Your concern is unlikely to end with nationalizing health care. People already use ’since the health effects of X are born by society, we have a right to control X’ logic is already used to justify government interference in all sorts of personal decisions. It’s incredibly naive that these tests won’t be used to justify further intrusion.

But in a national health care system (of whatever type) there are levers to prevent these things from happening. Right now, there are insurance companie sin Cali that wont insure firefighters. Think that happens in a national health care system?

>Think that happens in a national health care system?

Yes. Just look at what we do to our soldiers in the VA.

SD

No, thats an Army facility, not a VA facility. The VA hospitals offer the best health care in the country. Army facilities are different because the patients have no meaningful way to influence the system.

>Army facilities are different because the patients have no meaningful way to influence the
>system.

Agreed. But given the nature of Beuracracy, it’s unlikely most patients in a nationalized healthcare system will be able to influence the system either. The ability to go to another doctor or hospital will be gone. They won’t be able to sue because of sovereign immunity. If treatment is denied they won’t be able to pay for it out pocket.

Admittedly, the current system has many of the same problems, but I don’t see any reason to expect they wouldn’t get even worse by having the government do it.

SD

Well, patients as a class would have the ability to influence a national system through the normal levers of politics (thats one of the ways in which the VA got so good) And I am not opposed to a private system along side the national system, as long as the national system guarantees basic care for everyeone. I prefer, to be honest, a system like Germany’s or France’s.

And, no, it won’t be a panacea and it wont be without problems of its own, even systematic ones. I just think the system we have now incentiviezes not treating people, and that just isn’t tenable in my mind.

“as long as the national system guarantees basic care for everyeone.”

This is already the law. If you don’t believe it, visit your local hospital emergency room and see how many of the people there are going to pay for their services. By law the hospital cannot refuse basic services to them.

My understanding is that hospitals that offer emergency care must offer emergency care to those who can not pay. No emergency room, no requirement. Also, emergency care is not the same as basic care.

Fred

As bad luck would have it, I have been a few emergency rooms over the last year. In both states this occurred, the message said something along the lines of “we are obligated to get you stable or deliver your baby. Then we can ship you somewhere else.” So Ted is right — its not care, its triage.

“we are obligated to get you stable or deliver your baby. Then we can ship you somewhere else.” So Ted is right — its not care, its triage.

Who do they ship them to? Do they not get basic care there?

If a person is stable or her baby is delivered, how does that happen without being given basic care.

As usual, Ted is not right.

They ship them out the door.

As I have posted in the past, there are some hospitals that do treat anyone, regardless of ability to pay. But they do so because they choose to, not because they are compelled to by law.

“They ship them out the door.”

You are not very bright, are you?

Fred, by “out the door”, I mean they are discharged. Once a patient is stabilized, the hospital has met its EMTALA obligation and the patient can be sent home. (In the case of active labor, stabilization means the baby is delivered and both mother and baby are stable.)

There is no requirement for hospitals to administer basic care. They must screen for emergency conditions based on how the patient presents, and if an emergency condition is discovered, stabilize the condition or (under certain circumstances) transfer the patient to another facility for treatment.

You have an inflated idea of what basic care means.

Fred, yes, I figured this is where you would go next. As far as I know, there is no generally accepted definition of the term “basic care” (as opposed to emergency care, which is defined as part of EMTALA). However, it is worth noting that Kevin introduced the term “basic care” to this thread and in the context of his original comment, it is pretty clear he is referring to something other than emergency care. If he is still reading along, he can verify this, at which point I think you might want to consider capitulation. Unless of course you can cite an accepted definition of “basic care” that coincides with the definition of emergency care, in which case I will concede the point to you.

Believe it or not, emergency rooms dispense more than emergency care. Go to most emergency rooms, and you will most likely find uninsured people there for non-emergency care.

“in which case I will concede the point to you.”

That’ll be the day.

The problem you identify is a very serious one; it already exists in different forms. The underlying issue is what insurers call “risk rating”. The general theory of insurance is that insurers calculate the average cost, over a large number of people, of providing certain services, based on what those services cost and how often they’re needed. The annual premiums for insurance for those services come to the expected cost of the services, plus the company’s overhead and profit. In theory, in an “efficient” market (one in which everyone has access to the necessary information and a reasonable set of alternative products), what people actually pay is as close as possible to the average cost. Even though you’re paying a bit more than, statistically, you expect to get out of it in services, it’s a good deal because it saves you from catastrophic one-time expenses. But insurance companies distort this market in two ways: they have vast amounts of information on actual costs which they do not share, so the consumer has no idea what their expected costs really are, and, realizing that services are not distributed randomly (some people are more likely to get sick; some are likely to stay healthy), insurers “cherry pick” the healthiest patient populations and try to avoid insuring those who will actually get sick. Since consumers only know that insurance is “expensive”, without having information to tell them what their own expected costs are, young healthy patients pay close to the national average premium – getting hugely overcharged – while old or sick patients may not be able to get insurance at all. The whole point to an insurance market is that costs are expected to be distributed randomly – only some people use certain services, but over the long run everyone has roughly the same chance of needing them – so everyone pays the same premium; by “risk rating” the customers – dividing the insurance pool into selected sub-pools – without changing the premiums proportionately, the insurers gouge the healthy while abandoning the sick, and simultaneously destroy the shared-risk aspect of uncertainty that makes insurance work in the first place.

The more information insurers have to make these distinctions, the greater disadvantage the consumer is at. Already they risk-rate based on age and other demographic factors, health history, occupation, and other information they have. (One hidden benefit of employer-sponsored health insurance is that it forced insurers back into randomized risk pools. Since employment is mostly random with respect to health – employers are legally prohibited from asking your health history before hiring you – insurers offering employer-sponsored plans have to just take what they get as a patient population, and calculate premiums based on average costs for the whole population healthy enough to hold a job – which is what insurance is all about.) Your personal health history, including past treatments and test results, is available to them if you ever apply for insurance on your own. Prospective diagnosis – genetic testing for diseases that might appear later – is only the latest concern. In a way, it seems especially unfair to penalize people for a condition they don’t even have, but from the insurer’s point of view it’s only another way to avoid selling health insurance to people who actually need it – something they’ve been doing all along.

National health programs may or may not bring particular benefits, but one thing they almost inherently do is avoid the risk-rating dodge. Universal-coverage single-payer plans, by definition, treat the entire country as a single insurance pool; it’s impossible to risk-rate under such a scheme because you can’t leave the riskiest part of the pool out. The only rational thing to do under such a plan is set the “premiums” (which may take the form of taxes rather than actual monthly payments) equal to the true average cost. (It would be possible to individually evaluate every patient and assign extra fees for unhealthy conditions, which is not the same thing as risk-rating. Such things have been proposed but are politically unpopular.)

A single-payer plan, or a mandated commercial insurance plan that prohibits medical screening of applicants, would inevitably cover everyone with equal premiums, spreading the risk across the entire population the same way we do for schools (everyone pays property taxes; only some people have kids in the schools), highways (everyone pays for construction; only some people drive), and national defense (everyone pays taxes; only some people invade foreign countries at the whim of insane liars). This is partly justified by the random nature of illness – nobody can be really sure they won’t need coverage – but even to the extent that illness is predictable, this is part of the broader burden we share as members of the same national community. We don’t charge people fees to have the police arrest their muggers or the fire department put out their house fires, even if they live in bad neighborhoods or old buildings. We can choose to make healthcare one of the burdens we share, too. And if we did, it would not only cover more people, it would do so at a lower average premium. It’s amazing what lengths we go to to retain the right to pay insurance companies more than it costs to deny us our healthcare.

Fred, yup, as expected your next switch. Emergency rooms do serve as walk-in clinics for those who do not have a family doctor, and in some cases for those who have no ability to pay. But non-emergency care is administered by a hospital via the emergency room at their discretion, not because they are compelled to do so by law.

KTK, two points. HIPAA is a step to address some of your concerns in that it greatly reduces the ability of an insurance company to cherry pick. Also, customers do have access to the actual costs of their medical service. At least I do. My insurance company sends me a notice of every expense they incur, including the original charge from the provider, the amount the insurance company disallows, and the amount I have to pay. Thus, if I am paying attention, I know exactly how much my medical care costs. I also get a summary at the end of each year.

It is good sport to blame all of our health care problems on insurance companies, but a simple exercise might be revealing. If indeed insurance companies are taking advantage of their customer base by extracting unfair premiums and eliminating costly patients, this would be reflected on their balance sheets. I have read a lot about how the profit motive of insurance companies is the root cause of our health care fiasco, but I have never come across a piece that makes this claim and then backs it up with empirical evidence that the health care insurance industry has profit margins that are consistently above other industries. (Health insurance profits are notoriously volatile, so a one year spike or drop is relatively meaningless.)

I do believe that health insurance is an area where some government regulation will improve the public good, and we are not yet where we need to be in that regard. But I think there are plenty of other forces at work holding down our health care system. Before we institute a comprehensive national policy, I would like to wait a few years and see how things work out for some of the state programs, most notably Massachusetts. I hope a few other states try different approaches and then we can make a more informed decision at the national level. I only wish the states had acted a sooner.

Ted

yes, by basic care I mean mor ethan emergency — I mean the range of preventative care and needed treatment that keeps people alive in the face of common medical problems.

My insurance doesn’t provide that complete information to me (or, it didn’t — we have changed insurance this year and I haven’t gotten my first statements from the new company yet). Not that it matter much: from my contracting days, I know darn well that whatever my company plan is, its going to be much, much more affordable than one I could get on my own.

I would be interested in seeing a profit study, too, but that kind of begs the question: what do we get as a society in exchange for those profits? Especially considering that the profit motive can and has encouraged bad behavior by those companies. Since things like Medicare and the VA prove that the market is not a requirement to get effective, efficient care, I am not sure what the insurance companies bring to the table.

Ted:

HIPAA puts almost no restrictions on insurance company access to their own customers’ information. It explicitly allows sharing information with payers, including treatments, tests, and history – not just diagnosis.

And it’s true that customers have access to fees for their personal treatments, but not to average costs, or the costs for other plans. The only way to find out how much a given treatment costs is to have one. There’s no way to comparison-shop among plans on the basis of cost-effectiveness for the treatments you need or want.

Insurance industry profits is a telling metric, but not a highly transparent one. Every insurance company gets a large chunk of its profits from investment of the money in its premium pool, not just from the premiums themselves. And most are in multiple areas of insurance, not just healthcare. It’s not always possible to break out the total service fees and cost of service provided from their financial statements, and it’s never possible to break that down to the level of individual treatments or patient types (though the companies themselves design their fee structures with that level of information).

As for state experiments, we have decades of experiments at the national level from almost every industrialized nation – every one of which covers almost its entire population at lower per capita cost than the US. We see their drawbacks, as well – almost all related to funding level, which is simply a matter of choice. We can choose among them, or take the best elements of each. We can also build on two excellent and popular US national plans – Medicare (when it was funded right) and the VA system – that already exist but which by law are prohibited to most of the population. We can have any kind of national plan we want right now, with assurance that it will work better than what we already have.

KTK, my point re HIPPA is that it (HIPPA) requires an insurance company to pick up an individual if they already have insurance with another company. In other words, if I am insured with company A and I want to switch to company B, B has to accept me. This does not help those who have no insurance, or those that let insurance lapse, but it is a step in the right direction. In the past, switching jobs (and thus insurance companies) opened people up to pre-existing condition scenarios. (It is obvious why portability is more palatable than accepting non-insured. If non-insured were guaranteed insurance, everyone would postpone signing up until they actually needed insurance.)

I don’t see how the fact that insurance companies invest their capital reserves has any bearing on the discussion. All companies do that. Either the health insurance industry is more profitable than other industries or it is not. If it is not, then that is a telling statistic re the relationship between premiums and costs, notwithstanding efficiency concerns.

I honestly do not think Medicare can be held up as a great success. The future projections for Medicare are very scary indeed. The objective is to get good health care to the entire population without incurring a back breaking cost. Is Medicare more cost efficient than the private sector? Is VA more cost efficient? I don’t know the answer. Also neither of those systems are functioning as the sole insurance model for a region, so their impact on other aspects of the system are diluted. I’m not saying they have adverse impact, I’m just saying the impact is not quantifiable at this time.

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