The Stakes

by publius

Amanda Marcotte writes that many insurance companies treat domestic violence as a pre-existing condition.  This is one of those "read the whole thing" posts, but I've excerpted a bit below.

Other than the obvious grotesqueness of it, I think it shows the dangers of allowing coverage decisions to be made purely by market forces.  After all, even though these actions are immoral, they're not economically irrational.  As Marcotte explains, victims of domestic violence are very likely to suffer much worse injuries in the future.  To a for-profit insurance company, that means more costs.

The answer, of course, is to stop leaving these decisions up to private insurers.  Indeed, one positive aspect of regulation is that it eliminates these types of collective action problems that insurers face.  For instance, if one insurer gains a cost advantage through this type of behavior, it's hard for other insurers to resist adopting it as well.  Anyway, here you go:

According to a press release for SEIU, 9 states allow insurance companies to consider domestic violence a pre-existing condition, and use that to deny insurance claims. Eight of the 16 major insurance companies have used this right to deny coverage to victims of domestic violence.

. . .

For those of us in the humane world, the fact that a woman who has been slapped today is in grave danger of receiving a massive beatdown in the next few months or years is a tragedy that we should seek to prevent. From the insurance company’s perspective, however, a woman who is slapped today is likely someone who will incur a massive hospital bill in the future, and that’s all they need to know.

These are the stakes.

Comments

[John Thullen]

Yes, but wife-beaters are rational economic actors, even while drunk.

Your average wife beater ...... who probably just watched teabaggers massing in Washington on FOX from his barcalounger (she got it for him for Xmas) in South Carolina, with a segment on illegal wife-beating aliens receiving healthcare at his expense thrown in to really get the testosterone pumping .... at the request of his beloved will often hit the woman in places that may bruise badly but that cause little lasting and visible physical damage and preclude a judgement of a pre-existing condition and denial of care by their insurance "provider".

"Remember, honey, the last time our insurance rates skyrocketed!" Kablam!!

A government-run system, which would eliminate the normal incentives and disincentives in our rational economic landscape, would cause a massive increase in wife-beating, especially of the pistol-whipping sort, and would likely even encourage new and more creative ways of kicking the old lady's butt, say by slamming her head in the refrigerator door repeatedly.

Now, of course, we would have the death panels under Obama's Nazistalinistgingrich plan to take up the slack and really teach the woman a lesson, but still, let's not distort the current free market in wife-beating, for we shall rue the day.

[mckinneytexas]

Or, you could eliminate spousal violence as an allowable 'pre-existing' condition. That nine states do this is not a good reason for taking over the entire health care system when there is such an obvious and minimal legislative fix available.

[Jesurgislac]

But the obvious and minimal legislative fix is government-run healthcare.

Anything else is just an endless run of legislation fixing lethally profitable decisions by health insurance companies after they've killed people.

[Bruce Webb]

Do I have this right?

These companies have incentivized covering up for your abusive partner precisely BECAUSE you fear he will hurt your badly enough some day to put you in the hospital?

In my state if you call in a case of domestic violence somebody is going to jail and the other person, if visibly hurt is likely to be escorted to the emergency room. But in those nine states making such a 9/11 call risks not having coverage in case he really hurts you on release from jail? BECAUSE you were beat up less the night before?

This is crazy. Because the next logical step is calling child abuse a pre-existing condition and not taking your kid to the ER because the bruising is not THAT bad and the kid wasn't actually knocked unconscious and you have to keep your medical care options open in case the next beating is life-threatening.

I have been making the case here and there that the people in the insurance industry weren't inherently evil, just that their business plan drives them to bad outcomes. But I may have to reassess that after this, whoever thought up this loophole is rivaling John Yoo for Olbermann's Worst Person in the World contest.

[someotherdude]

The Market has its reasons, and the world is better for it….amen…

[someotherdude]

& is "The Market" in the Constitution?!

[cleek]

i would never have imagined such a policy could exist.

and that makes me wonder what other 'conditions' the insurance companies amorally take advantage of.

they really are parasites.

[Bernard Yomtov]

there is such an obvious and minimal legislative fix available.

Yes, but "obvious and minimal" does not translate into "easy, quick, and certain to pass." You can bet that such legislation would meet with fierce opposition, arguments about federalism, insurance company lobbying, filibusters, and so on.

And then there is Jes' point. Endless patching is not a great way to fix a dysfunctional system. We don't need a government takeover, I think, (and it's not on the table anyway) but we do need a serious overhaul which would take care of this sort of nonsense.

[wonkie]

Di insurance companies cover the victims of child abuse or elder abuse?

[stonetools]

5,4,3,2,1..............

http://www.youtube.com/watch?v=ExjDzDsgbww

[publius]

One problem, stonetools, with using the Daisy ad as an analogy is this scary thing has already happened.

[efgoldman]

jeebus!

[Catsy]

The Daisy Ad? Bwahahahahahaha!

We really need better trolls. When the best response they can come up with to a post like this is a 45-year-old commercial...

[Bernard Yomtov]

You know, if the insurance companies want to reduce claims, maybe they could contribute to programs aimed at reducing domestic violence, or helping victims get out of abusive environments.

One plausible reason they might not do that is that many of the victims are uninsured (conjecture alert!!) so the benefit is small. Another reason to support universal coverage.

[Tyro]

Or, you could eliminate spousal violence as an allowable 'pre-existing' condition. That nine states do this is not a good reason for taking over the entire health care system

You're right. Because of the strength of your argument, I've been convinced that the government should not take over the entire health care system. Instead, I think we should have strict regulations of health insurers alongside our current Medicare, Medicaid, and VA system with the addition of a full-featured, efficient public insurance option available. Fair?

[hidflect]

...and black people are more susceptible to cycle cell anemia than whites. So.. gonna have to max up their premiums too.

[anonymous]

Domestic violence should not be treated as a pre-existing condition. And screw pre-existing conditions anyway, insurance companies should be insuring us no matter what.

Regardless publius, your sexist and ignorant writings should be corrected.

Domestic Violence researchers know that women are just about as likely to initiate domestic violence as are men.

http://www.oregoncounseling.org/Handouts/DomesticViolenceMen.htm

That Amanda Marcotte grossly ignores this and makes the sexist and disgusting assumption that only men can beat up their partners is no excuse for you.

And it's downright homophobic as well on your part, since domestic violence occurs between same sex couples (and specifically lesbian) in the same degree as in heterosexual couples.

You could google this if you weren't a dipshit. But it's easier for you to make sexist assumptions, and then pat yourself on your back for your progressive feminist point of view, which apparently, is NOT that the genders are equal.

By taking Marcotte's point on this what are you doing by ignoring, trivializing, dismissing, and actually blaming many victims of domestic violence.

Just because Marcotte wants to be a sexist pig, even though she has been repeatedly shown the actual facts, there is no reason for you to be a sexist pig.

Popular emphasis has tended to be on women as the victims of domestic violence.[7] Many studies[8][9] show that women suffer greater rates of injury due to domestic violence, and some studies show that women suffer higher rates of assault.[10] Yet, other statistics show that while men tend to inflict injury at higher rates, the majority of domestic violence overall is reciprocal.[11]

Modern attention to domestic violence began in the women's movement of the 1970s, particularly within feminism and women's rights, as concern about wives being beaten by their husbands gained attention. Only since the late 1970s, and particularly in the masculism and men's movements of the 1990s, has the problem of domestic violence against men gained any significant attention. Estimates show that 30 of every 1,000 females and 45 of every 1,000 males are victims of severe violence committed by their spouses.[3] A 1997 report says significantly more men than women do not disclose the identity of their attacker.[12] A 2009 study showed that there was greater acceptance for abuse perpetrated by females than by males.[13

[Dan S.]

Anonymous, that oregoncounseling site you link to is pretty interesting. For example, I've now learned a great deal about "the differences between men and women". Did you know that "[w]Women tend to be intuitive global thinkers," while "[m]en tend to focus on one problem at a time or a limited number of problems at a time"? Amazing.

Incidentally, I missed the part(s) of the post where publius connected domestic violence to a gender or sexual orientation (indeed, it's almost eerily nonspecific). At most, there's the reference to "a woman who has been slapped today", which is not publius', but actually from the quoted portion of Amanda's post, and is consistent with the study she cites (which focuses on violence against women.) I suppose that as a man I'm not being an intuitive & global thinker here, and instead, as that oregoncounseling site suggests, "view[ing elements in a task as less interconnected . . . and fail[ing] to appreciate subtleties".

Given that domestic violence against men by women does seem to be under-reported, under-recognized, and rather less likely to result in injuries, though, it would appear that having one's abuse defined as a pre-existing condition in order to deny coverage - the subject of the post - really is a problem mostly facing women.

(Also, It would have been nice to link to the wikipedia article you quote in your comment, so one doesn't have to google around for it - that's 14 seconds of my life I'll never get back!)

[Phil]

As I've mentioned here, I recently completed a four-month term of service on a grand jury in Cuyahoga County, Ohio, one of four concurrently-running grand jury panels in that term. Each panel heard anywhere from 20-50 cases presented for indictment every day.

During that term, my panel heard, in my estimation, some 100+ domestic violence cases. Under Ohio law, police do not have to have a cooperating complainant to arrest for domestic violence. They just need to determine whether a) there was a clear instigating party, and/or b) whether a party caused or attempted to cause serious physical harm -- which doesn't have a statutory definition, but does have case law supporting what's considered "serious," usually meaning that the victim sought medical attention -- to a family or household member.

In many of the cases, yes, women started arguments and fights with men. In some cases, they even hit them. Out of those 100+ cases, in only two -- that's T-W-O -- did the man seek or require medical attention. And in both of those cases, the woman in question cut him with a knife, one on the arm, one on the face.

In at least two cases, after starting a fight, the women were beaten so severely by their husbands or partners that they required not only medical treatment but long-term hospitalization. One of those we added a charge to the indictment of attempted murder. We did the same with another case in which the man choked the woman into unconsciousness so severely that the blood vessels in her eyes ruptured.

In another case, after yelling at her live-in boyfriend of twenty years over the use of her car, he simply pulled a gun out and fired two shots at her, both missing her.

No man in any of these cases suffered abuse severe enough to require hospitalization overnight, let alone long-term. None suffered abuse so bad that charges over and above felony domestic violence were considered.

Now, granted, this is all anecdote, but I have no reason to believe that the experience of the other three grand jury panels was any different. I'm willing to discuss this under my name. Is "anonymous" willing to do the same in between the flinging of insults?

[AIMAI]

I think all you need to know about the ambient level of hostility that women face in this country is indicated by the immiediate appearance of hysterical Men's Rights Trolls every time Amanda Marcotte's name, or Domestic Violence, are mentioned. It never fails. I don't have any problem with the creation of men's shelters for battered men, or even specialized police and court training so that our beleagured police can recognize the signs of male spousal battering. Go for it, anonymous. YOu can put in the thirty or forty years of hard, slogging, grassroots activity that feminists did to create awareness of the problem, as they see it, for women. They had the benefit of the statistics and the hospital records on their side, of course. But there's nothing to stop you all from taking your whining on the road--load up those buses with sobbing battered men and their crying children!--and raising awareness. Why you think you need to do it by attacking women in general I don't know. If you are right battered men should be looking to other victims of violence as their natural allies, not their enemies. Unless women are really the enemy, to you?

aimai

[mckinneytexas]

I think Phil has this one right. I suspect that the prevalence of male physical abuse is substantially greater than that of female physical abuse. Emotional, psychological, verbal-type abuse is probably more evenly distributed . . . at least that is my sense of it. I also suspect demographics, and more fundamentally, social factors play the dominant role. Children growing up in a violent, contentious, dysfunctional home tend to learn and take as normal what they see in their formative years.

[Jesurgislac]

Also, the key problem with anonymous-style ranting: It actually makes no difference to the issue of healthcare denied for pre-existing conditions whether women are equal or greater victims of domestic violence. No one should be denied healthcare because their partner was in the habit of putting them in hospital regularly. No one would disagree with that except for libertarians, right-wing Christians, and health insurance companies.

[Prup (aka Jim Benton)]

I entirely agree with the thrust of this post, but I'm always careful to check the facts. I'll let the teabaggers go marching on after having been 'kneecapped' by reality.

Therefore, I have to ask this. This survey that Marcotte mentions was conducted before -- and probably as a part of -- passing the Violence Against Women Act, and all the examples date to before this time.

Will someone who knows where to find the information check and see if this is still true?

[Prup (aka Jim Benton)]

On the other hand, maybe we should be grateful at the restraint shown by insurers. After all, by th same reasoning, as one of Amanda's commenters points out, 'living in a edangerous neighborhood' is also a 'pre-existing condition' and thus they could avoid compensating people for crime-related medical bills.

For that matter, any geneticly-linked duisease is, by definition, a pre-existing condition. Get that research going, guys, and you'd never have to pay anyone anything.

THIS is why I'm so insistent we get some bill, any bill that is even a minimal improvement over current conditions. Once we've shown we can accomplish any sort of health care reform, the 'aura of untouchability' will be gone, and the fight to improve on it will be much easier.

[Jay Jerome]

Prup (aka Jim Benton) said:
'living in a edangerous neighborhood' is also a 'pre-existing condition'

Same mind-set of Auto Insurance Companies: higher rates if you live in higher crime areas. When I moved from Orange County to L.A. my auto insurance nearly doubled, from the same company and the same broker.

Anyway, the politicians will eliminate 'most' pre-existing conditions from the health care landscape. That's the one provision you can be certain will pass. A done deal.

[Hartmut]

I still expect that the insurance industry owned congressbeings will slip a few loopholes in evn for that.

[von]

These are the stakes.

Are these really the stakes? If this proposed regulation was put up for an up-or-down vote, would it really fail? I guess it's possible, although I don't see any evidence for it -- particularly given that every reform package out there involves a host of new (federal) insurance regulations.

I also think that it's a mistake to present this issue as "market v. regulation." Insurance is already one of the most heavily regulated on the planet, but the regulations are almost entirely at the state level and there is definitely room for some federal regulations. That includes regulations regarding what are sometimes called a "pre-existing condition" (including this disgusting example). There's also room to relax certain regulations, however, such as the regulations that make interstate competition among insurance companies more difficult (the cause of the many de facto state monopolies).

What we need are smarter regulations.

As a kinda-relevant aside: my very first "real" pro bono experience was as a summer associate on a case bought by Lambda Legal Defense challenging the so-called "AIDs limits" on insurance coverage: these were ridiculous limits on the amount of money paid to cover the treatment of HIV, AIDs, and related illnesses. Something like a 15,000 cap on lifetime treatments. The plaintiffs filed suit anonymously because they were afraid of repercussions as being outed as gay men: I never even knew their real names.

That was 1998 in Chicago. It sometimes boggles my mind how far we've come on gay rights.

[Jay Jerome]

"I still expect that the insurance industry owned congressbeings will slip a few loopholes in evn for that."

And maybe a few that deserve debate...

If drug addiction is a disease, should the previous condition of heroin or alcohol addiction be covered?

[Turbulence]

If drug addiction is a disease, should the previous condition of heroin or alcohol addiction be covered?

Um, do you really think it will be cheaper for society to imprison a drug addict who wants to get treatment than to just pay for their treatment? Do you really think that the social costs of untreated drug addiction are small compared to the costs of treating the addiction?

[Dan S.]

If drug addiction is a disease, should the previous condition of heroin or alcohol addiction be covered?"

Yes. Think this one through for a minute.

[Bernard Yomtov]

If this proposed regulation was put up for an up-or-down vote, would it really fail? I guess it's possible, although I don't see any evidence for it

No evidence at all? Even after the "death panels" fiasco? Common sense provisions are no lock.

Also, as we are informed by SEIU via Marcotte and Publius:

9 states allow insurance companies to consider domestic violence a pre-existing condition,

So some legislatures don't like this regulation.

[Prup (aka Jim Benton)]

Again, this was BEFORE the Violence Against Women Act. Is it still true? I don't know the answer, but I really wish someone would confirm it.

[Jay Jerome]

Turbulence says:
Um, do you really think it will be cheaper for society to imprison a drug addict who wants to get treatment than to just pay for their treatment? Do you really think that the social costs of untreated drug addiction are small compared to the costs of treating the addiction?

Double Um... First, don't slice and dice the question. The number of druggies sent to jail just for possession is small compared to the overall addicted population. There are about 23 million Americans with substance dependence or abuse, or about 9% of the population. That includes abuse of both alcohol and illicit drugs, of which about 15 million were alcohol abusers.

That's a lot of people with drug problems. You want them all to be covered in the new expanded click your heels three times over the rainbow health plan?

If they're added into the system won't that negatively impact the cost, and make it more expensive for all the hard-working non-druggies who are going to have to pay for it with higher taxes or premiums? Isn't it fairer to be able to provide grandpa with a pacemaker then enroll another boozer or prescription drug abuser in some Betty Ford-like clinic that will further sabotage a system that is going to be severely cash-strapped for the next decade (if it survives that long)?

[CharlesWT]

"If they're added into the system won't that negatively impact the cost, and make it more expensive for all the hard-working non-druggies who are going to have to pay for it with higher taxes or premiums?"

Calling off the war on (some) drugs might save enough to cover it with a nickel or two left over.

[Dan S.]

" Isn't it fairer to be able to provide grandpa with a pacemaker then enroll another boozer or prescription drug abuser in some Betty Ford-like clinic . . ."

Besides the obvious moral and financial responses - your premise is that addiction is a disease, not, eg, a manifestation of immorality or 'weakness'. In that case (which I essentially agree with), it's not at all clear why it would be fairer to provide grandpa with treatment for one disease instead of providing dad or (daughter, or sister, or, well, grandpa) with treatment for another disease.

[Dan S.]

Again, this was BEFORE the Violence Against Women Act. Is it still true?

If you look here,

http://www.healthreform.gov/reports/denied_coverage/index.html

they say that "It is still legal in nine states for insurers to reject applicants who are survivors of domestic violence, citing the history of domestic violence as a pre-existing condition.8"

footnote 8 is something published in 2008 by the National Women’s Law Center.

[Turbulence]

Double Um... First, don't slice and dice the question.

The question as written was incoherent. Learn to write competently please.

The number of druggies sent to jail just for possession is small compared to the overall addicted population.

I guess I'm confused. If we have lots of drug addicts whose addiction does not significantly increase their chance of going to prison or significantly detract from their earnings potential, then...I'm not sure I see a problem. I mean, if you are an addict and your addiction does no harm to anyone, I don't see why you'd seek treatment. But for addicts whose lives are seriously harmed by their addictions, it seems to make financial sense for society to pay money to help them with their addictions. If getting clean means you can double or triple your effective earnings, that means lots more tax revenues for the state and a lot less cash spent on public assistance. Plus there are multiplier effects.

That's a lot of people with drug problems. You want them all to be covered in the new expanded click your heels three times over the rainbow health plan?

In my experience, many people with addictions have zero interest in treatment. Heck, many people with addictions refuse to believe that they're addicted. People who don't think they're addicted generally don't seek treatment just like people who don't think they have cancer generally don't spend their free time hanging out with oncologists and getting chemotherapy.

Moreover, lots of insurance programs right now already provide treatment for substance abuse. My insurance always has. Furthermore, some states, like MA, mandate that all insurance has to cover mental health and substance abuse. MA also requires that every person in the state have health insurance. I'll note that the requirement that everyone in the state have substance abuse coverage has not exactly destroyed MA. It still has the lowest divorce rate of any state and a (relatively) strong economy.

Instead of ignorantly speculating, perhaps you could go and do some research and find a think tank or CBO report or something where experts provide some support for your idea that substance abuse coverage is somehow problematic?

[Fran in Virginia Beach, Va.]

Publius, I really appreciate your posts. I'm glad you are back after leaving Legal Fiction. I have read all the posts so far on domestic violence being considered a pre-existing condition and an opt out for coverage by insurance. My thought here is that the most egregious and over looked need for treatment is mental health care. If there was more psychiatric treatment available in our Health Policies maybe there would be way less anger and violence in our country. Domestic violence is just the latest chapter in a violent pattern that was established in the childhood of the perpetrator as well as the victim. Benign neglect to our societal ills catches up to all of us. We pay a huge price for violence in this country and the medical profession is left to deal with it. Insurance companies have reduced the Medical Arts to a for profit business. We have a lot of work to do in this country to clean up our act when it comes to social resposnsibility. We can continue to act like the other guys problems are not my own or we can see that there is a collective responsibility to fix the social ills that cost us all anyway.IMO.

[russell]

If drug addiction is a disease, should the previous condition of heroin or alcohol addiction be covered?

Whether drug addiction is a disease or not, people should be able to get treatment for it as a matter of public health. I'm not sure why private insurance companies need to come into it at all.

Of course, this will create a moral hazard and millions of people will immediately acquire serious chemical habits just so they can get the freebies.

I mean, wouldn't you?

But you can't have everything.

[CharlesWT]

So, a person's anger management therapy won't be covered because the propensity to beat the crap out of their spouse or significant other will be treated as a pre-existing condition?

[Jay Jerome]

Turbulence: I guess I'm confused.

Finally, you're making progress. You've recognized your main problem...

If we have lots of drug addicts whose addiction does not significantly increase their chance of going to prison or significantly detract from their earnings potential, then...I'm not sure I see a problem.

Huh?

many people with addictions have zero interest in treatment. Heck, many people with addictions refuse to believe that they're addicted. People who don't think they're addicted generally don't seek treatment...

Good. We don't have to worry about the majority of addicts receiving universal health care for their addictions because they won't miss it when it's not provided under the new plan.

And for the others who want help, they can get it from AA and DA or other private programs and charities, as they have been for decades.

See, we solved that in a New York second.

Furthermore, some states, like MA, mandate that all insurance has to cover mental health and substance abuse. MA also requires that every person in the state have health insurance.

Yes, by law Maine insurance companies have to offer Substance Abuse care, with the standard following restrictions: $25 copayment per visit (double ordinary copayments), with inpatient max visits of 15 days per year, and 30 day lifetime.

I'll note that the requirement that everyone in the state have substance abuse coverage has not exactly destroyed MA

By 'everyone' I'm assuming you mean every insurance company, because Maine has more than 100,000 uninsured citizens, despite the fact that it has a state subsidized government program, much like what the Obamaites wanted (but no longer) which was supposed to insure the uninsured, but somehow managed to screw that up.

Yeah, Maine's a wonderful health insurance state. For Typical Blue Shield or Blue Cross family coverage (hubby, wife and kid) you only have to pony up a measly $2,439 a month, with a $250 deductible (and no smokers in the mix, otherwise they charge you an extra $200 a month).

It still has the lowest divorce rate of any state and a (relatively) strong economy.

Goody good. That's wonderful to hear. But you forgot to mention Maine's HIGH insurance rates. Way higher than nearby New Hampshire, for instance, where a family of three would pay less then half what they pay in Maine. Why? Because in addition to required substance abuse coverage, Maine requires insurers to cover anyone who applies. Think those requirements have anything to do with that cost disparity? That's not to say they should exclude previous conditions, only to alert you what's coming down the road when universal coverage is extended nationally -- way higher premiums and/or way higher taxes. So be ready, because if you're in the middle-class, you're going to pay for it one way or another.

And you also forgot to mention DirigoChoice, but that's a can of worms you probably don't want to open.

[Jay Jerome]

CharlesWT says: Calling off the war on (some) drugs might save enough to cover it with a nickel or two left over.

I agree with that 100%. Possession of small quantities for personal use should be decriminalized, or at worst, charged as misdemeanors. If we did that, we'd save BILLIONS and BILLIONS of dollars, enough to pay for standard health care, and dental and optical too. But that's not going to happen.

[Jay Jerome]

Dan S says: your premise is that addiction is a disease, not, eg, a manifestation of immorality or 'weakness'. In that case (which I essentially agree with), it's not at all clear why it would be fairer to provide grandpa with treatment for one disease instead of providing dad or (daughter, or sister, or, well, grandpa) with treatment for another disease.

No, I don't really think addiction disorders are diseases. I was being partially facetious. I believe some people are predisposed to addictive behavior, but I don't consider those behaviors as weakness, more like low resistance to potentially self-destructive behavior. Like compulsive gambling, which some people also describe as a disease.

And if you think grandpa and aunt Harriet are not more deserving of the limited medical resources that will be available in the next few decades than Uncle Phil the Town Drunk or Aunt Harriet who can't resist going all-in with her bi-weekly pay check on an inside-straight draw -- well, we just don't see eye to eye on the morality balance scale.

[Anarch]

MA is Massachusetts, Jay, not Maine.

[Harald Korneliussen]

Turbulence wrote: Um, do you really think it will be cheaper for society to imprison a drug addict who wants to get treatment than to just pay for their treatment? Do you really think that the social costs of untreated drug addiction are small compared to the costs of treating the addiction?

I'm not sure what you think, but addiction treatment is frightfully expensive and doesn't really work (huge remission rates). And that's if people want to be treated. Most people with drug use harmful to themselves and/or their surroundings do not.

As a way of reducing harms to society from drug use, preventing people from starting is vastly more cost-effective than treating them. Addiction treatment is something that is done for humanitarian reasons, not because it's a good way of solving a problem.

[Dan S.]

Jay - thank you for clarifying that point. Two things - as I suggested in the previous comment, what about when Grandpa who needs a pacemaker is also Phil the town drunk? Also, do you feel that mental health issues should be covered, & not count as 'pre-existing conditions' (remember, currently insurance companies can respond to pre-existing conditions in a variety of CEO profit-boosting ways, from simply refusing to treat them to charging higher premiums to denying/dropping coverage altogether)?

[Dan S.]

"And if you think grandpa and aunt Harriet are not more deserving of the limited medical resources that will be available in the next few decades than Uncle Phil the Town Drunk or Aunt Harriet who can't resist going all-in with her bi-weekly pay check on an inside-straight draw . . ."

Appeal to scarcity aside; why do you see grandpa more "deserving" than Uncle Phil?

[Turbulence]

No, I don't really think addiction disorders are diseases.

If you had just written that originally rather than trying to be coy, this conversation would have been much simpler.

Of course, what you think on this subject is irrelevant. Lots of crazy people think all sorts of things aren't diseases. I've met people who think cancer is a state of mind. We entrust experts to set criteria on what qualifies as a disease and the DSM has entries for addiction.

And if you think grandpa and aunt Harriet are not more deserving of the limited medical resources that will be available in the next few decades than Uncle Phil the Town Drunk or Aunt Harriet who can't resist going all-in with her bi-weekly pay check on an inside-straight draw -- well, we just don't see eye to eye on the morality balance scale.

I have lots of opinions about how social capital should be distributed and who is the most "deserving." But I also think it is none of damn business. Maybe Bob the 5 pack a day smoker does not "deserve" to get treatment for his lung cancer, but I really don't think we as a society should be empowering you, or anyone else to make that decision. Now, if you want to talk about a system where we parcel out dollars based on treatment cost and life expectancy improvement like the NHS does, I think that would be a good idea but that's very different from parceling out dollars based on how "deserving" you think people are.

I'm not sure what you think, but addiction treatment is frightfully expensive and doesn't really work (huge remission rates). And that's if people want to be treated. Most people with drug use harmful to themselves and/or their surroundings do not.

The cost of treating addicts who don't want treatment is 0. If they do want treatment, the costs of treating them are certainly less than the cost of imprisoning them, and often less than the costs of improved social functioning, even taking into account the low probability of success.

I'm not saying current addiction treatment methodologies are amazingly successful -- I'm just saying that even given a low probability of success, they are often cost effective given the costs they eliminate when they are successful. This is unlikely to be true if you live in a country that does not imprison vast swathes of addicts.

Having said that, I'd be delighted if we had a real comparative effectiveness agency that did research and decided what addiction treatments Medicare would pay for and what it would refuse to cover. Presumably, private insurers would follow suit.

[Turbulence]

That should have been: But I also think it is none of MY damn business.

I won't comment on your confusion of Maine and Massachusetts. Because it is too funny.

[Jesurgislac]

I won't comment on your confusion of Maine and Massachusetts. Because it is too funny.

Actually, I think it's a clue that Jay Jerome isn't American. *grin* Speaking as a non-American. I wouldn't remember whether MA was Maine or Massachussets without looking it up.

[liberal japonicus]

I think Jay's based in California, so his confusion between Maine and Mass might be attributable to lowered standards of education. Or a profound lack of interest in the East Coast.

BTW, this just brought up a memory. I remember my uncle looking at a postcode for a friend who lived in a distant part of the UK and he said 'oh, she's in Darlington' and something else came up before I could ask him how he knew. A quick look at Google suggests it is not too hard to do this, but I wonder if Brits can do this generally.

[Jesurgislac]

A quick look at Google suggests it is not too hard to do this, but I wonder if Brits can do this generally.

...depends. I'd say it's not too hard to remember quite a large subset of UK postcodes - but (never having known or written to anyone in the DL postcode area) I wouldn't have known that Darlington was DL without looking it up.

Looking at the list of cities in the UK, I have no trouble remembering the postcode for any of them down to Plymouth - below that, it's more dependent on how likely I am to have noted/remembered an address with a postcode on it.

My impression was, though, that the 50 states by abbreviation was just something Americans get taught in grade school - though I guess that's no indicator of whether they're paying attention...

[Eric Martin]

That nine states do this is not a good reason for taking over the entire health care system when there is such an obvious and minimal legislative fix available.

Yes, but which groups/legislation/Dem Party leaders/legislators are suggesting something so big? Or, what Tyro said:

You're right. Because of the strength of your argument, I've been convinced that the government should not take over the entire health care system. Instead, I think we should have strict regulations of health insurers alongside our current Medicare, Medicaid, and VA system with the addition of a full-featured, efficient public insurance option available. Fair?

Let's compromise mckinney: I'll campaign as hard as I can against a complete government takeover, if you meet me half way and agree to the program enunciated by Tyro. Deal?

[Jay Jerome]

Dan S says: Also, do you feel that mental health issues should be covered, & not count as 'pre-existing conditions'

I'd like everything to be covered -- I'm in favor of universal care; I think a combo public and private option would be best (but that's not in the cards now). And yes, I think mental care should be covered (there's a lot of people on this blog who definitely would benefit from it). But we're facing a dire economic situation, for at least a decade, maybe more. And if 40 or more million people are added to the ranks, a good portion of whom will pay little or nothing for their care in premiums or taxes, middle class working families will end up paying for it, one way or another. Therefore preexisting addictive behavior treatments are not high on my list for coverage inclusion.

[Jay Jerome]

turbulence says: I won't comment on your confusion of Maine and Massachusetts. Because it is too funny.

Yes, you're right, I read MA as MAine, not (MA)ssachusetts.
Sorry about that, I'm mildly dyslexic, but I'm glad you got a laugh out of it.

But guess what -- the comments about the Maine health care plan match the (MA)ssachusetts plan. Insurance in both states are more expensive than comparable plans in other states, like New Hampshire. Both are affordable for low income people, but more expensive for middle-class families. Middle-class families of three pay about double what they would in in New Hampshire. So yes, I read the abbreviation wrong, but got the numbers right.

Plus the (MA)ssachusetts system is stressed to the seams. Money to finance it is short, and primary care doctors are in short supply: there aren't enough of them to treat the additional 428,000 subsidized patients added to the ranks. This has led to longer wait-times for patients to see doctors, now taking up to 50 days for an adult primary care doctor, and up to 100 days wait-time for new patients.

Those kinds of shortages and extended wait times are expected nationwide if health care legislation is enacted and another 47 million patients are insured. Estimates predict we'll need additional 40,000 general practitioners over the next decade, or face even more severe backlogs.

[Nombrilisme Vide]

there's a lot of people on this blog who definitely would benefit from it

And this coming from the person who was chiding commenters in another thread for their nastiness and invective not four hours earlier.

Stay classy, Jay.

[Jay Jerome]

turbulence:(re: alcohol as disease) If you had just written that originally rather than trying to be coy, this conversation would have been much simpler.

First, it wasn't a conversation with you -- it was with Dan S. When I direct comments at opinionated buffoons I do it in a more straight-forward fashion, to try to eliminate incoherent replies. Like this, for instance:

Lots of crazy people think all sorts of things aren't diseases. I've met people who think cancer is a state of mind. We entrust experts to set criteria on what qualifies as a disease and the DSM has entries for addiction.

Are you insinuating people who don't believe alcoholism and drug addition should be categorized as a disease are crazy for that opinion? If so, 80% of doctors surveyed at the International Doctors of Alcoholics Anonymous (IDDA)conference in 1997 responded that they perceived alcoholism as 'simply bad behavior.' There are numerous other healthcare professionals who believe addictions are psycho-social willpower or conduct problems, and shouldn't be classified as diseases. And there are many scholars and professors of the same opinion, who contends the issue is primarily one of self-control, or the lack of it.

And so there seems to be a difference of opinion on the subject, but from your narrow-minded perspective I'm certain if any of those doctors or professors stated that view here, you'd tell them what they thought was irrelevant, and they should defer to DSM experts, who are always right, except when they're not (like all the years the DSM classified homosexuality as a mental disease).

But not to worry, the DSM is adding more mental and addiction disorders all the time: if it's a disease, your insurance will have to cover it under the new mandatory guidelines; which will mean more paid visits to doctors, and higher premiums for payers). Among the proposed additions is IAD (Internet Addiction Disorder), which I'm sure will end up being a gold mine for psychiatrists everywhere.

[Phil]

First, it wasn't a conversation with you -- it was with Dan S.

You seem to have mistaken a blog comments section for email. Might want to work on that.

[Turbulence]

I'd like everything to be covered -- I'm in favor of universal care;

Universal health care refers to what what fraction of the population have health care rather than what health care covers. Just in case you're confused about basic definitions.

I think a combo public and private option would be best (but that's not in the cards now).

Yeah, it looks like we're only going to get a private system.

But guess what -- the comments about the Maine health care plan match the (MA)ssachusetts plan. Insurance in both states are more expensive than comparable plans in other states, like New Hampshire. Both are affordable for low income people, but more expensive for middle-class families. Middle-class families of three pay about double what they would in in New Hampshire. So yes, I read the abbreviation wrong, but got the numbers right.

Cite please?

Plus the (MA)ssachusetts system is stressed to the seams. Money to finance it is short, and primary care doctors are in short supply: there aren't enough of them to treat the additional 428,000 subsidized patients added to the ranks. This has led to longer wait-times for patients to see doctors, now taking up to 50 days for an adult primary care doctor, and up to 100 days wait-time for new patients.

A month ago I tried to get a new primary care doctor in MA. The first office I called offered me an appointment in three weeks. The second office offered me one in two weeks. The third offered me an appointment in "a few days". These wait times don't seem so bad. So, again, cite please?

First, it wasn't a conversation with you -- it was with Dan S. When I direct comments at opinionated buffoons I do it in a more straight-forward fashion, to try to eliminate incoherent replies. Like this, for instance:

You're writing comments on a public blog. That means you're participating in a group conversation, whether you like it or not. If you do not want to do that, please refrain from commenting.

Also, calling anyone here a buffoon violates the posting rules. Do you think you can refrain from violating the posting rules or would that be too difficult for you?

Are you insinuating people who don't believe alcoholism and drug addition should be categorized as a disease are crazy for that opinion?

I'm saying quite explicitly that lots of crazy people think all sorts of diseases aren't actually diseases.

If so, 80% of doctors surveyed at the International Doctors of Alcoholics Anonymous (IDDA)conference in 1997 responded that they perceived alcoholism as 'simply bad behavior.'

Cite please?

There are numerous other healthcare professionals who believe addictions are psycho-social willpower or conduct problems, and shouldn't be classified as diseases. And there are many scholars and professors of the same opinion, who contends the issue is primarily one of self-control, or the lack of it.

That may be true. Or it might not be. But you haven't actually cited these "numerous" other experts. So we can't really believe you when you claim that they exist and further claim that you are correctly representing their opinions.

I'm not sure why willpower is relevant to whether something is a disease. Cigarettes are highly addictive. Does that mean that insurance should not provide lung cancer treatment for smokers? I mean, isn't the problem with nicotine addiction simply one of psycho-social willpower? If smokers had stronger wills, they'd be able to resist the temptation to smoke, right?

And so there seems to be a difference of opinion on the subject, but from your narrow-minded perspective I'm certain if any of those doctors or professors stated that view here, you'd tell them what they thought was irrelevant, and they should defer to DSM experts, who are always right, except when they're not (like all the years the DSM classified homosexuality as a mental disease).

So, you're not speculating on what hypothetical doctors would say if they were here. And then you're speculating on what I'd say to these hypothetical doctors that aren't here if they were here. What possible purpose could such idle speculation serve?

But not to worry, the DSM is adding more mental and addiction disorders all the time: if it's a disease, your insurance will have to cover it under the new mandatory guidelines; which will mean more paid visits to doctors, and higher premiums for payers). Among the proposed additions is IAD (Internet Addiction Disorder), which I'm sure will end up being a gold mine for psychiatrists everywhere.

Actually, states that mandate mental health parity can choose to define what constitutes required mental health care. They might defer to the DSM or some other expert panel, but they're also free to make their own modifications.