I am trying to find out more about this and having trouble locating sources.

[Guest]

For information, the UK far exceeds the 2% of GDP recommended for NATO support. NHS and NATO funding in one country. Here's Fox on the subject:

 

http://www.foxnews.com/world/2014/06/03/glance-at-military-spending-in-nato-european-members.html

You realize there is far more to funding a functional military than NATO, right? The UK has decent military spending for the region, no doubt. But again, pretty much the only projected way to cover the healthcare expenses without a higher tax burden is shifting from defense or other entitlements like social security or medicare/medicaid. I don't have time right now but there are some great studies with analyses of spending by governments and where the priorities are. A shocking number of European countries spend almost nothing on defense and have no effective standing military other than ceremonial, but spend a great deal on their social safety nets. If they were required to maintain the bulk of their own defense and couldn't call in another country's bigger and more stable force they could not afford both. Heck, a handful can't maintain the safety net anyway - not enough revenue coming in.

 

I can't remember for the life of me which thinktank had the best breakdown on this but it was a fascinating look - essentially, what happens to spending in other countries if the US military dissolved all foreign presence and just maintained borders.

[Guest]

Thank you. Yeah, orthopaedics are best paid, but for most of his career my husband left the house at 6am and returned at 7 or 8. He was on call several days a week, which meant that he was often gone until 11pm -2am those nights. And yes, he left at 6am the next day. He was on call one weekend a month which meant working most of the weekend. When I was keeping track, he was often working 90-100 ) hours a week at least. We figured out his hourly earning one time, and it wasn't that high. It is also why the stress caused a major health issue. He has now cut back to half time ( only working 40-50 hours a week. I also know that medicaid doesn't come near to paying enough to cover expenses and Medicare barely does. So yeah, thank you for everything you said.

These are the hours of most professionals I know.

[Audrey]

You realize there is far more to funding a functional military than NATO, right? The UK has decent military spending for the region, no doubt. But again, pretty much the only projected way to cover the healthcare expenses without a higher tax burden is shifting from defense or other entitlements like social security or medicare/medicaid. I don't have time right now but there are some great studies with analyses of spending by governments and where the priorities are. A shocking number of European countries spend almost nothing on defense and have no effective standing military other than ceremonial, but spend a great deal on their social safety nets. If they were required to maintain the bulk of their own defense and couldn't call in another country's bigger and more stable force they could not afford both. Heck, a handful can't maintain the safety net anyway - not enough revenue coming in.

 

I can't remember for the life of me which thinktank had the best breakdown on this but it was a fascinating look - essentially, what happens to spending in other countries if the US military dissolved all foreign presence and just maintained borders.

 

 

Reductive fallacy.

Epistemic fallacy.

 

The bolded is not the only alternative.  It is not an all or nothing proposition.  Reducing military spending to assist funding universal health care does not equal dissolving all foreign presence and just maintaining borders. It is possible to re-allocate a small portion of spending on military to support social programs.

[Scarlett]

These are the hours of most professionals I know.

Really? I don't think I know anyone who works 100 hours a week.

[Twolittleboys]

You realize there is far more to funding a functional military than NATO, right? The UK has decent military spending for the region, no doubt. But again, pretty much the only projected way to cover the healthcare expenses without a higher tax burden is shifting from defense or other entitlements like social security or medicare/medicaid. I don't have time right now but there are some great studies with analyses of spending by governments and where the priorities are. A shocking number of European countries spend almost nothing on defense and have no effective standing military other than ceremonial, but spend a great deal on their social safety nets. If they were required to maintain the bulk of their own defense and couldn't call in another country's bigger and more stable force they could not afford both. Heck, a handful can't maintain the safety net anyway - not enough revenue coming in.

 

I can't remember for the life of me which thinktank had the best breakdown on this but it was a fascinating look - essentially, what happens to spending in other countries if the US military dissolved all foreign presence and just maintained borders.

But shifting some money from defense would surely not create that many problems?

 

I don't know a lot about the military so bear with me here (by which I mean don't take it quite literal if I don't use the right expressions). Let's say the US buys fewer destroyers/aircraft carriers/planes etc for a couple of years (say 3 to 5). I am not sure that would have much impact on how much European countries have to spend on defense. I mean, just because there are somewhat fewer destroyers/carriers/whatever (I am not talking about none or even a huge reduction) doesn't mean Italy will suddenly attack Germany, would it?

 

And again, I feel the US's only obligation is to provide for their own defense and fulfill NATO obligations. Everything else is extra (not saying it is bad or unnecessary). I do feel a country's first obligation is to its own citizens and that includes at least somewhat decent health care.

 

Germany as far as I know has very little of an army, partly because we aren't really supposed to (or at least weren't). But if we had to pay for a bit more to make up for a cut-back by the US, we would presumably do so. Maybe that would suck for us, but it is not really the problem of the US.

 

Again, I am not talking about a sudden, complete withdrawal of all US military etc. But some money could surely be re-allocated to health care.

[QueenCat]

Really? I don't think I know anyone who works 100 hours a week.

 

Same  here. Dh is definitely in a "professional field". Even during major projects, dh wouldn't put in 100 hours. Maybe 60-70 but that's not often. Normal workweek is more like 45-50.