Below The Radar

While everyone is preoccupied with Social Security, another Bush agenda item is moving quietly forward. From the LA Times:

"Emboldened by their success at the polls, the Bush administration and Republican leaders in Congress believe they have a new opportunity to move the nation away from the system of employer-provided health insurance that has covered most working Americans for the last half-century.

In its place, they want to erect a system in which workers — instead of looking to employers for health insurance — would take personal responsibility for protecting themselves and their families: They would buy high-deductible "catastrophic" insurance policies to cover major medical needs, then pay routine costs with money set aside in tax-sheltered health savings accounts.

Elements of that approach have been on the conservative agenda for years, but what has suddenly put it on the fast track is GOP confidence that the political balance of power has changed. (...)

Critics say the Republican approach is really an attempt to shift the risks, massive costs and knotty problems of healthcare from employers to individuals. And they say the GOP is moving forward with far less public attention or debate than have surrounded Bush's plans to overhaul Social Security.

Indeed, Bush's health insurance agenda is far more developed than his Social Security plans and is advancing at a rapid clip through a combination of actions by government, insurers, employers and individuals.

Health savings accounts, known as HSAs, have already been approved. They were created as a little-noticed appendage to the 2003 Medicare prescription drug bill.

HSAs have had a strong start in the marketplace. Although regulations spelling out how they would work were not issued until mid-2004, as of Sept. 30, about 440,000 people had signed up. And more than one-quarter of employers say they are likely to offer them as an option.

The accounts are available only to people who buy high-deductible health insurance, either through an employer or individually. Consumers can set aside tax-free an amount equal to their deductible. Employers can contribute to workers' HSAs but do not have to. Unused balances can be rolled over from year to year, and employees take their HSAs with them when they switch jobs.

The idea that losing one's job would not automatically mean losing protection for medical costs has bipartisan appeal. "Portability" was a key feature of President Clinton's ill-fated healthcare reform plan. But the GOP approach is significantly different: Whereas Clinton would have required all employers to chip in for universal health insurance, Bush wants to leave responsibility primarily to individuals.

"This is certainly getting a lot of attention from employers," said Jack Rodgers, a healthcare analyst for PricewaterhouseCoopers LLP.

One reason is potential cost savings to employers.

A typical catastrophic health insurance plan carries an annual deductible of about $1,600 for an individual when purchased through a large employer. That means the worker pays the first $1,600 of healthcare expenses each year. By contrast, under the more comprehensive, employer-provided health insurance programs common today, the company begins to pay after about $300 in expenses have been incurred. Deductibles for families are considerably higher under both types of plans."

This is a very, very significant change. One of the considerations driving it is a desire to do something to contain the cost of medical care. Oddly, though, this shift does not affect the health insurance plans the government actually runs. What it does affect is the health insurance available to the rest of us through our employers.

The basic idea behind combining catastrophic coverage and health savings accounts is this. If consumers have to pay not just the first $300 of their medical bills, but the first $1,600, they will be a lot less likely to pay for medical care that they don't really need. This will cause medical spending as a whole to go down, by forcing consumers to make more intelligent choices or (literally) pay the price. To help them pay for this, we allow them to put money into a health savings account, which gets various tax benefits and can be used only for medical expenses (until the age of 65, after which you can withdraw money for other purposes.) If they don't pay the full deductible this year, they can save the money for next year. This way, in theory, the money is there if people truly need it, but they will be less likely to spend it wastefully.

The counterargument says: first, the effects on people's decisions about health care will depend a lot on how much money they have. The rich are unlikely to care about a few hundred dollars here or there. Middle and upper-middle class people will probably make somewhat more intelligent decisions, although this will be limited by how complicated their choices are, and how much complex medical information they are able and willing to process. But poor people are likely to end up foregoing necessary medical care because they simply can't afford it. And this is bad. Second, this sort of proposal favors the healthy over the sick. If you have a chronic illness, you might spend your full deductible year after year, and never be able to set any money aside in your health savings account. To people with chronic illnesses, the main effect of this plan will just be that if they're insured at all, the amount they have to spend every year rises dramatically.

Here's how Uwe Reinhardt, one of the best health care economists out there, describes the effects of these proposals (pdf):

"It is widely recognized by actuaries and health services researchers that a switch from the current, more comprehensive insurance policies to catastrophic policies coupled with tax-favored Health Savings Accounts (HSAs) would have two redistributive effects:

1. By making deposits into the HSAs and the premiums for catastrophic healthpolicies tax deductible, one effectively makes the after-tax dollar cost of health care at the time health care is received cheaper for high income families (facing high marginal tax rates) than for low-income families. (Thishighly regressive effect could easily be avoided, of course, simply by allowingall households, in all income groups, to claim a refundable tax credit equal to a flat X% of whatever the household spends on deposits into the HSA or onpremiums for catastrophic coverage. The fact that this fix is so easy andobvious suggests that the Administration and the Congress actually prefer the more regressive approach to health-care financing—a fact that shouldpique the curiosity of journalists).

2. High deductible health insurance would redistribute the overall financialburden of health care in society from the chronically healthy (who normallywould not have to spend the whole deductible) to the chronically ill who probably would have to spend out of pocket the whole deductible, year after year."

Likewise, there is some reason to doubt that this program would realize savings as large as its proponents claim. For instance, a RAND study published in JAMA (subscription wall) found that "Medical savings account legislation would have little impact on health care costs of Americans with employer-provided insurance." (They estimate that health care spending would change by +1 to -2%.) This is partly because it's hard to figure out which procedures you really need if you're not a doctor, and hard to do intelligent comparison shopping (just try comparing, in advance, all the items that will occur on your hospital bill). It's also because a surprising proportion of health care spending is done by a small number of people: those with expensive serious or chronic illnesses. Precisely because such people often spend more than the amount of their deductible under either the current system or the President's proposal, their spending is unlikely to be affected by it.

Obviously, with proposals like this, the devil is in the details. One is as follows: this basic approach will almost invariably lead some people to make smarter choices and others to forego health care that they really need because they cannot afford it. This possibility can be minimized, though not eliminated, if the money in their health savings accounts does not come from them alone. If everyone is supposed to put money into their own health savings accounts without assistance, then people who are trying to raise their children on a low-wage job will probably not put much (or any) money aside, since they don't have enough money to live on to start with. And if they don't put money into their health savings accounts, then as far as they are concerned all the move to a system of catastrophic coverage plus health savings accounts will mean is that their deductible gets more than five times bigger, and thus if they get seriously ill, they are more than five times as screwed.

There are alternatives to asking individuals to contribute everything to their health savings accounts. Employers, for instance, could be given tax incentives to contribute some share of them. (Preemptive note for von: I am not a big fan of putting the costs of health insurance on employers to start with, for various reasons one of which is: I think it's bad for business. But since employers save a lot under this proposal, I don't think the suggestion that they should contribute to HSAs is out of line.) Alternately, the government could contribute some amount for low-wage workers, and phase this amount out gradually as income levels get higher -- sort of a health care version of the Earned Income Tax Credit. Either step would make this proposal a lot less likely to drive low-income people, who cannot be expected to set aside a lot of money for anything, to forego necessary medical care because they can't afford it. It would also mitigate the effects of these proposals on people with chronic illnesses, since they would not end up paying the full amount of their deductible every year.

The Bush proposal, however, makes employer contributions voluntary, though it offers some assistance for low-income people. (The article says this assistance is capped at $3,000 per family, which sounds like a lot until you realize that it wouldn't cover the out-of-pocket expenses incurred by a family of two. The article also gives no details about how low-income you need to be before this assistance is available.) That means that if you're poor, but not poor enough to qualify for assistance, and you have no way to save money, and you then get sick, your insurance won't kick in until you've paid $1,600 that you don't have. And that's really bad.

A second detail: who pays for your catastrophic coverage? According to the Times article, the answer is: you, not your employer. Bush proposes tax deductions to help, but tax deductions are worth a lot more to those in the top bracket than they are to those in the bottom. Besides, catastrophic care policies cost thousands of dollars a year, and how low-income families would pay for them is completely unclear to me.

But there's another very, very important point. Mark Schmitt made it so well about a year ago that I'm just going to quote him:

"As long as you're well off, healthy and relatively young, don't have and aren't planning to have small children, and don't spend much on ordinary doctor stuff, a catastrophic plan could be a very sweet deal. Health savings accounts, as passed in the Medicare bill, make it an even better deal. If I had a catastrophic plan, whatever costs I did incur under the deductible, I would pay for with pre-tax money from the account, which in a high tax bracket is the equivalent of a 35% discount. Plus, investment earnings in the account accumulate tax-free, so if I had doubled my money in the account, as long as I spent the money on health care, that would also be, in effect, free money. I could even spend it on plastic surgery. (Get that chin implant so I look more presidential.) Now this is starting to look like an irresistible deal.

And then, if on top of that, the premium on the catastrophic plan became 100% tax-deductible, the combination would be an even better deal. Now, if I'm in the 35% bracket, I'm paying that much less for my premium, plus anything I pay under the deductible is coming from tax-exempt funds. I'd have to be crazy not to go for this deal, especially because premiums for ordinary self-employed health insurance are not fully tax-deductible, and out-of-pocket costs are not tax-deductible unless you itemize and the costs exceed 4.5% of income.

If I were an employer, I'd figure out a way to start offering this deal to my higher-paid employees. It could be as simple as giving them $5,000 cash instead of health insurance. I'd get my costs under control, and they'd get a chunk of money tax-free to put straight into their health savings account and pay the premiums on the catastrophic plan.

But what if I'm not in the 35% bracket? If I'm in the 10% bracket, then both the deductibility of the premium and the health savings account are worth a lot less to me. But much, much more important: I can't deal with the risk of a catastrophic plan. If I'm making $25,000 a year, I can't handle the risk of $5,000 in health care costs. That would be a disaster. And I probably can't put that much away in a health savings account. The catastrophic plan combined with a health savings account simply isn't an option for poor and middle-class people, even if healthy.

Health savings accounts, combined with deductible premiums, are really just a giant bribe to better-off people to OPT OUT of the comprehensive health insurance system. What the administration is doing, first with health savings accounts, which are now the law, and then with this proposal, is to confer enormous tax advantages on a type of insurance that is already advantageous, but only for the relatively wealthy. But the consequence of it would be that, as young and healthy people withdraw from the standard, low-deductible insurance market, premiums in that market would go through the roof, insurers would desperately try to find ways to deny coverage to higher-risk people, and the whole delicate balance would surely collapse."

Or, to put it more simply: insurance is all about spreading risk among large numbers of people. Premiums basically reflect the amount of risk per capita: when everyone ends up needing big payouts, premiums are high; when most people don't, they are low. Bush's proposal creates enormous incentives for young, healthy people to opt out of normal medical insurance and into a system of catastrophic coverage plus health savings accounts. The poor, old, and sick, by contrast, wouldn't be able to afford to. But if all the young, healthy people opt out, then the premiums for those who remain -- the poor, old, and sick, mostly -- will skyrocket. At that point, the costs for those businesses who still offer normal health insurance also skyrocket, and those businesses will (quite understandably) try to move to a system in which they offer only catastrophic coverage, which is much cheaper. And what this means is: Bush's proposal has the potential to break our current system of employer-provided health care, leaving healthy and wealthy people, as well as corporations, better off, but at an enormous cost to the poor and the sick.

I think it's just wrong.

Comments

[Catsy]

It's that bad, and worse.

What the government really ought to be doing is fully, 100% subsidizing basic maintenance--things like yearly dental cleanings, checkups at the doctor, that sort of thing. Then, if those visits identify something which needs to be further investigated, those tests and treatments would fall under whatever health plan an individual has.

I can't stress strongly enough how important this is. One of the things which drives up the cost of health care is the fact that so many people put off or skip those basic maintenance visits because they simply can't afford them--which means that many of these people eventually end up needing far more expensive care (which they still can't afford) to treat conditions that shouldn't have progressed that far in the first place.

Sound too much like socialized medicine? I don't much care what you call it. It's just the right thing to do.

[Bruce Baugh]

I agree strongly with Catsy. Underwriting basic care would be an extremely wise step, but it's the sort of thing with benefits measured mostly in costs not incurred, which makes it diffuse and hard to calculate in detail - just the sort of thing the state really is good for. A healthier population creates fewer costs and distractions at every age and every social stratum.

[Jesurgislac]

But this is nonsense:

If consumers have to pay not just the first $300 of their medical bills, but the first $1,600, they will be a lot less likely to pay for medical care that they don't really need.

I ask you: who goes for medical care that they "don't really need"? I have fully comprehensive medical insurance, and I go to the doctor when I need to see a doctor. How many people do anything else? (Don't respond with urban myths of the kind "well, I know someone who says...")

[Jesurgislac]

Catsy: Sound too much like socialized medicine?

Course it does. That's because socialized health care is the only really efficient way to run a health system. The further you get away from this basic principle, the worse the health care system gets.

[blogbudsman]

jesurgislac is incredulous "I ask you: who goes for medical care that they "don't really need"?

Robert Brook of the Rand Corporation maintains that "perhaps one-fourth of hospital days, one-fourth of procedures and two-fifths of medications could be done without."

http://www.ncpa.org/w/w51.html>Unnecessary procedures, many due to the threat of litigation, abound.

Most diagnostic and therapeutic services are ordered by physicians, but http://content.nejm.org/cgi/content/abstract/299/2/76>physicians practicing under fee-for-service conditions have few incentives to contain the costs of medical care.

There was a time when HMO's were considered a good thing. It was the Dr. Beeper's of the world with their 'golfing Wednesdays' prescribing procedure after procedure, sucking off Medicare, that had been reduced to caricatures of their once noble profession.

HMO's were formed to 'manage' doctors, review those performance excessive procedures, bring them back in line. That went over well. The smear campaign was on. Well this is what we've ended up with. Skyrocketing costs borne by employers providing 'benefits' to their employees. Most business medical policies call for the employer to pay for the actual cost of their employees medical costs, usually capped by a substantial umbrella mark. Throw in a couple gastro bi-pass operations and many a business has to scramble to cover the expense.

Many things have to happen, and a lot of it will have to either fall on the shoulders of trial lawyers and physicians or us taxpayers. For some detractors to deny the challenge exists to fit their Bush hating meme won't help a thing.

[Jesurgislac]

Blogbuds: Robert Brook of the Rand Corporation maintains that "perhaps one-fourth of hospital days, one-fourth of procedures and two-fifths of medications could be done without."

Are those his hospital days, his procedures, and his medications (or those of his immediate family) that he's talking about? If not, how seriously should anyone take the opinion of the vice-president of an extreme right-wing think tank?

[Jesurgislac]

Blogbuds: For some detractors to deny the challenge exists to fit their Bush hating meme won't help a thing.

Certainly there's a problem with the US health care system. In fact, that's understating the case. When one of the wealthiest nations in the world has a health care system that ranks below the health care systems of any other nation in the industrialized West: and when that country spends a higher percentage of its GNP on health care than any other nation: yes, you have a problem.

It's also clear where the problem lies. It's not in patients wanting "unnecessary" treatment, or doctors spending too much for fear of malpractice suits: it's in the health insurance corporations who make billions, and the millions of Americans who have no health insurance. The solution is what American veterans, and Congresspeople, already have: a socialized health care system, free at point of use. It'll cost less, it'll work better, and Americans will be healthier and better cared for.

But blaming the patients is a typical Bush non-solution to a recognized problem.

[kenB]

blogbudsman, you bring up an interesting point -- it will still be in the interests of doctors to be aggressive with the procedures they recommend, but under this arrangement patients will have more reason to question them because of the cost. I wonder, is that a good thing? Will patients be knowledgeable enough to be able to decide when the treatment is truly "necessary" (assuming for a moment that there's a bright-line difference between necessary and unnecessary)?

Any effort to hold down health care costs by putting more financial pressure on the patient runs into this sort of thing -- it basically forces non-medical people to make medical decisions, which may or may not be for the best.

[caleb]

It's funny how reflexsive it is that someone who does not agree with a Bush agenda equals de facto "Bush hater".....facts be damned!

Well.....not funny....but sad.

[blogbudsman]

blogbudsman "For some detractors to deny the challenge exists to fit their Bush hating meme won't help a thing."

caleb "It's funny how reflexsive it is that someone who does not agree with a Bush agenda equals de facto "Bush hater".....facts be damned!

I fully recognize there are many who do not agree with the Bush agenda, "..ain't that America." But it's not hard to recognize a Bush hating meme. (Keyword - 'meme')

[votermom]

The Bush admin is caught between two powerful lobbies -- health care and business. Health care costs are the number one increasing overhead cost of business.
Employees, who depend on group insurance provided by employers, (and that includes me), are going to be so [bleeped] if we don't speak up.

Aside from the obvious direct benefits of universal health care, indirect benefits are often overlooked. It will stimulate the economy. Many people who would like to start small businesses cannot quit their jobs because their families will lose health insurance. Many small business cannot grow because they cannot provide insurance to their employees.

[heet]

Great post hilzoy...

Catsy's point is spot on... Early treatment and prevention can save big money down the road. Under our current system this isn't done. Fact is we already HAVE a socialized system of sorts. Somebody will be paying for the diabetic alchoholic to get his treatment in the emergency room. It's you and me in the form of taxes paid out to a county or teaching hospital or such-like. So now we pay for expensive procedures in the ER to stabalize patients and then send them on their merry way until they come back in for the same problem. Continuous treatment or early detection would be much cheaper for everyone involved.

How to get to this outcome? True socialized medicine is one answer. It's also the only method that has seemed to work in our present universe. It just plain saves money. I don't think we will live to see the day this is implemented in the US, however. Bush's plan might work, though it has some problems. I hate the regressive tax scheme, that has got to go. And as with all privatization schemes, I'd like some assurance that the financial sector isn't being given free reign. Regulation is key here.

As for how to deal w/ the poor/ middle class -- what if you were allowed to donate part of your tax-free HSA to a "poor healthcare fund." This fund would be used to subsidize the HSAs and catastrophic insurance for some lower income tiers. This could be graduated so the poorest got more assistance. I happen to think Americans are giving people and there would be some moral and spiritual incentives to donating. Companies and charity organizations would have an easy target to throw donation dollars at. Heck, if you were worried about the amount of donations, part of the fund could be used to hire marketing and ad agencies to help get the word out. Something has to be done, though, that is without question in my mind.

[Anarch]

I fully recognize there are many who do not agree with the Bush agenda, "..ain't that America." But it's not hard to recognize a Bush hating meme. (Keyword - 'meme')

To paraphrase Henry Ford, "You can have any opinion as long as it's Bush's."

[CaseyL]

We already have socialized medicine in another way: people with insurance pay padded charges that subsidize the uninsured.

A few years ago, I broke my arm. There were bone fragments, and the attending physician recommended surgery to secure them. I was in the hospital overnight. My total hospital bill was $8000. $8000 for a broken arm?? I later found out at least one-third of that is padding - overcharges - to make up for people who come in without insurance.

I don't know why HSAs are considered a solution. They're out-of-pocket expenses borne by the consumer, and (unless the law has changed) they're also "use or lose." So I can put $2000 into an HSA (assuming I can afford to do so in the first place), and then lose whatever part of that money I haven't spent at the end of the year. Great.

[heet]

lose whatever part of that money I haven't spent at the end of the year.

The proposal actually treats the HSA as a 401k or sorts. It rolls over each year and can be used at age 65 for other purposes.

[Jeff Rubinoff]

It sounds a bit like the lamebrained thing the Germans have done. I have a friend over there working as a bank management consultant, very good salary. He was astonished to discover that he could opt out of universal State health insurance altogether and instead buy purely private cover, which offers him more services and for less money than the (income indexed) state service.
Even an old school Tory like him noted that if everyone in higher income groups opts out of the state system, that system is going to have severe financial difficulties.

[hilzoy]

A few points. First, Jes: actually, there is a fair amount of waste. For instance: neither doctor nor patient has any incentive to use a cheap medicine as opposed to the Newest, Hottest Thing (usually more expensive), even if the NHT isn't really much better. This is made worse by direct-to-consumer marketing: in addition to raising the costs of medications (iirc, what pharma. companies spend on marketing exceeds what they spend on research), but it also leads to people thinking that if their doctor prescribes boring old Tylenol instead of Celebrex, their doctor is old-fashioned/doesn't take their complaint seriously enough/etc. The trick is to find a way to get rid of the wasteful spending without keeping people from getting health care they really need.

One of my problems with this proposal is that it would really not do this effectively: it might get rid of wasteful spending for middle and upper-middle class people (though i'm not really convinced by that; see the RAND study I quoted, and consider also the plastic surgery in Mark Schmitt's post), but it would prevent the poor from getting health care they really need.

I should say that I am all in favor of "an ownership society", if this means: adopting policies that would help people, especially those who have a hard time accumulating savings etc. (e.g., the poor), to own things: their property, their savings, their 401k, etc. I think that it would be unmitigatedly wonderful if we had policies that enabled the poor to really accumulate savings. What bothers me about Bush's policies is that they often seem to have a very different effect: they reward people who already e.g own stocks, while making it much harder for others to lift themselves out of poverty by 'working hard and playing by the rules'. Policies that have that effect aren't helping to make everyone 'owners', they're cementing in place the current division between people who are basically making it and people who are basically not. I think this policy proposal would have that effect, which is why I think it's wrong.

[liberal japonicus]

people with insurance pay padded charges that subsidize the uninsured

Actually, this WaPo article suggests that the costs for the insured are pooled and bargained down, but the uninsured are charged at a much higher rate, which permits hospitals to perform various accounting wizardry.

[hilzoy]

LJ: As I understand it, it's like this: (a) the uninsured pay much higher rates than anyone else, since insurers get what is, basically, the equivalent of a volume discount. (b) The costs for everyone are higher than they would be if hospitals didn't have to eat the costs of medical care that no one ends up paying for; that is taken out of everyone who pays, insured and uninsured alike, in the form of higher costs for a given service.

[votermom]

What about the structure of Health Insurance companies? If we look at wall street, mutual fund companies that are structured so that they have stock holders have much higher costs per fund than companies that are structured so that they are "owned" by the people who invest in their funds.

Are there health insurance companies that are structured in this "non-profit" way? How well do they perform?

[Jeff Rubinoff]

Please forgive me for double-posting.
CaseyL brought up a very pertinent issue. I used to work as a research assistent in a hospital and ended up one of the few people with access to both the financial and medical sides of a patient's record.
Every hospital has a department of billing experts. This is not a small department. They have to keep track of the regulations of a host of private insurers plus the state Medicare/Medicaid. Where I was, in DC, that was 3 states' worth of Medicare/Medicaid.
Part of their job is to optimize the procedure and diagnosis coding on a patient's record, which is what the bills are based on. The idea is to squeeze the maximum possible amount from insurers while limiting the paper losses on uncovered treatments. If you are classified 'self-pay,' (this was by far the most common classification at this inner-city public hospital) they try to minimize your bill with the expectation that you will pay none of it. If you are Blue Cross/Blue Shield turboninja covered, they maximize the bill. If you have DC Medicaid, they try to push your bill to $6000/month, because DC Medicaid pays 100% of the first 6 grand and not a penny over.
Doctors and nurses are shielded from this system. They do not have access to this part of the patient database. They have no idea how much services are charged for. Medicaid patients are also shielded, since they never have to think about the cost they incur.
One side effect has been the establishment of the emergency room as the primary health provider for inner city working and lumpen classes. Every time a family came in the door of the emergency room to declare 'my baby has a fever,' it was at least an $800 bill. Most of the fevers disappeared in the waiting room. When they did not, the most minimal treatment pushed the bill up to $1200 or $1500.
A visiting resident from an NHS hospital in Leeds said that where he practiced, these patients would have been politely shown the door and instructed to go to their local 'health center' or equivalent, where care is far cheaper.
The hospital claims not to do this because of fear of litigation--a bone for you, Mr Blogbudsman. However, whether this is the real reason or whether the profit from the automatic $800 a pop from Medicaid versus the minimal loss on the self-pay (it doesn't really cost anything for someone to sit in the waiting room an hour and see a nurse for 5 minutes) means there are more basic economic factors at work here is more than I can say.
Oh, one anecdote. One of the mothers got herself sorted a bit, got a job and a private doc. She still brought her kid to the emergency room when he had a cold. Why? Because she "couldn't bother the doctor over a little thing like that," much to the nurses' anger. So we are not now dealing with purely economics and issues of access, but of entrenched social and cultural behavior.

This is not a left/right issue. There is enough wrong with this system to outrage any American of any political belief. And though pretty much every Western health care system has gone through financial difficulties in the last 10 years, ours is undoubtedly the least economically efficient.

[Nicholas Weininger]

A historical note: in the early part of the twentieth century in the US, there was a system called "lodge practice" run by numerous sorts of fraternal societies, insurance providers, and other community organizations. The way this worked was, the organization would hire one or more doctors at a fixed salary to provide basic care for a fixed number of members-- checkups, house calls, and sometimes also the few medicines and minor surgical procedures available at the time. The members (who in many of these organizations were lower-income working-class folks; the fraternal societies often catered to immigrant workers, for instance) then got, for a low flat fee, access to the sort of preventive primary care Catsy describes, without any government subsidy whatsoever.

Lodge practice was run out of existence by the AMA, which saw it (quite correctly) as a threat to the lucrative profits to be made from fee-for-service medicine, and used its leverage over medical regulation and physician licensing to basically make it impossible for physicians to accept this sort of arrangement. For a more detailed account, see David Beito, _Mutual Aid and the Welfare State_.

The moral of the story is: regulation and regulatory capture really matter in determining the shape of our sort-of-free, sort-of-private health care mess; the devil is in smaller details than you think.

[smlook]

"I think it's just wrong."

Does anyone here actually have an HSA?

As someone who has paid for their own health insurance for the last 10 years and signed up for the HSA the first day it came out I think its a decent start, but needs some tweaking.

"If consumers have to pay not just the first $300 of their medical bills, but the first $1,600, they will be a lot less likely to pay for medical care that they don't really need."

In my family this works out well and saves me money. My wife is quick to make me or anyone else in the family go to the doctor immediately. Especially the kids. Now she thinks it through more before she goes to the doctor. I counted that we went to the doctor 13 times in 2003. 2004 we went once and amazingly we are all still healthy. FYI, this is not an urban myth it is experience talking.

"If not, how seriously should anyone take the opinion of the vice-president of an extreme right-wing think tank?"

Well, certainly not more than your opinion should count.

"but under this arrangement patients will have more reason to question them because of the cost. I wonder, is that a good thing?"

As I said above it can be, but I suppose I can only speak for myself.

"it basically forces non-medical people to make medical decisions, which may or may not be for the best."

I don't disagree, but my frustration during the last few years is that is already the case. The doctors don't make medical decisions either. I think they are afraid to give a definite yes on anything. It has been extremely frustrating. I am already having to make all the medical decisions and yes I do feel underqualified, but the doctors have been no help. (My wife was in the hospital twice.)

With my HSA, I just had this experience two weeks ago. I had to take one of my children to get an x-ray at the hospital. The x-ray was for a mild case of plagiocephaly. When I was signing in I asked how much the x-rays were going to cost. I swear that after 30 minutes of trying the final answer was, "We don't know, you will have to wait until you get your bill." I was amazed.

Now, the other thing I know from my experience. This is based on someone already providing their own health insurance and this is extremely frustrating. It doesn't matter much whether you choose an HSA or go with full coverage. It's the same cost from my perspective no matter what plan I choose. That's how they have it priced out.

I could get a Blue Cross plan for about $900/quarter with a $5000 deductible. Or I could get and HSA/quarter with the same deductible. The only difference is that if I don't go to the doctor then I will save a little money. If I go to the doctor over 10 times/year then I will lose money with the HSA.

I know that I said "the only difference". Please don't try to argue the details of the different types of plans. If they give you something on the full coverage and the HSA doesn't cover it, the HSA gives you something different to equal it. If they give you something on the HSA, then in some way the full coverage will equal it. It's a wash.

[Katherine]

What happened to the proposal to eliminate the tax deduction for employers' contributions to workers' health insurance? Is that still on the table?

I suggest we build a time machine and offer to send Bush, Rove et. al. back to the 1890s, rather than them trying to bring the whole country back to the 1890s. Karl could meet his hero William McKinley and everything. Who's with me?

[hilzoy]

smlook: it may or may not make no difference whether you go with a Blue Cross plan with a high deductible or an HSA. But I'm not sure that's relevant here. First, the President's proposal seem to be to encourage you to have both. Second, the alternative, for most people who have employer-based insurance, is not one of the two alternatives you cited, but having coverage with a much lower deductible. To them, the difference between low deductible (around $300) and high deductible (around $1,600) (just using figures from the article) is significant.

[hilzoy]

Katherine: "What happened to the proposal to eliminate the tax deduction for employers' contributions to workers' health insurance? Is that still on the table?"

Last I heard, yes. And besides providing a huge incentive for employers to drop insurance coverage altogether, it would also provide a huge incentive for those who do not drop medical benefits to go with catastrophic coverage, since the costs are much lower.

And, of course, the main reason the costs are much lower isn't that the total amount paid in medical bills will be lower; it's that a lot of risk is shifted from insurance companies to individuals. I rather thought the point of, well, insurance was to pool risk, but silly me.

[votermom]

smlook, I'm glad your choice works for you, but here's some questions:
Was anyone in your family born with a chronic illness like asthma or diabetes?

(In our immediate family, we have one person with asthma and one person with thyroid disease. Both are hereditary conditions, not acquired through lifestyle. Both require periodic medical monitoring.)

Would you have switched to that coverage if one of your kids was still under two years old (immunizations are monthly for infants, then space out to around after the first year.)

It sounds like our company offers the same options, and I have opted for the BC/BS turboninja coverage (love that description). In my one kid's 1st two years of life, she had two real emergencies -- non-febrile seizures requiring CT scans and an anaphylactic reaction to, of all things, cold water in a backyard dipping pool. (She'll be the death of me, I swear).

[votermom]

I suggest we build a time machine and offer to send Bush, Rove et. al. back to the 1890s, rather than them trying to bring the whole country back to the 1890s. Karl could meet his hero William McKinley and everything. Who's with me?

Sounds good to me. :)

[LizardBreath]

Something I keep on hearing in discussions of single-payer medicine is that "the demand for health care is infinite -- without costs to the patient, the system will go out of control." As Jes pointed out, that isn't obviously true: medical care is something people only want when they're sick. Beyond a minimal (and inexpensive) level of preventive care, healthy people don't consume any medical care. To the extent that there is out-of-control health care spending, it's at the high end -- end-of-life care, etc., and that's an area where health care consumers are not really making consuption decisions on their own; instead, they're relying on doctors' advice.

The proposed HSA system, if it does anything will drive down consumption of health-care at the low end, where disease is prevented and maintained. We're going to encourage people with chronic diseases, like asthma or high-blood pressure to undertreat themselves, and end up spending more as a society on care for them rather than less.

[Jeremy Osner]

I'm confused about the article's assertion that "The accounts are available only to people who buy high-deductible health insurance, either through an employer or individually." I have such an account, and I have a lowish-deductible health policy provided by my employer.

[Dianne]

Argh! The LAST thing the US needs is to discourage people from getting health care. Too many people already skip health maintanence procedures such as routine physical exams, routine labs, pap smears, prostate exams, colonoscopy, mammograms, etc because they are uncomfortable, take time, or are otherwise inconvenient. Add a $1600 cost a year and even fewer people will get these tests. The result will be that more people will have heart attacks and strokes because of untreated high blood pressure; more people will find out about their diabetes when it destroys their kidneys, eyes, heart, or nerves; more cancers will be found in their late, symptomatic, and incurable stages; more children will die or be disabled from preventable diseases; more preterm babies will be born as women skip prenatal care, etc. Since it is more expensive to pay for the treatment of heart disease, late stage cancer, neonatal intensive care, etc than for prenatal care, screening tests, control of high blood pressure, etc, we as a society will end up paying more for medical care and getting worse results.

[hilzoy]

Did something happen to the last several comments? Someone -- Jeremy Osner? -- asked whether the HSAs are really linked to high-deductible plans. Answer: yes. Here's a link to a USA today story (the first with details that popped up in my Google Search). Excerpts:

"President Bush and Republicans in Congress favor investment accounts to help more Americans cover expenses until a high-deductible policy kicks in. As defined in the new Medicare legislation, which Bush is expected to sign, a high-deductible policy is $1,000 for individual coverage, $2,000 for a family.

The accounts have the potential to accumulate huge balances over years of contributions and investment gains. In theory, that puts consumers in a better position to pay for their own health care as they grow old, when costs typically peak. The new law imposes two requirements for opening an HSA:

• It must be done in conjunction with high-deductible health coverage.

•A taxpayermust be under 65 — the age of Medicare eligibility — when opening an account."

Here is another kinds of accounts:

"Flex-spending accounts permit workers to make pretax contributions by payroll deduction to meet health care costs.

But they have two big drawbacks: Money in the accounts earns no interest; and unspent funds must be forfeited at the end of each year.

Also:

"HSAs now have a first cousin in tax law, Archer Medical Savings Accounts. In seven years of existence, Archer MSAs haven't gotten much use, partly because of strict eligibility requirements. HSAs replace them."

[Dianne]

"this is not an urban myth it is experience talking."

I won't question your experience, but keep in mind that it is an anecdote and may not be typical. My family has a traditional insurance plan and none of us have been to the doctor except for routine health maintanence exams in the last year either, depsite the fact that all expenses except for the copay are covered. If the postulate the people must pay large amounts for their health care or they'll overuse it is correct, why aren't we in the doctor's office every other day?

[Slartibartfast]

If not, how seriously should anyone take the opinion of the vice-president of an extreme right-wing think tank?

Exactly as seriously as one ought to take the opinions of an extreme left-wing noncitizen: on the strength (or lack thereof) of their argument.

Or, you could just go for the character assassination, if you've got nothing else. Your choice.

[Jesurgislac]

Slarti: Exactly as seriously as one ought to take the opinions of an extreme left-wing noncitizen: on the strength (or lack thereof) of their argument.

Well, when Blogbuds presents an argument, as opposed to an urban myth ("I heard that he says that there are people who...") I'll pay attention.

By the way *grin* I am a citizen. If we're going to be nationalistic about it, you're the noncitizen.

[Katherine]

speaking of devil in the details, are these deductible on top of the standard deduction or only if you itemize?

the more I learn, the more it seems that they really are trying to dismantle the safety net. And HOW did we let that godawful Medicare bill pass?

[Slartibartfast]

Well, when Blogbuds presents an argument, as opposed to an urban myth

Not his argument, Jesurgislac. It may very well be that this was an unsubstantiated argument, in which case the best way to disable it is to simply point that fact out.

By the way *grin* I am a citizen.

Really? Of the United States? Well, color me embarrassed.

[hilzoy]

Slarti: in yet another bid for a Karnak, if I read Jes' comment correctly, you'll be even more embarrassed when she explains it.

[Jesurgislac]

Slarti: I asked (the world) (this thread) for actual examples of people going for healthcare they don't need. I specifically asked not for reports in the urban myth format of "Well I heard someone say that they think people"... but of actual first hand or second hand examples. (SMlook's comment that he and his family don't go for health care they don't need is precisely the kind of reportage I was looking for.) Blogbuds provided an example of the urban myth format: "I [blogbuds] heard someone [Robert Brook] say that they think people..." that I had specifically said I wasn't asking for (and without even a cite to give the context in which Robert Brook said it - he might have been reporting on a survey of hospitals or doctors...) Hence my response.

Really? Of the United States? Well, color me embarrassed.

Heh. My point: I am a citizen. You are a citizen. Neither of us are noncitizens. though you are a not a citizen of my country, nor I am a citizen of yours.

[Dianne]

"I asked (the world) (this thread) for actual examples of people going for healthcare they don't need."

I don't know of any examples like that, but I can give you numerous examples of people not going for healthcare that they did need because they lacked insurance/money, if you'd like.

[Sebastian Holsclaw]

"I ask you: who goes for medical care that they "don't really need"? I have fully comprehensive medical insurance, and I go to the doctor when I need to see a doctor. How many people do anything else?"

Sigh. I've been thinking about this a lot regarding these discussions. I think it is very important for people on both sides here to remember that we are not exactly your average consumers of information. If the nation were us, there wouldn't be very many people who see the doctor when they don't need to (liberals pay attention) and we would plan for our own retirement (conservatives pay attention). The problem is that we aren't typical--in ways both good and bad. The typical constructive conservative approach to such things is to encourage and aid people in making good choices. The typical constructive liberal approach is to protect people from bad choices. Both can be very helpful, but there is quite a bit of tension between the two. This particular plan is not one of the better ones I have read about, but in the health care arena I definitely think we need to do a little more encouragement of looking at things as choices and not just inevitable health outcomes. So if the proposal causes us to look at such things, I'm thrilled.

As for the specific question, I am close personal friends with three general care doctors. Each of them work in different areas of town. One works in the high income area, and the other two work in fairly low income areas. All three complain that at least one full day a week is spent catering to people who don't need their care. So I'm relatively confident that such concerns are non-ridiculous.

[smlook]

Hilzoy,

"it may or may not make no difference whether you go with a Blue Cross plan with a high deductible or an HSA."

I was only trying to identify what I think is a problem with how it is currently implemented.

"I'm glad your choice works for you, but here's some questions:
Was anyone in your family born with a chronic illness like asthma or diabetes?"

No, and I am not trying to say the plan is perfect. I know it is not from experience. But, it has the potential to have the effect I mentioned about my wife. If we can figure out how to get the deductible to something more manageble it COULD be good.

Right now I that it COULD benefit those of us who don't have corporate provided health coverage. It depends on how healthy you are.

"Would you have switched to that coverage if one of your kids was still under two years old (immunizations are monthly for infants, then space out to around after the first year.)"

Actually both my kids are under two.

Jeremy,

Lower than $3,000?

"Argh! The LAST thing the US needs is to discourage people from getting health care. Too many people already skip health maintanence procedures such as routine physical exams, routine labs, pap smears, prostate exams, "

I just went an got my yearly physical. I paid for it with my HSA. It only discourages people who don't want to take care of themselves or lack the mental capacity to see that preventative care is the route to go. But, I doubt those people go now anyway.

[crionna]

I asked (the world) (this thread) for actual examples of people going for healthcare they don't need.

Depends on what you mean by need doesn't it? Is ACL reconstruction, for instance, needed healthcare? I mean, John Elway played Hall of Fame football for years without his ACLs. Where does quality of life come in?

Jes, in GB, do you know anyone who received ACL reconstruction surgery? If so, was it needed (i.e. they were a firefighter) or was it quality of life (i.e. a desire to ski again)? How long was the process of getting that surgery approved?

[crionna]

out bold!

[crionna]

Sorry, just meant to bold Jes's name for ID sake.

[CaseyL]

Is childbirth something that would be covered under 'catastrophic' health insurance, or is it something one pays for out of one's HSA?

What does an in-hospital birth cost these days? and pre-natal care?

If it's more than $2000...well, I guess people should just plan way, way in advance, eh? Save up for 5 years or so, *then* have the baby!

Nicholas: I hope to god you're not saying the only reason the AMA didn't want lodge doctors was to preserve their monopoly on medicine in the late 19th-early 20th Century. If that's what you're saying, you really, really need to do a little research on the state of medical practice in that time period.

[Dianne]

"I just went an got my yearly physical. I paid for it with my HSA."

Good. May I say that I hope it was a waste of money in that it showed that you were perfectly healthy?

However, as Sebastian H points out, people who post here aren't necessarily typical. I suspect that $1600 a year isn't a lot to you. To tell the truth, I could pay it too. But to a person trying to support him or herself and family with a minimum wage job (or two or three), paying that $1600 a year may be the difference between being able to rent an apartment or living on the street. Given those choices, I suspect most people would choose to live indoors and hope for the best with their health.

[Anarch]

All three complain that at least one full day a week is spent catering to people who don't need their care. So I'm relatively confident that such concerns are non-ridiculous.

Interestingly, the doctors of my acquaintance all argue that more people need to come in for basic "maintenance" than in fact do; a large number of the cases they see could have been prevented earlier had they simply come in for a routine check-up.

Which raises the question: is it "better" (and under what metrics should we ask this question) for people to err on the side of medical caution and come in too much, or for people to err on the side financial caution* and not come in often enough? If there is such a "preferable" bias, is it then right to skew the system to encourage it or is it the kind of skew that should only arise by, to quote Sebastian, "encourage and aid people in making good choices."**

* I'm aware that these two don't form a particularly good dichotomy, but that's the closest I can get without writing some kind of thesis.

** I completely disagree with your characterization of liberal and conservative approaches, Sebastian, but I figured you probably could have guessed that ;)

[votermom]

What does an in-hospital birth cost these days? and pre-natal care?

Oh, I don't know, but I do know that using a midwife practice or a midwife attended birth center is considerably cheaper and actually safer for healthy women with normal pregnancies.

*I just had to get a plug in for midwife-attended natural childbirth. You may now return to your regularly scheduled debate

[Dianne]

Concerning the question of unnecessary doctor's visits: Some visits may be medically unnecessary but socially necessary. For example, a person with a flu-like viral illness. 99% of such illnesses will pass with no intervention except rest, liquids, and perhaps some acetaminophen. None of which requires a doctor. However, many employers will not allow their employees time off for an illness without a doctor's note, making the visit necessary not only for the patient but also for his or her co-workers who would otherwise be exposed.

[Nicholas Weininger]

CaseyL: no, I'm not claiming it was the *only* reason. Whenever regulatory capture occurs, those pushing for some regulation that will benefit them have less selfish-sounding arguments for said regulation, and very often some of those arguments have a grain of truth to them. There were real concerns about doctors' competence and non-quackery at the time, yes. It doesn't follow that those concerns made it worth strengthening the AMA's guild-like power to restrict supply and dictate pricing structure.

Indeed, it's a classic pattern, repeated in many industries, for a guild association to come in and say, "Look at all these incompetent quacks providing service X badly out there! You need to give us coercively-enforced licensing and accreditation authority so we can make sure all practitioners of X know what they're doing, and thereby Protect the Public." And they always have a sort of point, since in any free market for a service, especially a new or rapidly advancing one, there will be a certain percentage of incompetent and/or fraudulent providers. But it's still regulatory capture, and it still does more harm than good in the end.

[Sebastian Holsclaw]

"However, many employers will not allow their employees time off for an illness without a doctor's note"

Is this still true? I was under the impression that a company isn't supposed to ask about exercise of sick days to avoid problems under the ADA. Maybe that is just a 9th Circuit issue or something?

[Alex R]

Blogbudsman wrote: There was a time when HMO's were considered a good thing. ... HMO's were formed to 'manage' doctors, review those performance excessive procedures, bring them back in line.

Correct me if I'm wrong, but I thought that the *original* HMO's were something else entirely... My first memory of this term being used is for an entity that provided *both* health insurance and medical services. In other words, unlike today's usual system, in which doctors and hospitals contract with insurers to provide particular services for a fee, the hospitals were *run by* the HMO, and the doctors were *employees of* the HMO.

The only HMO that I know of that still seems to work this way is Kaiser-Permanente. Is Kaiser still an HMO of this type? Are there any others?

It seemed to me at the time that this is a pretty good idea. There is lots of incentive to provide necessary preventative care. An HMO of this type *will* have an incentive to provide the least expensive care that does the job, but so will any insurer. And if the doctors are paid salaries, and don't make extra money by performing extra procedures, the incentive to over-medicate or over-operate should be greatly diminished. Why didn't this kind of HMO catch on?

[votermom]

However, many employers will not allow their employees time off for an illness without a doctor's note

Where I work, and where my kids go to school, three consecutive sick days require a doctor's note.

[smlook]

"What does an in-hospital birth cost these days? and pre-natal care?"

About $8,000. I know unfortunately from first hand experience.

[Slartibartfast]

you'll be even more embarrassed when she explains it.

Nah. I had a good idea of the truth of things; and that she was just playing around with me. It's true that my use of "citizen" could be ambiguous, but really, could anyone have possibly mistaken me to mean she wasn't a citizen of any country at all?

[ScottM]

Yes, Alex R, Kaiser has its own buildings and doctors. I don't know why it's the only one that does. My employer is a small business that buys into a plan that allows individuals to select from a limited menu of doctors.

Kaiser constantly charges less for coverage (versus other plans, like Blue Cross), though their co-pay and rates have both increased the last few years.

[smlook]

Dianne,
"However, as Sebastian H points out, people who post here aren't necessarily typical. I suspect that $1600 a year isn't a lot to you."

I have yet to say anywhere that an HSA is the best way to go. And if you ask my wife she would probably say that I consider every penny alot. The only fact I know is that my HSA provides a shot at spending just a little less than a full coverage plan. I admit how much I MAY save is less than $1,000. The main thing that I think is good about the HSA is that it provides for more personal responsibility. Somehow that needs to be worked into the equation. I haven't been able to read all the posts today, but I don't think anyone has shown how that is going to be worked into a full coverage plan.

CaseyL,
"Is childbirth something that would be covered under 'catastrophic' health insurance, or is it something one pays for out of one's HSA?"

No it doesn't cover it.

[praktike]

Personally I think that if you're poor than you're frankly unAmerican--possibly traitorous--and deserve to die penniless.

[Edward]

Personally I think that if you're poor than you're frankly unAmerican--possibly traitorous--and deserve to die penniless.

You're certainly not as patriotic as the "productive class." If you really believed in "America" you'd have been born with a trust fund.

[CaseyL]

So, per smlook, OB-GYN care is something you pay for out of pocket, to the tune of $8000. That's quite an HSA. Now, one *could* make a case that, if you can't save $8000 over X number of years, you've got no business having kids anyway - actually, I'd even agree with such an argument, though I doubt many (any?) would agree with me.

The husband of one of my coworkers' was laid off yesterday - 4(?) months after undergoing triple-bypass surgery, for which he's still taking a dozen medications a day. His odds of finding another job are slim to nil, he figures.

His wife (my coworker) is grateful she kept him on her insurance for 'expenses not covered by primary carrier' - but the expenses that *were* covered by his employer now aren't. (We've all told her COBRA would extend the full coverage. For some reason, she doesn't think COBRA applies to her husband.)

They had already been using HSAs, and now the HSA payments are vitally important. But here's something she just found out: The HSA administrator we use here will not cut a refund check for amounts less than $25. That's more than the usual office visit copay, and possibly more than an Rx copay. So she has to wait until she's accumulated more than $25 worth of charges and send in combination requests. And with the lag between the time a repay request is made, and the time the repay actually arrives, more charges accumulate and more requests need to be sent, and it gets difficult to keep track of what they have been repaid for and what they haven't.

This was all huge news to me, as I thought HSAs functioned almost like ATM accounts: you can access the money directly. I didn't realize some plans make you go through an administrator.

My first, instinctive reaction to HSAs - that they're lousy ideas - just keeps getting confirmed.

[Sebastian Holsclaw]

COBRA might not apply if the whole company went under--when that happens there is no group to continue under.

[smlook]

CaseyL,

"So, per smlook, OB-GYN care is something you pay for out of pocket, to the tune of $8000."

Save, the snark and don't go looking for a fight, I think maybe you are unaware of how an HSA actually works. My HSA pays for all my medical expenses above the deductible. My last child cost me less than $3,000 because I maxed out my deductible.

"So she has to wait until she's accumulated more than $25 worth of charges and send in combination requests"

I understand, but I had to do that with one of my full coverage plans. That's not done just on HSA's.

"My first, instinctive reaction to HSAs - that they're lousy ideas - just keeps getting confirmed."

I don't see how that happens. If you read my posts I have stated how they do benefit me. I guess if you ignore my experience then your statement would still be wrong and you can confirm what you already believ. If you read my posts above no where did I say HSA's a were a cure all. I find it interesting that so many want to argue with me about that. I really do think it is because they consider it a Bush Admin plan.

Anyway, right now HSA's are not that great of a solution unless you are self-employed. Someone please show me a better solution that could be implemented without turning the whole industry upside down.

Perhaps... and only perhaps if more people used them insurance companies could offer lower deductibles. I don't know. But still no one has tried to figure out how we are going to work personal responsibility into the current system. Right, now that is about the best thing an HSA does for the system.

And again, so that I won't get attacked. Currently, HSA's really only benefit self-employed people who don't go to the doctor much. I was only describing my experience with an HSA. And Oh, yeah Bush sucks! I guess I should really put that at the beginning so someone might actually read the posts I wrote instead of just trying to tear them apart.

[Anarch]

That's more than the usual office visit copay, and possibly more than an Rx copay.

Lucky sumbitch. My various copays have been around around $15-25 per prescription; if he's on a dozen meds, it seems like that ought to put him over the limit almost immediately.

[CaseyL]

smlook - I'm sorry; I really didn't intend to attack you. When I said 'per smlook," I meant only that, that I was referring to information in your earlier posts.

And, believe it or not, I'm not opposing HSAs on the basis of whether Bush is for them: I first heard about HSAs in...1998? 1999? maybe longer ago than that? And didn't think much of them *then,* either!

I swear on my Siamese cat's grave, smlook: this once, just this once, I wasn't being snarky about a single word on your post. At any rate - I wasn't being snarky at you. Any snark was intended solely as an editorial comment on HSAs.

Now, I'm not and never have been self-employed. I now things are MUCH harder for self-employed people. If HSAs are useful to you, great and good. I'm saying, though, that I find them unconvincing as a substitute for employer-paid health insurtance.

[liberal japonicus]

I see that hilzoy and Jeff Rubinoff have posted about the uninsured/insured gap. Of course, a great tradition on the internet is to pick on the newbie (just kidding, it's great to have someone here with some actual experience), but I will side with Jeff and suggest that a point is being missed. The WaPo article suggests that charity hospitals overbill, and then use the deductions made to insurance companies as write-offs to justify their charity status. They also seem to systematically discourage charity patients, relying on the volume discount to show their charity. This has the effect of having the taxpayers foot the bill, yet actually reduce the real amount of charity given.

[Slartibartfast]

Since others seem to be inclined to throw out unevidenced opinion, what the hell:

I think it's possible that the relatively few people who overuse the healthcare system (and make no mistake, there is one. Just not one on purpose) are probably more than balanced out by those who, for one reason or another, disinclined to use it enough so that positive prevention is maximized. Plus, all those people who voluntarily engage in health-risky activities.

Not gonna explain any of the above, because I don't know and furthermore don't attach any particular weight to the above. Just an opinion, probably even less well-informed than the mean (to date) on this thread.

[smlook]

CaseyL,

Thanks.

To all,
I still haven't seem my real issue addressed anywhere. How do we implement personal responsibility?

I don't doubt what Slarti says in the previous post, but that is no guarantee. I don't want to implement a system that isn't somehow self-correcting. Or we will wind up with a program like S.S.

is, "How do we work

[praktike]

Hilzoy, check npr.org later today ... on my way into the office I heard a story about a Harvard study to the effect that half of all personal bankruptcies in the US are due to medical expenses.

[Slartibartfast]

Wouldn't surprise me, praktike. Today, we're able to work what would have been regarded as miracles a century ago. But those miracles don't come for free. Is it anyone's position that they ought to be?

[praktike]

"Is it anyone's position that they ought to be?"

Nope. But we ought to take this problem seriously.

[praktike]

Hilzoy, here's a Times article on the study.

[Slartibartfast]

But we ought to take this problem seriously.

Which problem?

[Jesurgislac]

Slarti: But those miracles don't come for free. Is it anyone's position that they ought to be?

Other countries manage to perform those miracles for people without forcing them into bankruptcy. Socialized health care systems are just so much more efficient.

[Slartibartfast]

Which other countries, Jesurgislac?

[Jesurgislac]

The UK. France. Canada. You know. Countries with better health care systems than the US...

[Slartibartfast]

Really? What's the wait time in Canada for an angioplasty? Can you really say people are getting the exact same (or better) health care?

[Sebastian Holsclaw]

We also need to be attentive to where the greatest percentage of medical miracles are discovered and why that might be so.

[Gary Farber]

Slart asks: "What's the wait time in Canada for an angioplasty?"

For someone who can pay for it, either with private insurance or cash? I don't know for sure, but since you are implying that it is longer than the U.S., what's your cite for that?

As for the wait time for an angioplasty in the U.S. if you don't have coverage of some sort, I'm reasonably sure that the median wait is somewhere near infinite. Am I in error?

Would you say that the 40 million or so without health insurance in the U.S. get better health care than those in the same circumstances in Britain or Canada?

[Slartibartfast]

what's your cite for that?

It's not my thesis, and it was a question besides.

:p

[smlook]

Jes,

"The UK. France. Canada. You know. Countries with better health care systems than the US..."

Please answer this one question as honestly as you can.

Have you had to go to the doctor in the UK, France, Canada or the US?

I had to go to the doctor in the UK. I was there 4 hours waiting because of a sinus infection.

I took my niece to the doctor in France. 3 waiting.

I went to the doctor in Canada about 30 minutes like the U.S.

[praktike]

"I went to the doctor in Canada about 30 minutes like the U.S."

I threw the horse over the fence some hay.

[Jesurgislac]

Smlook: Have you had to go to the doctor in the UK, France, Canada or the US?

In the UK, yes. Many times. Not in France, Canada, or the US.

I've waited between 5 minutes and 3 hours to see a doctor, depending whether or not I had an appointment, how busy the practice was, and how serious my problem was.

The major difference I've found between the UK and the US is that in the UK doctors routinely make housecalls at need: in the US (so I've been told) doctors never do.

[Slartibartfast]

Smlook, anecdote is not the same as data. If it were, I'd be talking about how many Canadians journey south of the border for various surgeries, as related by my father-in-law.

[Phil]

smlook, you know how you're always getting in people's faces when they make unwarranted assumptions about you and post based on those assumptions? I'll give you 25 guesses as to where Jesurgislac lives, and the first 24 don't count.

[sidereal]

"We also need to be attentive to where the greatest percentage of medical miracles are discovered and why that might be so."

ER.
Because it makes for riveting drama.

[Dianne]

I've been to doctors in the US and Germany. It's probably a coincidence, but generally the wait has been longer in the US.

[Dianne]

"We also need to be attentive to where the greatest percentage of medical miracles are discovered and why that might be so."

Well, since 2000, seven of the Nobel Prize winners in medicine or physiology have been from the US, 5 from the UK, one from Sweden. Since the UK has a population of a little less than 1/4 that of the US, I think they win that comparison.

[Slartibartfast]

Of course, of the five, one lives and does research in CA. But that's probably irrelevant. Another is a physicist, but that too is probably irrelevant.

[Gary Farber]

"It's not my thesis, and it was a question besides."

I asked a question, as well.

You said: "Really? What's the wait time in Canada for an angioplasty? Can you really say people are getting the exact same (or better) health care?"

So, you had no thesis, no point of view, no opinion, no point you were trying to make? You're merely neutrally asking for information so as begin learning about the topic? Respectfully, I am doubtful of this.

What's the wait time in America for an angioplasty without some form of medical insurance or cash to pay for it? Can you really say such people are getting the exact same (or better) health care as in Canada or the UK?"

[Gary Farber]

Smlook says: "I had to go to the doctor in the UK. I was there 4 hours waiting because of a sinus infection."

Was this a private doctor, or a doctor working for the NHS? If it was a private doctor, what's your point? If it wasn't a private doctor, why not?

I'll ask you a similar question as I asked Slart: what's the average waiting time to see a Medicaid-paid doctor in, say, Colorado, where I live, if you're a single male, for a sinus infection? I'll helpfully give you the answer: infinite.

Here's another: what's the average waiting time to see a Medicaid-paid doctor, if you're a single male, in Colorado, for any medical problem whatsoever, no matter how serious? Answer: infinite. Yes, it's a fine system if you have no health insurance, isn't it?

[Slartibartfast]

So, you had no thesis, no point of view, no opinion, no point you were trying to make?

Just questioning the unsupported claim that countries with socialized healthcare provide medical services more efficiently. As elsewhere, I thought this was obvious, but more directly:

show me, Jesurgislac.

[JerryN]

Given that the US spends a higher percentage of GDP on healthcare than other other industrialized nations, there is certainly a circumstantial case that that these countries provide medical services more efficiently than the US. For this not to be the case, one would have to assert that some combination of rationing in those countries and higher demand in the US accounts for all of the difference in spending.

[smlook]

"Of course, of the five, one lives and does research in CA. But that's probably irrelevant. Another is a physicist, but that too is probably irrelevant."

And who actually selects the Nobel Prize winners is also irrelevant.

Jes,

So despite having no actualy experience... you have a strong opinion.

I take comfort knowing now that you are not a U.S. citizen.

Gary,

Great so you believe in providing everyone with Health care. I suggest you start by donating your money. I however am not comfortable providing everyone with unlimited health care. I think that is a bad idea. If they can come up with a system that somehow takes into account personal responsibility then I probably would. Until then, NO. I still have not heard anyone talk about how that might be accomplished.

I don't desire to put down anyone's health care system, but going to a doctor in the EU made me feel like I had been transported back in time.

" If it wasn't a private doctor, why not?"

Cause 4 hours is a long time to waste?

"Yes, it's a fine system if you have no health insurance, isn't it?"

It depends on why they have no health insurance.

[Slartibartfast]

there is certainly a circumstantial case that that these countries provide medical services more efficiently than the US

Not necessarily. You'd have to show that the same care was supplied for less.

[Sebastian Holsclaw]

People without health insurance get treated for heart attacks too. Just sayin.....

[Jesurgislac]

Slartibartfast: Really? What's the wait time in Canada for an angioplasty? Can you really say people are getting the exact same (or better) health care?

For obvious reasons, Slarti, I find it easier to do research in UK waiting times: since the purpose of this question was for me to demonstrate that a socialized health system is more effective than the capitalist version you have in the US (so your most recent question says), I trust this will suit.

(I had to look up angioplasty on google to be sure I was looking up the right thing, though...)

From Scottish Health Statistics for coronary heart disease procedures: out of 1433 people waiting for an angiography, 168 have been waiting for over 8 weeks, 16 have been waiting for over 12 weeks. (The standard set is that everyone should be seen inside 12 weeks. cite) From the same website, the time from angiography to angioplasty can be up to 24 weeks: the stats show that out of 753 people who required an angioplasty, 53 had to wait more than 12 weeks, and no one had to wait more than 18 weeks.

These records are provided so that the public can see how each health service is failing the waiting times set: there's no equivalent set of statistics to show how fast someone can get an angioplasty if they need one. (But - anecdotal evidence - when my great-aunt had a heart-attack at the age of 90, she was in hospital and in an intensive care unit within two hours, stayed in hospital for several weeks, and was returned home to regular home visits from the practice nurse, the local Health Visitor, her GP, a new set of prescription drugs to take (free, of course; as an OAP she didn't pay prescription charges), all of which preserved her life for another three years.)

The UK pays 6% GNP for the NHS. What is the GNP cost of what the US pays for in health services? How long would someone without private health insurance wait for an angiography in your home state? How long would they wait after that for an angioplasty?

[JerryN]

It depends on how you define efficiency, doesn't it? Are we talking about the cost of an individual procedure? The average annual cost of care vs. level of care for a healthy adult? Do we factor in the accessibility to basic care across the population? Accessibility to advanced treatment? Cost of medication?

Perhaps we can we look at health statistics (infant mortality, life expectancy, disease rates) to determine relative health levels between countries and infer that those statitics correlate to the level of medical care. We could then look at this level vs. spending as a percentage of GDP. US spending is well above the levels in Western Europe, so I would be very surprised if the inferred level of care was commensurately higher. Like I said, it's a circumstantial case.

[Slartibartfast]

It depends on how you define efficiency, doesn't it?

Certainly. That's exactly the point.

How long would they wait after that for an angioplasty?

Your thesis, Jesurgislac. Making sweeping statements like you did sort of demands a modicum of legwork.

[Jesurgislac]

Slarti: Your thesis, Jesurgislac.

If you're not sufficiently interested to do the legwork to defend your thesis that the US health system is more efficient than a socialized health system, fine. Seems a little unreasonable of you to start a debate and then drop it once you have to do your side of the work, but I'm sure you have other things to do.