Health Care Reform?
Thanks for that dose of reality.
When it comes to healthcare, I would rather not have the government involved, if necessary (same as what most of you’ve said). But, I can’t get past this thought: at least in my town, the firefighters answer the call and do their best to save the one bedroom rental with a carport, the same as the mansion on the hill. Is property protection a right but healthcare is something you get if you can afford it? Yes, we shop around for car insurance and car repair but we can choose to not own a car. Can a child choose to not have a body? Can a child choose to have wealthy parents? Maybe adults can just say "I’ll take my chances on not being insured" but children, at the very least, should have healthcare. I have no suggestions for how to fix the system. I actually feel rather hopeless about it. And, I know I’m rambling. Wow. My ears are ringing — I think this is actually raising my blood pressure. A bit of dark humor for a forum on healthcare. I will go think some happy thoughts now…
RNcarl, I agree with a lot of what you’re saying. When I worked at the hospital, I saw some pretty hinky cooking fo the books going on depending on who was getting what procedure and who had which insurance company. My own surgery was deemed "not medically necessary" and I had to self-pay… so I ended up having to pay my surgeon, up front, out-of-pocket almost 3 times more than they would have accepted had my insurance authorized it. I was also charged almost double for the other medical expenses… that’s double the claimed amount, not double the amount after write-off. Later, it was deemed in court that my surgery was medically necessary and my insurance had to reimburse me… but only for the amount that they would have paid via adjustments and wirte-offs had they originally authorized it. So, I only ended up getting back about 1/4 of what I had to fork over (which was the money I’d saved for my last two years of college – no degree for me!)
How in the world does charging a self-pay patient MORE than an insured patient make any sense?
I don’t think it’s necessarily the practitioners or the patients at fault here. It’s that sneaky co-dependence between insurance companies and the governments, with a healthy dollop of pharmaceutical kick-backs. The docs have to pay exhorbitant liability insurance premiums and have to jump through all the hoops if they want to be an accepted provider. The patients have to pay exhorbitant health insurance premiums and have to jup through all the hoops if they want their condition treated. Docs get shafted by the HMO-model and the only way they can break even is to stack their patients up every 10-15 minutes… which means we get crappy care. It’s not their fault, it’s the insurance companies fault for fleecing us on both ends, and the government’s fault for getting their grubby little, pharmaceutical lobbyist money-taking, meat hooks all up in the mix.
A true healer wants to heal. He wants to feed his family, too; but his primary interest isn’t the money. A doctor out for the money is a capitalist businessman, not a healer… and someone like that won’t ever get near my body again! Hospitals used to be places of healing, but now so many of them have become bureacratic and microbial cess pools… despite the best intentions of the docs, nurses and other care givers.
I think many patients would take better care of themselves if they just knew what they were supposed to do… seems there is a new discovery and a new treatment method every week and with every doctor you go to. Fat is bad, sugar is bad, high fiber is good, cholesterol is bad, exercise is good… every single one of these recommendation can be utterly WRONG in certain cases. But the pharmaceutical companies make more money on treatments and supplements than "cures"… which means they can pay the government some more money to not do real research on how many medications we actually DON’T need, and provide some better food guidelines (that pyramid, even the new one, sucks… 9 servings of grain? are you kidding… ooh wait, what’s America’s most productive crop… GRAIN!). Long gone are the days when you could sit down with your doc for a whole hour and discuss what your specific issues are and what your specific treatment plan should be… nope, nowadays you’re lucky if you get 10 minutes, a prescription for whatever the new cocktail is, and the party-line edict to quit smoking/exercise more/reduce stress/eat less-more of XXXX.
So, no, I don’t believe that health care should be a business. Free market will only work if you cut out all the insurance, government and pharma meddling… and all the hospitals are run as non-profits again. Just take profit right on out of the equation. If my doc will take a chicken, I’ll give him a chicken for his table to feed his family; if I don’t have a chicken, I’ll go paint his porch when I’m feeling better so that his family can live in a well-maintained home. That’s the way it used to work before industrialized-capitalized medicine.
I realize that it can be hard to understand how a free-market healthcare system would be better than the system we have now. It is particularly difficult given the fact that everyone posting has lived their entire lives within some version of the current system, and it is hard to see beyond those boundaries.
Still, the only option beyond a free-market system is some version of what we currently "enjoy", one with governmental regulation of how business provide healthcare to their employees, regulations on insurance companies, de facto "price setting" in the form of Medicare reimbursements, etc. Time has shown, again and again, that government’s attempts to correct problems typically only create more problems.
Healthcare is not a right, it is a personal responsibility. Accordingly, there is no guarantee that healthcare will be equal and fair to all. Life is not fair. Those that are wealthier could afford more healthcare, just as they could afford to have nicer cars. Everyone likes the idea that healthcare should be fair to all, me included. The problem comes when government tries to ensure that fairness. And, even if we went fully down the road to a socialized system of healthcare in the U.S., we would almost certainly see the same two-tiered system of healthcare that has developed in many other countries with taxpayer-subsidized healthcare. One would be the public system, that would be "free", but typically associated with delays in care, rationing, and not infrequently, less than ideal care. The second would be a private system, available only to those that could afford it.
Carl, in a system of free-market healthcare, I do not envision potential patients "price-shopping" their healthcare for urgent medical conditions. But, without the "price-fixing" that currently exists (most private insurers base their reimbursements on Medicare standards, set be the government) and the "middle-man" costs you correctly identified, prices would come down to more sustainable levels. As to elective medical issues, I would fully expect potential patients might "price-shop" their care, and even weigh those potential healthcare costs against other expenditures they face. To borrow your knee replacement analogy, perhaps one more expensive an MRI is not absolutely necessary, and your orthopedic surgeon would be willing to proceed based upon cheaper plain-film x-rays, alone. Or, perhaps the knee replacement could be reasonably delayed in preference for continued, less expensive, conservative management, especially since you need to replace that furnace this year.
Again, we have finite resources, and rising costs. Rationing of healthcare is inevitable, and I would much rather see rationing done by the individual, rather than a government bureaucrat or an insurance company.
Health savings accounts should be thought of as any savings account, except that deposits are from pre-tax income. You direct how much you save, and how much you withdraw for needed or wanted medical care. Any surplus at the end of the year rolls over to the next. I honestly don’t know whether HSAs are run by insurance companies, or not, but the contributions to the HSA are yours, not the holding company (excepting any management fees, of course). Catastrophic health insurance is a different matter, and would presumedly be purchased from a conventional insurance company. The HSA would be used for routine care, such as physician visits, routine diagnostics, medications, elective procedures, etc. Catastrophic health insurance would be to cover more serious illness or injuries. This would restore the traditional role of insurance to healthcare.
As to hospitals, the majority of hospitals in the U.S. today are still non-profit, most established originally by various religious organizations. And, while many were originally established in wealthier neighborhoods, many were also established specifically to serve those that are economically less fortunate. Hospitals still provide an enormous amount of free care, and I don’t see any reason that that would change. The same applies to physicians.
Like it or not, healthcare is, has always been, and likely always will be, a business. It is just a very poorly run business, currently. There are any number of egregious examples of how our healthcare currently is too expensive, unfair, poorly administered. The question I would ask is whether you think that more government regulation and oversight is actually going to make things better?
How in the world does charging a self-pay patient MORE than an insured patient make any sense?
I apologize for not addressing this question above. It absolutely makes no sense that a self-pay patient should pay more than an insured patient, and they wouldn’t in a true free-market healthcare economy, but that is exactly how it is engineered in the current system.
Let me illustrate with a fictional procedure, a double brain transplant (I borrowed that from Toy Story 2). I’ll be the surgeon who performs said procedure. I work with three insurance plans that pay for that procedure. Insurance company #1 will reimburse me $5000, insurance company #2 will reimburse me $3000, and Medicare will reimburse me $2000. I am required by law to set one price for each service that I provide. I would be foolish to set my price any lower than the maximum I could receive from insurance company #1, so I set my price something close to $5000. If a patient covered by insurance plan #2 comes in, I will charge my $5000, but my contract with that insurance company will require me to accept $3000, and to write-off the $2000 balance. If a self-pay patient comes in, I run the risk of committing insurance or Medicare fraud if I charge that patient less than my customary amount. In actual practice, many providers will make such deals, but they are potentially putting themselves at risk. For example, if I performed the double brain transplant on a self-pay patient, and charged them at my lowest reimbursable rate, Medicare’s $2000, I could potentially be sued by insurance companies #1 and #2 for overcharging them.
This example, of course, only looks at the costs from the practitioners point of view. The situation is similar, for hospitals. Their costs are also typically inflated, not only for the reasons above, but also to cover losses incurred by providing "free" care for those without insurance.
I hope this helps you understand the situation in which you found yourself, and to understand the frustration that many of we healthcare providers have with our current system.
Single Payer Health Care is the only true solution to our Health Care system.
THE REVOLUTION WILL NOT BE MEDICALIZED, By Kellia Ramares
There should not even be a debate over single payer. All of the objections to it are a bunch of baloney. Waiting times: I remember my dying grandmother stooped over her cane in agony while waiting hours for Montefiore Hospital, a prestigious private hospital in the Bronx, to find a bed for her – in 1964. And insurance wasn’t an issue; they just didn’t have the space. Surely everyone who has been delayed or denied approval for care from an insurance company knows the waiting time issue is a red herring.
Maybe doctors would have more time for their patients if they didn’t spend hours dealing with insurance companies. Freedom of choice: Yeah, you can have any doctor you want, so long as he or she is in your insurance network. If the doctor is out of network, you pay through the nose. Some freedom! The government can’t afford it: Well, if we shifted our priorities away from bailing out banksters and waging wars, we could afford it easily.
Why is it that we can throw trillions of dollars at bailouts and bombs but we can’t afford health care for all? ocialized medicine: This argument is the biggest hoot. First of all, so what if single payer were socialized medicine? If you want to talk about efficiency, as the people against single payer are wont to do, then let’s talk about the inefficiency of having the capitalist system, which was designed to provide goods and services, based on profitability, attempting to provide services for everyone, based on need. The process doesn’t work well because capitalism was never designed to provide for everyone based on their needs. Trying to shame, cajole, sue or entice it to work that way only results in inefficiency at best and injustice at worst. Several years ago, I saw a newspaper photo of a black women in a Third World country; she was wrapped in a white sheet and sitting in a wheel barrow on the street. She had been put out of the hospital she had been in because she could no longer afford to pay for her care. In the United States, we would rightly consider such treatment barbaric, and then hypocritically hide our own barbarism in myriad bureaucratic maneuvers to deny a patient access to the hospital in the first place.
Secondly, we shouldn’t react as if we don’t already have socialized services in America. We have plenty of them: police and fire services, street lights, libraries and public schools to name a few. If they aren’t working as well as they should, at least part of the blame can go to the anti-tax attitudes of the last thirty years, which have led to underfunding. So single-payer health care would not be the first time we had a public service available to all, funded by the taxpayer i.e. socialism. Lastly, single payer wouldn’t really be socialized medicine under a Medicare-for-all type of program. Only payment for services would be socialized. The actual rendering of health care would remain private. The practices and facilities that are private now would not become government-owned and run.
The Real Reason
The focus on all of these issues hides the real reason why single payer has been stymied. The real reason is that a “Medicare-for-all” system would put the private health insurers out of business. Corporatists and their bought politicians cannot allow the insurers to be run out of business because it would set a dangerous (to them) precedent of having a society decide that certain types of industries heretofore wearing the respectable label of “legitimate business” do not have an automatic right to exist. If that happens, then what comes next? As food activist Michael Pollan, author of The Omnivore’s Dilemma and In Defense of Food, points out, many of our health problems in America have their sources in food. For example, a triple-chocolate cake sent to me as a gift last December contained, according to its ingredient list, silicone and propylene glycol, the latter a substance also used as a solvent and as anti-freeze. Ingesting those kinds of substances cannot be healthy if one is not a car.
Will a society that has the temerity to abolish health insurance companies then totally revolutionize its food system to run the purveyors of artificial and toxic “edible food-like substances,” to use Pollan’s term, out of business? (Monsanto, watch out!) Once we break free of the notion that any particular industry is entitled to existence, will we then finally repeal corporate personhood, stating what should be the obvious: that corporations are things that human beings have created to aid in performing certain functions. They are not our masters who have rights that can trump those of flesh and blood people. Single-payer health care could be the snowball that could start the avalanche that flattens and buries corporatism. Imagine such a thing because I can assure you that the corporatists have. And the thought makes them sweat. It’s is not simply a matter of lost near-term profits. It’s a matter of control — permanent control — over our lives, money and choices. The “public option” sell-out of single payer is allegedly a form of competition for the private insurance industry. Under capitalist theory, industry works more efficiently, innovation is fostered, and consumers have more choices when competition is promoted. But what do you want to bet that the “public option” will draw the poorest and sickest people, i.e., those who under the current system are deemed uninsurable, or who can’t afford what insurance they could get, leaving the prime customers, i.e., the young, healthy and well-off people who will make fewer claims, to the private companies.
The public option will be underfunded in these “hard times”, and the mainstream media will sniff everywhere for stories of how people on public insurance had to wait for their care (to reinforce the “private good – government bad” brainwashing), while stories of private insurance companies delaying or denying care will be buried, sometimes along with the patients. The only true health care reform is universal single-payer health care. Health insurance is a scam! Public option is a sham!
I felt a single-payor system made the most sense, until fairly recently. And, one could certainly argue that a single-payor system is a reasonable proposal, if one could reasonably guarantee that such a government-sponsored, single-payor system would be more effective and more economical than other government programs have proven to be. Unfortunately, I do not believe such a guarantee can be made.
Doc Peters – I know the trials practitioners have to go through dealing with the insurance companies and all the price-fixing that the insurance companies and government regulations dictate. I do understand how and why my particular situation occured, and I don’t blame it on the doctors or the hospital at all. Blame for this mess rests squarely on the shoulders of the insurance companies, government and pharmaceutical companies.
I think part of the problem is that our current system actually forces practitioners to think in terms of profit because they have to. Using your double brain transplant analogy… the surgeon knows that a double brain transplant will take him most of the day to perform, during which he won’t be able to see any other patient or get any other work done. So, he knows that he normally makes about $2k a day doing normal business, so he charges $2k for the surgery… maybe a little more to set aside to cover some "pro bono" surgery for another patient at some future time. Now, simply because Insurance #1 will pay $5k, he sets his price at $5k even though his effort/expense is really only $2k… and the uninsured patient gets nailed by artificial price inflation. If the surgeon simply charged a set rate for the surgery, regardless of whether the "going rate" was higher, then neither he nor the patient would have to be concerned with the whining insurance companies or possibly commiting insurance fraud. Again, this is the fault of the insurance companies & government… not specifically the practitioner (although there are some money-hungry practitioners out there who do milk the system).
Perhaps I’m lucky in that I lived in a small community where healthcare was not overly monetized. The docs and the tiny hospital charged everyone the same amount, regardless of insurance, and you pretty much had all the time you needed to discuss your issues with the doc. If someone couldn’t afford their treatment, then mutually-equitable deals were worked out. Fund raisers were held 2-3 times a year to make specific improvements to the facility or to pay for specific treatments for specific individuals… i.e. "we need to send Johnny to the city for a kidney transplant, won’t you please buy a cupcake?" Conversely, the community had fund drives to help pay tuition for the practitioners… i.e. "Peggy just got accepted to med school, won’t you please buy a raffle ticket?". This community-based system worked quite effectively, everyone got reasonable health care at reasonable cost and the hospital ran in the black without being excessively reliant on government, pharma or insurance programs. To the best of my knowledge, it’s still going strong and still operating pretty much the same.
So, no, I don’t believe that more government regulations are the answer… unless the regulations are strictly applied to the INSURANCE companies, while leaving the healthcare practitioners to operate less burdened. I fully believe that the healthcare system would function more like a true free-market system if we could remove the blood-sucking leeches (insurance companies) from the mix. But, on the flipside, healthcare practitioners shouldn’t be able to jack up their prices simply because they can… and that is the problem with free-market and consummate-demand commodities. Getting rich off the suffering of others just because you can is just plain wrong… black market, war lord stuff! I think community-based "socialized" healthcare (like I described above) is a happy medium. No one should get in the way of a doc who wants to help someone even if that person can’t afford to pay… if the doc doesn’t care about doing the work pro bono or discounted, then it’s nobody’s business. Sliding-scale doesn’t have to end in price-gouging unless the practitioners get greedy… perhaps more transparency of costs and reasoning would keep people from getting too grumpy about the discrepancy of charges.
One of my favorite stories goes something like this:
One day a tractor-trailer semi truck is driving a small mountain road and goes into a tunnel at full speed, only his trailer is several inches too tall and the whole thing wedges into the tunnel and traffic backs up in both directions for miles. Finally they are able to get some help to the scene and they try everything they can to pull this truck out of the tunnel. They have several bulldozers, chains wrapped all around the truck, even people inside the tunnel pushing just to get it to move but nothing works. After several hours of this a 5 year old girl who has been near the tunnel watching the whole time speaks up and asks one of the engineers, "Why don’t you let the air out of the tires?"
The whole point of telling you this story is that sometimes we try so hard to fix a problem a certain way that we don’t think about alternative solutions. The problem, as I see it, is that we are trying to fix the notion of "Health Care" when we should be trying to get rid of it altogether.
When did this begin? When did we get "health care"? When I was growing up it used to be known as "health insurance" and it was treated as just that – INSURANCE. Insurance is something we buy that we hope we never have to use: car insurance, property insurance, life insurance, etc. I don’t get car insurance and at the end of the year realize that I’ve had no accidents so I go out and cause one so that I can use up my insurance. And yet people do just that when it comes to their health insurance, only now we call it health care as if it is something that is intended to be used. We created this entire system based on the moral hazard of having to use it since we’ve already paid for it.
What’s worse is that people don’t think about the whole sum of their health care expenditures throughout the year. I went without insurance for a couple of years up to about a year ago. It was a bit of a scary time but I still went to the doctor for the same types of things I normally would. When I’d get there I’d explain that I had no insurance and they billed me directly. Then I realized that for a typical doctor’s visit I would pay anywhere from $40-$100. In a years time it would be a lot if I went 3 times. That’s a total of approximately $300 out of pocket for the entire year. But the people with the healthcare plans go to the doctor and only have a $20 copay. They think to themselves that $20 is much better than the $80-100 they may have paid for the same visit without realizing that they are paying several hundred dollars each and every month through their paychecks for the privilege of saving the 80 bucks from their last doctor visit. I can get homeowner’s insurance to cover a $250,000 house for just $750 per year. Why couldn’t I get a similar plan for my medical emergencies.
I understand that different people have different needs and some require much more extensive medical care than I might but the point is that instead of paying $12,000 per year plus what their employers match that could have gone in their paychecks too, they could get an awful lot of medical care for that same amount of money and pay a lot less in just plain old insurance if the system wasn’t as screwed up as it is. There’s nothing wrong with the idea of insurance. If I get a heart attack, get into a car accident, develop cancer, need brain surgery, whatever. Those things can be very expensive and I would want insurance to cover that. But I’m talking about normal, typical daily type medical stuff. Why should we need a healthcare plan for that?
Employers used to contribute health care to an employee as a benefit or a perk like stock options, vacation time or a company car. It is no longer a benefit but, apparently, a God given right that we all deserve it because we’re Americans. What’s next? You’re going to tell me that I need a "car care" plan to take care of my normal maintenance such as brake jobs, oil changes and car washes? Then I can get a "house care" plan to take care of my lawn, cut my hedges and give me maid service too. Why stop there? Let’s get a "food care" plan so that we can be sure we eat on a regular basis and first our employers can give it to us and eventually the government can step in to fix our "food care" problem. How about an "education plan" for me and my children. This is getting ridiculous.
We can come up with a plan for everything we use in life but normal doctor’s visits are just a part of normal living expenses and should be treated as such. If I get a cold and want antibiotics, then I will go and buy some from a doctor if I have the money, if not I guess I’ll have to spend a few more days in bed. If I break my arm then I guess I’ll have to find a way or come up with some sort of repayment plan much the same way I would if the transmission breaks on my car. Let’s get rid of the idea of "health care" reform and get back to the idea of paying our share for what we use and keep the system simple. Let doctor’s decide what their going rates are and let the free market decide if they are charging too much for their services or not.
Thanks for listening. I’ll step off my soap box now.
[quote=PlicketyCat]I think part of the problem is that our current system actually forces practitioners to think in terms of profit because they have to. Using your double brain transplant analogy… the surgeon knows that a double brain transplant will take him most of the day to perform, during which he won’t be able to see any other patient or get any other work done. So, he knows that he normally makes about $2k a day doing normal business, so he charges $2k for the surgery… maybe a little more to set aside to cover some "pro bono" surgery for another patient at some future time. Now, simply because Insurance #1 will pay $5k, he sets his price at $5k even though his effort/expense is really only $2k… and the uninsured patient gets nailed by artificial price inflation. If the surgeon simply charged a set rate for the surgery, regardless of whether the "going rate" was higher, then neither he nor the patient would have to be concerned with the whining insurance companies or possibly commiting insurance fraud. Again, this is the fault of the insurance companies & government… not specifically the practitioner (although there are some money-hungry practitioners out there who do milk the system).[/quote]
Yes, we do have to think about profits, at least those of us in private practice. I will always try to get the best price that is offered, as there are other services I provide that are routine a loss for me financially, and I have four employees.
[quote=PlicketyCat]Perhaps I’m lucky in that I lived in a small community where healthcare was not overly monetized. The docs and the tiny hospital charged everyone the same amount, regardless of insurance, and you pretty much had all the time you needed to discuss your issues with the doc. If someone couldn’t afford their treatment, then mutually-equitable deals were worked out. Fund raisers were held 2-3 times a year to make specific improvements to the facility or to pay for specific treatments for specific individuals… i.e. "we need to send Johnny to the city for a kidney transplant, won’t you please buy a cupcake?" Conversely, the community had fund drives to help pay tuition for the practitioners… i.e. "Peggy just got accepted to med school, won’t you please buy a raffle ticket?". This community-based system worked quite effectively, everyone got reasonable health care at reasonable cost and the hospital ran in the black without being excessively reliant on government, pharma or insurance programs. To the best of my knowledge, it’s still going strong and still operating pretty much the same.[/quote]
This is a great model; one that would be a pleasure in which to practice, and one that puts accountability for services in the hands of individuals and the community, in whose hands I believe it belongs. I have written elsewhere on this site about community-based medical services, particularly for primary care services, which would fit well into the experience you describe.
[quote=PlicketyCat]So, no, I don’t believe that more government regulations are the answer… unless the regulations are strictly applied to the INSURANCE companies, while leaving the healthcare practitioners to operate less burdened. I fully believe that the healthcare system would function more like a true free-market system if we could remove the blood-sucking leeches (insurance companies) from the mix. But, on the flipside, healthcare practitioners shouldn’t be able to jack up their prices simply because they can… and that is the problem with free-market and consummate-demand commodities. Getting rich off the suffering of others just because you can is just plain wrong… black market, war lord stuff! I think community-based "socialized" healthcare (like I described above) is a happy medium. No one should get in the way of a doc who wants to help someone even if that person can’t afford to pay… if the doc doesn’t care about doing the work pro bono or discounted, then it’s nobody’s business. Sliding-scale doesn’t have to end in price-gouging unless the practitioners get greedy… perhaps more transparency of costs and reasoning would keep people from getting too grumpy about the discrepancy of charges.[/quote]
Overall, I think you and I are saying quite comparable things, but from slightly different angles. However, I would not describe a community-based healthcare system (at least, not as I would envision it) as "socialist" in any substantial way. This is just local communities coming together to do for one another what they are supposed to do, care and assist one another. And, as to free-market principles in healthcare, I think most practitioners (not all, mind you, and I know some) are very fair and generous people, and would not take advantage of those in need. Most of us provide care for free quite regularly. And, if a given medical service were able to premium prices, that would potentially attract more practitioners to that field, increasing supply, and ultimately decreasing costs.
I have a libertarian perspective on these things, I admit, but I can see much greater benefits to our healthcare system from the adoption of true free-market reforms, than I can see from any other possible system.