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October 11, 2007

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I can say from personal experience that the medical insurance specter is one of the largest barriers faced by anyone who wants to start or maintain a small business in the US.

So, basically, the current system is anti-business, anti-competitive and anti entrepreneurial.....

Bruce - it would be "HRC is the one common enemy that unites all the warring factions" in the Republican party, I believe. Doesn't mean she has any style in common with Malkin.

I had no idea that I had to include into the comparisons the fact that I've never called with my health insurance (or had a financial issue about them not paying) in the 25 years I've been insured on my own. And I've been through quite a lot. If they decided not to pay it was usually someting strait out of their general terms ("this bill is for a second crown in one year - your sedation is covered, but not the dentist costs").

I've always been able to choose my doctor, dentist, specialist or therapists and we are all aware of what is or is not covered. Visits, medication and needed operations are always covered. Optional ones means you have to check the coverage (IVF was covered in my time, but these days they only cover the second & third IVF in the standard package, birthcontrol pill was covered in my time, these days it is only covered thill the women is 21. If I want to correct my eyelids it is only covered if they cover 1/4th mm of my pupil and is thus not cosmetic but necessary. If I want to correct my belly I can only apply for coverage if I've lost more than 50 kg's, etc.).

One thing no-ones commented on is the extremely stupid and frustrating "network" system. I had an exam recently and made sure that the specialist was "in-network". I still had to pay high amounts for the hospital and lab, neither of which was "in-network".

I think if we eliminated "networks", especially in regards to things the consumer has NO choice over, it would go a little way to making the American system better.

Marbel: I had no idea that I had to include into the comparisons the fact that I've never called with my health insurance (or had a financial issue about them not paying) in the 25 years I've been insured on my own.

Yeah. What is and is not covered by the NHS is clear up front - if the NHS won't cover it, you'll be told promptly: if the NHS will, you get it without charges or worry.

(There are complaints about this being a "postcode lottery", always, but in 40 years and a fairly wide range of acquaintances I can think of exactly four instances where someone I know wanted a treatment that wasn't available on the NHS and had to go private: an eye exam for a problem that could have been serious (but turned out not to be) that a man wanted now, not in three weeks; tooth damage fixed after an accident that a woman wanted with a much better material than the NHS would pay for; and the best-quality hearing aid that a woman wanted now rather than going on the NHS's two-year waiting list. (She could have got an inferior model immediately, but would then not have been eligible to go on the waiting list.) And, though I think this falls into a slightly different category, a friend who wanted to keep trying for a baby and the local NHS fertility clinic would only give women a certain number of chances and only before 35, and she'd used up all hers and was now, by NHS standards, overage. This is the kind of thing that I think someone was talking about upthread, that "only basic care" is covered - there is a very, very large range of what's considered "basic".)

Ditto Jeff on "in-network" garbage. When I moved back to Ohio this year, I had to get a new Primary Care Physician. (Because, if I use my company's PCP plan I only pay $50 a month for myself and my wife, whereas if I want to use any old doctor I want at any time I have to pay $250 a month.) As it happens my sister works in a doctor's office and she recommended him highly, so I went to him, only to find out that, even though he WAS listed in my company's physician directory, he was not listed as a Primary Care Physician, just an in-network doctor, so I couldn't use him. What a bunch of bureaucratic nonsense.

Another side to the NHS: really, really cuts down on the bureaucracy, to practically nothing for the patient (I don't even have to keep track of my NHS number, though my records can be transferred faster when I move to a new practice if I do) and - quite evidently - simplifies it enormously even for the hospitals/doctors.

I'm reading the blog of someone who is on one of my mailinglists. She's American, married to a Dutch person and moved to the Netherlands. Unfortunately her daughter from a first (American) marriage was diagnosed with a terminal brain tumor.

For several (not medically relevant) reasons they decided to move her daughter from the US to her Dutch household. I'll quote from april last year:

April 10:

We proceeded to the MRI chamber where, much to my surprise, my husband and I were given earplugs and allowed to sit next to our daughter's feet during the procedure. She listened to her Beatles CD (only slightly better than nothing, she said, because the machine is so loud); I rubbed her lower leg. I was practically inside the machine by the end; it was a full craniospinal MRI, and every few minutes her bed inched inward. A second welcome surprise was the duration: just 45 minutes, compared to 90 minutes for the same procedure in the US back in the fall.

April 16th:
Our insurance company is stonewalling. They have to accept our daughter eventually, but they hope to make "eventually" later rather than sooner. First they said they'd be satisfied with proof of her registration as a city resident. Now they want to wait on her residence permit. I understand their reluctance--we're already two hospital visits, an MRI, and several prescriptions into the honey pot--as I'm sure they understand our ardor (we're already two hospital visits, an MRI, and . . .).

April 20:

The insurance circus is finally over. (Famous last words.) We've had to take out a separate policy for her (a "buitenlandverzekering," or travel insurance, oddly enough; she's rather the opposite of a Dutch person traveling outside the Netherlands) until her residence permit is finalized. Fortunately, our insurer is backdating the policy to April 5, the day she arrived. It will cover all her major medical expenses in Holland. For € 95 a month, that's a deal. In fact, it's already paid for itself for the up to six months we'll need it: her leg brace alone will cost € 513.

As it turns out, Dutch law stipulates that a foreigner cannot be covered under regular medical insurance until his or her residence permit is approved (I looked it up). So our insurance company wasn't being difficult after all. In fact, I think it's very generous of them to offer us the interim policy, knowing it will cost them (and big). Unlike for regular medical insurance, they have the right to refuse her for this policy.

In October she does have some insurance problems:

So I called the hospital billing department this morning and got one Ms. T. on the line. I explained that we needed the bill broken down into charges before April 5 and charges after April 5, and why. Her response:

"But we can't do that. This is the way it gets billed."

Now she could see on the screen exactly when we'd been and for what, so that's a load of bull patooey. But she's a good little cog in the wheel, and it didn't bother her at all that this administrative silliness is going to cost us € 14,904.78 that our insurance company should be paying. She didn't even feel any shame when I said our child would be dying soon and I really thought that was enough without an unnecessary hospital bill. She did condescend to communicate it to her coordinator. When I asked how long it would be before we heard back, she said:

"Could be a day, could be a week."

Socialized medicine has its benefits, but billing department drones remain the same everywhere. I don't know how they live with themselves.

The next day however:

After yesterday's call to the hospital billing department, I sent an e-mail detailing the situation and requesting a new invoice within a week stating a treatment start date of April 10 (the day my daughter went for her first appointment) rather than February 28. Ms. Teunissen called me in the afternoon to express her concern that a week might not be possible, but they would review the situation as quickly as they could. She called again first thing this morning to say a new invoice with a start date of April 10 would be sent to the insurance company.

To Ms. T. and her team: thank you for resolving this so quickly.


Two random points: first, on a personal basis I would probably receive minimal benefits from switching to an NHS-style system since I'm covered by the contract and HMO that serves pretty much every employee of the state of Wisconsin. Size matters.

That said, they don't do specialist stuff like surgery or neuropsych consults, the latter of which I needed, the former of which I'll need shortly. [Knee injury and possible {and misdiagnosed} neurodegenerative disease respectively.] That's where my real troubles have been: integrating my HMO-provided general health care, which has been excellent, with my specialist care, which has not. That's also leaving aside the fact that my HMO refuses to cover emergency room visits, requiring that I attend their "Urgent Care" center for which one has to make an appointment in advance. But whatever, I've had the same HMO for seven years now and I really can't complain.

So for me, no, it probably wouldn't make much difference were I to switch to an NHS system and might even drive the caliber of my personal care down somewhat. But so what? The social advantages -- not to mention the mass economic advantages -- so heavily outweigh whatever problems I might have, I would (and do) advocate a switch in a heartbeat.

@Anarch: What *is* covered by your insurance? For comparisons sake, assuming you have one of the better packages?

Lessee... general care, chiropracty and minor orthotic consults, physical therapy, mental health (including prescription medicines but not, unfortunately, the med I need for my sleep disorder), blood work, some kinds of radiology, optometry/opthamology, dental checkups, as well as prenatal and other things I don't use. That's all in-house. Drugs of various kinds can be obtained with a moderate co-pay, e.g. antibiotics, sleep meds and the like. It also covers -- usually without additional cost -- dental work (e.g. removal of wisdom teeth), surgical consults, MRIs and other hardcore diagnostic tools, necessary surgeries [I don't know how that's defined, sorry], neuropsych consults, sleep disorder consults and various other things that one needs to go to other institutions to obtain. All in all, I've been happy with the care... especially given the plethora of health problems I've had.

In short: there are real advantages to being unionized. We get paid like crap but the formerly-zero-premium health care more than made up for it in my case.

But in my socialized health care all of that is covered *and* all necessary medication without co-pay (necessary as in freely available painkillers will only be covered if you have a chronic ailment with pain). Detal checkups are not covered in the basic package, but are covered in my additional package (1 full X-ray every two years and detal clean up every year are in the basic package). Removal of wisdom teeth would be covered (that's surgery and surgery is specialist enough to be covered ;) ).

So in the Netherlands you would have all of that without co-pay and with free choice of doctors, hospitals and specialists for 95 euro per month. You might have to wait three weeks for your MRI unless it was a serious life-threatening disease. But you'd be able to get one privately immediately (and would only have to pay the difference between official price and what the private company charges) or go to a neighbouring country to get one. With your sleep-disorder I'd have to know the name of your medication to see if it was completely of partially covered, but most doctor-prescribed medication is completely covered.

Hey, I never said that I wouldn't take the European health care system over mine, just that I was doing well :) And since I have, or had, zero-premium health care as part of my job package -- hence the crappy pay -- I think 95 euros would end up costing more.

[There's also the issue on the MRI; I lucked into an appointment within two days of requesting one, but I have no idea how common that is around here.]

So ultimately, I suspect that my health care would slightly diminish if only because I've lucked into such good care within my HMO. But as I said, the social cost would absolutely be worth it.

Anarch: Well, aside from chiropracty (which is deemed a complementary therapy in the UK, and so not available on the NHS) as far as I can see everything that's covered on your HMO would be covered on the NHS, plus of course your knee surgery, consultation with a neuropsychologist and free use of any casualty department at any NHS hospital in the country.

Annual eye tests with an opthalmologist cost £10 but are free if you are under 16, in full-time education, on a low income, have a range of eye complications that mean it's essential you have a regular eye test (I fall into that category) or are over 40 (and that category, as of last birthday). If you need complex lenses, you get an annual voucher that part-pays for the cost, but pay for your own frames (though there are NHS frames, very cheap, which I wore for most of my childhood, because I was a dab hand at breaking my specs and besides, back then I needed a new prescription every three to six months - and got them all free).

Getting registered at an NHS dentist can be a problem, though there is a helpful website to find one in your area, but once registered, NHS fees for all regular dentistry are quite affordable - and are free if you're on a low enough income that they're not affordable. (I've gone through years, mostly when I was a student, when that was the case for me.)

(Dentists and opticians part-opted out of the NHS when it started, and as a result the situation is more complex and more expensive than it needs to be. Still. I wince whenever I think of Jeanne Darc, who went without glasses for three years because her mom couldn't afford to buy her another pair.)

Your prescription charges would be £6.65 per item, though again there are a whole range of exemptions (women get free prescriptions during pregnancy and for 12 months afterwards, for example, and so do insulin-controlled diabetics, and so does anyone over 60 or under 16...), and if you know you're going to be getting at least 4 prescriptions in three months/14 in a year, you can buy a pre-payment certificate, which apparently saves you money, though I've never looked into how this works.

chiropracty would depend on your insurer: it's one of the things they use for differentiation. So the basic package in insurer one would have it covered completely, number two a certain percentage up to a certain amount and number three not at all. Same for most 'alternative medications'; I'm always trying to find one that does NOT pay for homeopathic medicin since I'm not going there anyway.

opticians are free, glasses only if you are above or below a certain measure. But no prescription charges; I need medication I either visit or call the doctor/specialist, get a prescription, go to my pharmacy where they hand me the medication. No payment necessary at all, as long as I have a prescription.

For my thyroidism for instance I have never paid anything. Not the doctor, not the lab for regular bloodtest, not for medication. For my middle sons ear operations: never paid anything and he has been operated 5 times allready. No cost for medication, research, hospital and when I wasn't happy with our local specialist I informed who would be near and specialize in kids ears, and just called to make an appointment. I had to wait three weeks, but a few months ago his ear hurt and I could come the same day to see the specialist. No forms to fill in, no bills to pay, I just told the hospital my sons insurance number and that was the end of bureaucracy.


Marbel: But no prescription charges; I need medication I either visit or call the doctor/specialist, get a prescription, go to my pharmacy where they hand me the medication. No payment necessary at all, as long as I have a prescription.

Yeah, I wish we had that system. Prescription charges (I can just remember) used to be something like 50p per item, and then Margaret Thatcher decided it was time people on lower incomes started paying more tax while she cut taxes for the rich and richer, and prescription charges were one of the ways her little Tory creeps found of doing that.

As for chiropracty - they've been arguing back and forth about making it available on the NHS for years. I expect it probably will be - eventually - but right now, if you want to see one, you pay. I expect there are private health insurance schemes that would cover it, but I've never looked into those.

But we have a basic package that the government decides about but that is done via private insurers. So the government says "this is the premium and this is the basic package - and everybody has to be accepted". The insurers then compete with their additional packages, extra's and services.

For instance; the package I chose with my insurer was slightly cheaper because I opted for the 'in natura' version. That means that all the healthcare providers they have a contract with are immediately paid for by them, the ones they don't have a contract with I have to pay and I get the money back from them.

Healthcare providers have contracts with several insurers, so it is not exclusive. Which means I have to search really hard to find one that is NOT in a contract with them - but if I felt like it I could. And if I went to a private place I would declare the same way: They would pay the part that they would pay if it happened with one of their contractees back and I would pay for the remaining fee.

Incertus (Brian) made a point about SCHIP/healthcare that I want to comment on:

"Why hasn't the private sector already come up with policies to cover the working poor, people with pre-existing conditions, and people suffering from long-term intractible disabilities? If theprivate secvtor solutions are always the preferred ones, where the heck are they? What are they waiting for?"

You know, if you think back to many of the major humanitarian-style changes made within our country with regard to the 7-day work-week, 8-hour days, and so forth, it becomes clear that there's something other than government, and something other than the private sector. It's the external socializing influence of organized labor.

I wonder what the "something other than" factor might be today....?

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