Black Market Healthcare

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JAG's picture
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Black Market Healthcare

OK, enough with the politics on the healthcare debate, its time to apply the community braintrust to finding personal solutions to healthcare.

As small business owners (in the healthcare field, no doubt), my wife and I have never been able to afford healthcare insurance for ourselves, nor do we accept insurance in our practice. We have made connections with a few medical doctors that offer reasonable cash prices for their services, and so far this has sufficed.

I'm hoping that this new healthcare reform will encourage healthcare professionals and patients to create a "black market" for healthcare services. In doing a google search for black market healthcare I came across this post:

Black Market Medicine: Staying Off the Grid

In a previous post, DrRich made a (more or less) tongue-in-cheek suggestion that our healthcare system is now presenting American physicians with a brand a new business opportunity - Black Market Medicine. Doctors operating in this new, blacker healthcare sphere would offer their patients “off the grid” healthcare services, that is, clandestine medical care. Their customers would be comprised mainly of otherwise law-abiding individuals who want and need medical care and who are even willing to pay for it (which, admittedly, will limit the potential clientele to a very tiny proportion of the American public), but who are afraid to leave a paper (or database) trail of their medical problems. In other words, they want their medical conditions to be professionally addressed, but wish to avoid documenting that dreaded “pre-existing medical condition,” which will be used to deny them future healthcare.

The occasion for revisiting this seemingly absurd idea arises from an article appearing in the most recent Sunday New York Times, which describes the case of Victoria Grove, an individual who did not want her doctors to know that she had a genetic condition - alpha-1 antitrypsin deficiency - which predisposes her to emphysema. Ms. Grove made the discovery herself using a home test kit. Having several family members with this genetic disorder, Ms. Grove understood that her condition meant she would need immediate medical care for her occasional bouts of pneumonia - but at the same time, she did not want her genetic condition to appear on her medical records. Thus, whenever she got sick she sought medical care right away, but never divulged her alpha-1 antitrypsin deficiency to her doctor.

At last, there came the day when a nurse decided Ms. Grove merely had a cold and did not need a chext x-ray. Ms. Grove tried to tough it out, but her condition worsened. She called the clinic to beg for antibiotics, and was told she needed to be seen in person before a prescription could be written. But she was too sick to drive. Finally, under severe duress, she caved in. From the Times: “‘I have alpha-1,’ she remembers sobbing into the phone. ‘I need this antibiotic!’”

Ms. Grove got her antibiotic, but from that moment she was outed.

American physicians: The desire of American patients to receive medical care while remaining off the grid is now undeniable; even the New York Times acknowledges it. The demand is there. Which of you will rise up to will meet it?

When DrRich says Black Market Medicine, that’s exactly what he means. These doctors will be functioning illegally, in the proud tradition of their spiritual ancestors, namely, the old pre-Roe back-alley abortionists who also dispensed their special variety of medical services on the sly, clandestinely, taking pains to leave no traceable record of their activities or their patients’ medical histories.

These new Black Marketeers will not be offering medical services that are themselves inherently illegal (like abortion was in the 1950s), but instead will be offering the same legitimate, routine medical care that you can get from any “on the grid” doctor. The only difference is that no formal record will be created - none whatsoever - of the care thus dispensed. Once the patient leaves the office, the encounter never happened.

Black market economies of any variety, of course, are inherently bad. Any product or service provided illegally is not subject to normal rules, regulations, or safeguards. (If there are enforcers of the “norm,” they tend to be even less savory than those in the employ of the feds.) The purchaser of those products or services is pretty much at the mercy of the seller, and has little recourse if the product or service proves faulty.

This is why black markets only arise when the legitimate pathway to the desired product or service has become so exclusive, oppressive, expensive, or toxic that anything would be better.

Which, again, fully explains why the time for Black Market Medicine is nigh.

It seems likely that many people will choose to pay the fine (healthcare tax) for not having healthcare insurance because they won't be able to afford the "new" insurance. Thus, I see this healthcare reform as a boon for local healthcare professionals that are willing to work outside the system. 

Does anyone have any info on this new business model for medicine?

 

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Re: Black Market Healthcare

 

Looks like agorism is becoming more attractive.

http://www.peakprosperity.com/forum/agorism-option/13183

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Re: Black Market Healthcare

Jeff,

I don't see this working on an significantly sized scale.  Any physician who sacrificed years of his life and literally hundreds of thousands of dollars in educational costs and deferred income isn't going to put his license on the line and even more importantly, isn't going to risk the legal exposure of zero documentation.  The only ones I can see doing it are the hacks that you wouldn't want treating you.  It's the potential legal risks that will torpedo it.  The System has got the system wrapped up tight.

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Re: Black Market Healthcare

Jeff,

I can't speak to your question of "black market" healthcare, as I have no knowledge of the subject.  That said, I know that most physicians are willing to offer their services on a cash basis, at typically much less than the false-market-inflated price.  A record would typically be kept (at least, we do so in our office), and everything is "above-board" in all respects, but the cost of service is less.

We are already seeing increasing numbers of physicians (primary care, especially, but some specialists) entering into cash-only practices.  I suspect that we will see more of this in the future.  At the other extreme, we will see more physicians (especially specialists) becoming employees of a healthcare organization, such as a hospital, which will limit these opportunities for discounted, cash-basis, service.

Physicians, including me, are just trying to find a way to survive in an ever-changing marketplace.  Where it will end up, I can certainly guess, but how we will arrive there, is open to conjecture.

Chris

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Re: Black Market Healthcare

 

 a minor framing issue..

 

 NOT BLACK...

 FREE.

 

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Re: Black Market Healthcare

 

 Stefan Molyneux on the Healthcare issue....

 http://www.youtube.com/watch?v=MGvQcI4Vllo&feature=sub

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Re: Black Market Healthcare

AO and Dr. Peters,

Thanks for your input.

I failed to communicate clearly in my original post. The "black market" aspect is secondary to potential of the government regulating that a healthcare provider cannot offer services outside the new system (or for cash). I think in this situation, some physicians might be inclined to offer services to those patients that are in need but can't afford the government's plan, even if it had to be done in a clandestine manner.

What do you think?

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Re: Black Market Healthcare

Jeff,

For the foreseeable future, I see little reason to fear that physicians would be unable to offer their services on a cash basis, if they so chose. From my personal perspective, I am considering two of the extreme positions I mentioned above. First, I am considering a move to Hawaii (Big Island), and if I did so, it would be as a hospital employee. Second, if we decide to remain in Iowa, I think it is fairly likely that I will gradually migrate to a cash-based practice. I would first drop government contracts, and might ultimately eliminate all third-party payors. But, even if I did the latter, my practice would be pretty much the same; above-board, well-documented, etc.

Chris

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Re: Black Market Healthcare

Molyneux does a very good job at framing a discussion. I  think he has made some errors in his thesis. I have a friend who is an orthopedic surgeion and he told me that when he performs a surgery that costs the patient $40 k he gets $5k. The rest of the cost is  for the hospital and the administrative costs. So having doctors make less would not reduce the total bill for the patient very much.

He also told me that around 50% of medical costs today are due to paperwork. Thanks to insurance companies and our benevolent Uncle Sam.

Another point he raised with me is that less than 50% of doctors are members of the AMA. Many are members of organizations related to their specialty rather than the AMA.

I am sure Chris Peters can speak to these issues far better than I can but it is important to keep to the facts in this discussion.

V

ps About 2/3 thru I started to lose the audio so I did not hear the whole thing.

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Re: Black Market Healthcare

V,

You are correct on all points, as best I can judge.

For hospital-based procedures, the physician portion of the bill is very small. For a cardiac or lung procedure, for example, I collect somewhere between $1500-2200 for a Medicare patient, while the hospital receives (I believe) $30,000-40,000.

I can't precisely say what percentage of our costs go to "paperwork" (we are nearly entirely electronic at this point), but I would be surprised if it were nearly as high as 50%, in my practice. Our biggest cost, by far, is for medical equipment. But, for non-proceduralists, such as primary care physicians, I would not be surprised if the 50% estimate is correct.

I also do not know what percentage of physicians belong to the AMA, but less than 50% sounds about right. I have been an AMA member periodically throughout my career, until I became savvy enough to realize that they really didn't represent my interests, or the interests of my patients. I am a member of the American College of Surgeons and the Society of Thoracic Surgeons, as well as my local county medical society, which I feel do a (somewhat) better job in these regards.

Chris

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Re: Black Market Healthcare

Oh, I forgot to mention, I prefer the American College of Physicians and Surgeons over the AMA, as they seem to have a much more palatable libertarian-minded and patient-centric viewpoint, in my opinion. I haven't yet becoming a dues-paying member, but I like what I have seen thus far on their website:

http://www.aapsonline.org/

If anyone has comments regarding their viewpoints from a (prospective) patient point of view, I'd enjoy reading them...

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Re: Black Market Healthcare

Great discussion.  I can see a cashed based system working for office visits and procedures but what happens when a hospital's surgical suite is needed?  I guess "in office" health services could be increased but if you opt out of health insurance, what do you do when a major procedure is needed?

The Association of American Physicians and Surgeons, Inc. website is interesting, I will have to look further.  One of the things I often wondered about was why were doctors so quiet through-out the Obamacare debate...now I see that many were speaking out...they just weren't heard.

Larry

 

 

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Re: Black Market Healthcare

 

 what happens when a hospital's surgical suite is needed?

 Flight to cuba ? Or India ?

medical tourism is pretty massive already..

 http://en.wikipedia.org/wiki/Medical_tourism

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Re: Black Market Healthcare

Medical tourism is certainly an option. I remember joe2baba passed along some links regarding medical tourism that were quite interesting, and I have heard some favorable reports.

In the U.S., a hospital stay will remain excessively expensive for the foreseeable future, particularly for unexpected and/or serious illnesses that require a long hospitalization. Given the likely costs involved, having at least a catastrophic insurance plan would still seem attractive (this is what our family switched to this year). If a surgeon has a cash-only practice, he/she would still collect the physician fee in cash, even if the hospital still bills the patient's insurance carrier.

But, there are some communities, such as the sizable Amish population we have in Iowa, that do not carry insurance, and pay in cash from the community chest. They have negotiated rates with the local hospitals, which I expect (but do not know for certain) are significantly less than the "billed-for" charges hospitals usually use.

Also, our plastic surgeons have set rates that they have negotiated with our hospital for their cash-based procedures. For a bilateral breast augmentation, I believe $5000 is charged to the patient, from which the surgeon is paid, the anesthesiologist is paid, and the hospital services (O.R., primarily) are paid. I don't know if they have a similar arrangement for those procedures that might require an overnight or longer hospital stay. Other specialists might be doing the same in some areas of the country. This might be a very good pattern for me to consider emulating if I do migrate to a cash-only basis. (Putting on thinking cap...)

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Re: Black Market Healthcare
ccpetersmd wrote:

 First, I am considering a move to Hawaii (Big Island), and if I did so, it would be as a hospital employee. 

Hilo side or Kona side of the Big Island Doc?

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Healthcare for No One.

Its seems as though there will be potentially more people without healthcare coverage because of this "reform". 

Health Care Passed; How will Individuals and Corporations React?

What will your company do and what will you do?

Large corporations will probably pony up. There would be an enormous backlash if they dropped benefits.

Smaller companies are another matter. I suspect many struggling companies will drop coverage if there is an economic benefit.

Looking at individuals, the annual penalty is $695 dollars or 2.5 percent of income. The penalty cap is $2,250 per family as of 2016.

Many of the young and healthy will simply opt out. After all, the bill will not allow discrimination based on preexisting conditions. Thus, it practically begs the young and healthy to opt out.

Moreover, if we can judge from "The Reaper" many healthy individuals approaching retirement will opt out as well.

Illegal aliens sure will not be buying coverage.

Finally, there are many who cannot afford, or believe they cannot afford anything at all. They too will opt out if the fine is lower.

94% coverage as a result of this bill? Don't count on it.

I have yet to find any reliable numbers on what this plan will cost individuals. Denninger has posted $15K/year per individual plan and $10K/year for employers. 

It's Gonna Be Like Christmas! (Health Care)

You got the $10,000 for the policy and another $10k for the out-of-pocket deductibles, right?

Yes, I know if you are lower-income you'll get subsidies.  But that being laid off thing might become more-permanently laid off, you see, since if you go back to work your employer will have to either pay a fine (annually) or pick up the majority of that $10k in cost.

If your value in the marketplace is $20/hour, with a 2,000 hour man-year of work (50 weeks x 40 hours/week) your economic value in the economy is $40,000 (gross.)  From this your employer is going to have to take $10,000 out to avoid being fined, which means you now make $15/hour.  Then you pay taxes (FICA and Medicare) on that.  You'll likely get back the rest of your federal income tax (especially if you have a family) but your out-of-pocket medical expenses will still be that $10,000 either way.

So now you've got $30,000/year less about $2,300 in Medicare and FICA tax, and from that you subtract the co-pays and deductibles of $10,000.  You're left with about $18,000 to live on, or about $1,500 a month for your family of four.

Even in "normal" economic conditions, I seriously doubt that the majority of employers and individuals can afford this. It seems highly probable that given this predicament, a "black market" for healthcare services will flourish. Not to mention a growing need for good information on home (self-treatment) health care and supplies.

Does anyone have any other figures for the cost to an individual or family?

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Re: Healthcare for No One.

The sections described below are taken from HR 3590 as agreed to by the Senate and from the reconciliation bill as displayed by the Rules Committee.

http://www.investors.com/NewsAndAnalysis/Article.aspx?id=528137

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Re: Healthcare for No One.
JAG wrote:

Its seems as though there will be potentially more people without healthcare coverage because of this "reform". 

Health Care Passed; How will Individuals and Corporations React?

What will your company do and what will you do?

Large corporations will probably pony up. There would be an enormous backlash if they dropped benefits.

Smaller companies are another matter. I suspect many struggling companies will drop coverage if there is an economic benefit.

Looking at individuals, the annual penalty is $695 dollars or 2.5 percent of income. The penalty cap is $2,250 per family as of 2016.

Many of the young and healthy will simply opt out. After all, the bill will not allow discrimination based on preexisting conditions. Thus, it practically begs the young and healthy to opt out.

Moreover, if we can judge from "The Reaper" many healthy individuals approaching retirement will opt out as well.

Illegal aliens sure will not be buying coverage.

Finally, there are many who cannot afford, or believe they cannot afford anything at all. They too will opt out if the fine is lower.

94% coverage as a result of this bill? Don't count on it.

I have yet to find any reliable numbers on what this plan will cost individuals. Denninger has posted $15K/year per individual plan and $10K/year for employers. 

It's Gonna Be Like Christmas! (Health Care)

You got the $10,000 for the policy and another $10k for the out-of-pocket deductibles, right?

Yes, I know if you are lower-income you'll get subsidies.  But that being laid off thing might become more-permanently laid off, you see, since if you go back to work your employer will have to either pay a fine (annually) or pick up the majority of that $10k in cost.

If your value in the marketplace is $20/hour, with a 2,000 hour man-year of work (50 weeks x 40 hours/week) your economic value in the economy is $40,000 (gross.)  From this your employer is going to have to take $10,000 out to avoid being fined, which means you now make $15/hour.  Then you pay taxes (FICA and Medicare) on that.  You'll likely get back the rest of your federal income tax (especially if you have a family) but your out-of-pocket medical expenses will still be that $10,000 either way.

So now you've got $30,000/year less about $2,300 in Medicare and FICA tax, and from that you subtract the co-pays and deductibles of $10,000.  You're left with about $18,000 to live on, or about $1,500 a month for your family of four.

Even in "normal" economic conditions, I seriously doubt that the majority of employers and individuals can afford this. It seems highly probable that given this predicament, a "black market" for healthcare services will flourish. Not to mention a growing need for good information on home (self-treatment) health care and supplies.

Does anyone have any other figures for the cost to an individual or family?

Nope. And I agree it will equate to less coverage and less jobs.

But, if it is like anything else these morons have done since 2008 it'll be no more than a tax for what will equate to less services, and less pay for those who spent 8+ years of grueling study, if that means no health care for the middle class ~ then tough s#*t. Don't know what the big mystery is: So far the middle class has lost 22% of it's jobs, 30% of its' pay, 60% or more of its' home equity, millions lost their homes, they now live in tents or in their cars or crash with family, 38 million are on food assistance.

Anyone really thinks they are getting something for nothing is going to have a rude freaking awakening. 

But, hey, this guy calls it a miracle. So what if he lives 90 miles off the coast of Florida and was packing nuclear misiles for his communist bud's in Russia when we were kids.

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Re: Black Market Healthcare
JAG wrote:

Hilo side or Kona side of the Big Island Doc?

Neither. Upcountry, in Waimea, roughly between both coasts, at the northern end of the island.

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Re: Black Market Healthcare

I just received the following link from our Iowa ACS (American College of Surgeons) president:

http://www.washingtonpost.com/wp-srv/special/politics/what-health-bill-m...

It allows one to calculate, to a limited degree, one's insurance options, taxes, and/or subsidies under the new law. Conspicuously absent, largely because it is impossible to foresee with any certainty, is the effects on healthcare premiums due to the new law. In my opinion, as this law did nothing to address the fundamental problems with our current healthcare system, healthcare expenditures and insurance premiums will continue their past history of progressive growth.

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Re: Black Market Healthcare
ccpetersmd wrote:

I can't precisely say what percentage of our costs go to "paperwork" (we are nearly entirely electronic at this point), but I would be surprised if it were nearly as high as 50%, in my practice. Our biggest cost, by far, is for medical equipment. But, for non-proceduralists, such as primary care physicians, I would not be surprised if the 50% estimate is correct.

First off -- Hello Dr. Peters! -- always  a pleasure to see you 'round here!

FWIW, based on my limited experience, I can offer up a wee anecdote about the medical equipment.  

My wife had her hip replaced on 12/1/09.  I and two friends were in the tiny waiting area near the surgical theater.  There was another surgery room nearby and various docs, nurses and techs were back and forth between the two during the nearly two hours it took to complete my wife's procedure.  (side note:  at various points we could hear a surgical saw revving and we'd all exchange glances -- was that the sound of the top of my wife's femur getting taken off?  SQUICK!!)

Anyhow, this one cheery fellow kept ferrying some large piece of equipment (on wheels) back and forth between the 2 rooms.  I forget what it was -- some kind of ultrasound, maybe? -- but one of my friends kept hopping up to ask him to check on my wife's status (which he was happy to impart on his next orbit).  

The point being -- I guess equipment is so expensive that a small-ish hospital like Benedictine (Kingston, NY) is better off paying a (cheerful) fellow to ferry a given piece of useful surgical diagnostic equipment back'n'forth between locations than to buy 2 sets of that equipment...

Viva -- Sager

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Upcountry Dreams
ccpetersmd wrote:
JAG wrote:

Hilo side or Kona side of the Big Island Doc?

Neither. Upcountry, in Waimea, roughly between both coasts, at the northern end of the island.

That sounds fantastic Doc! My wife and I entertained a fantasy about living in Waimea a few years back, but we decided to wait and see if the housing market deflated there a bit. There might be some semi-affordable housing there now. To me, the Upcountry is heaven on earth, even if your a haole.Laughing

Thanks for the link.

 

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Re: Black Market Healthcare

Jeff,

Waimea is great! Lovely little town and upcountry ranch area that reminds one of the midwest (where I was raised and again live). Year round growing season. We visited two of the farmer's markets while we were there; the produce was amazing, and not appreciably higher than here in the midwest.

The housing prices in Waimea haven't dropped much, yet. Still, we'll plan on renting for a while, if we make the move. Also, the Big Island is auctioning off hundreds of acres of land on the east side, roughly 30 minutes from Waimea, in order to help meet budget deficits. Interested? Send me a PM, and I'll forward the link. I'm giving it some thought, myself.

Sorry to distract from the thread...

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Re: Black Market Healthcare
JAG wrote:

Black Market Medicine: Staying Off the Grid

The occasion for revisiting this seemingly absurd idea arises from an article appearing in the most recent Sunday New York Times, which describes the case of Victoria Grove, an individual who did not want her doctors to know that she had a genetic condition - alpha-1 antitrypsin deficiency - which predisposes her to emphysema. Ms. Grove made the discovery herself using a home test kit. Having several family members with this genetic disorder, Ms. Grove understood that her condition meant she would need immediate medical care for her occasional bouts of pneumonia - but at the same time, she did not want her genetic condition to appear on her medical records. Thus, whenever she got sick she sought medical care right away, but never divulged her alpha-1 antitrypsin deficiency to her doctor.

It seems that Ms Grove discovered her genetic predisposition, due to having affected family members, by using a test kit BEFORE she even had any symptoms of disease.

As far as I know she should, under existing law, have been insurable: http://www.medicalnewstoday.com/articles/62945.php

"At the federal level, the Americans with Disabilities Act proscribes discrimination against persons with disabilities which includes those with genetically-related conditions. The Health Insurance Portability and Accountability Act (HIPAA) expressly forbids a group health insurance plan from using genetic information to establish rules for eligibility or continued eligibility. HIPAA also prohibits insurance companies from treating genetic information as a "pre-existing condition in the absence of the diagnosis of the condition related to such information." Individuals cannot be denied health care coverage for a medical condition as a result of a genetic marker for the condition. However, individuals can be denied if they have symptoms of genetic disease."

I know that 15-20 years ago, before I retired from Medical Genetics, there was great concern over privacy and access to genetic records and the possibility of discrimination and inabilty to obtain health insurance in the US. Now a stated goal of DNA sequencing is to bring cost down to $1,000 per person, which puts a complete individual's DNA sequence at a price level affordable to both the individual and insurance company. Currently prices have only to drop between 1 and 2 orders of magnitude (which is trivial compared to the original 15 year, $4 billion effort to sequence the human genome using techniques that are now several generations old). The benefit of such knowledge would be for motivated individuals to follow a lifestyle that minimizes their medical risk, as well as having frequent testing for any mortality/morbidity threat that they are particularly prone to develop. The drawbacks are the response that the insurers will make when/if they have access to this information. In Canada our single payer system will use a shared risk approach while current philosophy suggests US insurers will use a tailored risk approach, making some individuals essentially insurable since they will not be able to afford the premiums.

 

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Re: Black Market Healthcare

Family Learns Pre-Existing Conditions Apply at Birth

Newborn Was Denied Health Insurance Coverage Days After Life-Saving Surgery

By LAUREN COX and LARA SALAHI

March 27, 2010—

Houston Tracy, a 12-day-old boy, has already survived a rare birth defect, a feeding tube and open heart surgery. Now his family is waiting to see how the battle with an insurance company will fare.

Last week, Houston's parents found out that the term "pre-existing condition" can apply the moment someone is born.

http://abcnews.go.com/Health/HeartFailureNews/newborns-family-learns-pre...

 

I can see why this could be tough from a technical perspective, but from a moral viewpoint, it seems readily clear that this child should be covered by his parent's insurance.

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Re: Black Market Healthcare

Jeff,

Here is a high-end version of black-market heatlhcare, according to this author's imaginings:

http://asonofliberty.wordpress.com/2010/03/26/american-medicine-2044/

Almost immediately a neatly dressed bruiser of a guy came out, walked around to the driver’s side and asked, “Mr. M?” He noticed the gun peeking out from the jacket, nodded and was relieved when the man opened the door for him. “Leave your keys sir and we’ll take your luggage up to your room. Everything will be there before you’re done checking in. Don’t forget your case,” he said, nodding to the passenger seat.

As he mounted the steps the door was opened by what seemed the first man’s twin. Probably also armed, he thought. He was directed to the admissions desk where a nurse waited. It wasn’t quite 5 AM and the place was alive, ready to handle the select few who could afford the best in medical care.

She handed him the forms, indicated where to sign, pointed discreetly to the cost and sat back waiting. He snapped open the case, turned it to face her. She nodded, rang a bell and another nurse appeared to take him to his room and prep him for the procedure. He was confident it would be counted before they ever began his operation but it was all there…all $110,000.

It was a lot of money, probably about 50 percent more than it should have been but what could he do. He’d been turned down by the government’s review panel. If he wanted to live to see his granddaughter married he needed the operation and the intensive follow-up treatments. So he’d made the decision, sold the necessary stocks and bonds and accumulated the cash.

The doctors here — and he was sure at the 60 or so other facilities around the country — were among the best in the country. They’d gone “underground” in 2014 when they’d “retired” and virtually disappeared off the grid……………

Prophesy or fiction? You decide.

 

 

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