Thursday, September 6, 2012

it's these expressions I never give

Should we take on health care today?  Yes, let's.  This is not going to be a cogent argument or anything.  I'm still trying to figure out what I think.  It's probably going to be boring and wrongheaded. 

I'm toying with the idea of thinking that health insurance should be mandatory up to 18, maybe 21, and optional after that.  I like the idea of letting adults decide if they want insurance or want to work out a payment plan with their doctor.  But then we have to be willing to accept the consequences of that decision.  Do we turn people away who can't pay?  If they can't pay for health care, how would they pay for insurance?  Hmm.  I'm not sure how to work it out.  If health insurance is mandatory and taxpayer funded, I know that I don't like the idea of having to pay for gastric bypass surgery or repeated trips to rehab.  But what if somebody else doesn't like paying for my IUD, or for Ike to have a plastic surgeon sew up his nose instead of an ER doc?  We all have different ideas of what is and is not necessary care, and if we're paying for each other's care we're going to start thinking we get a say in what care gets provided.  I don't like that.  I think that anytime you give somebody money, once the money leaves your hands you don't get to decide how it gets spent.  You can use your frustration from giving your sister rent money that she spends on getting an ombre dye instead and use it to guide your future decisions, but that money's gone.  Next time don't give her money, or write a check to the landlord.  If the money you donated to USU's English Department gets spent on the athletic program, then next year don't give them any money, and tell them why.  We think that money buys ownership, but in the case of other people's agency it just plain doesn't. But that's not going to stop us from thinking it, and that's where I think we might get into real trouble; when somebody else thinks they get a say in what our health care needs are.  But is that very different from how health insurance is implemented today?  We already are always up in each other's business.  Already employers think they get to tell you how to spend the money they keep back from your paycheck to pay for your health care. I think I'd rather get a bigger paycheck and I'll pay for my own birth control and mammograms before 50, thanks.  I wish individuals had more bargaining power with insurance companies.  And of course I wouldn't be smart with that bigger paycheck.  I'd just spend it on shoes and Charolais calves and then wring my hands in dismay when Grant tears his braces off eating a Sugar Daddy. 

John is a smart guy and a good guy.  I trust him to not tell lies, and he says that in his experience, countries with socialized medicine have excellent preventive care, often superior to the standard in America, but once you develop any expensive condition it gets very difficult to receive treatment.  But that's one man, and maybe other people have seen it work differently.  I know that stories are not statistics.  Has someone else coined that phrase?  If not, I want credit.  Stories are not statistics, you heard it here first. 

It's a mess, true enough.  I want people to be taken care of, but I expect them to do their part, however small it may be. 

Any ideas from you guys on how to fix it?  Just one little change you think would help? 


All8 said...

You know, somehow, to me, this kinda feels like a big boost for the insurance industry. Yeah, that kinda equals more jobs but if they're paying more people and the whole point is for them, as a company, to make more money, who gets the shaft? As someone with a chronic, lifelong couple of bits of health fun to deal with, insurance companies hate to pay out and make you suffer through trying to get something done. I hate insurance, but maybe not as much as socialized medicine.

As for Charolais cattle, they're known as being a tad on the wild side. Just so you know what you're getting into. However, they give great hybrid vigor when bred with Angus, but their offspring is as ugly as sin. They always look dingy and dirty, even when they aren't.

Alana said...

I don't think I have ever heard of a person get turned away from any health care because they didn't have insurance. By golly when we were poorer than dirt after my husband lost his job we didn't even have money to buy toothpaste let alone health insurance for our kids. Our oldest fell and got a nice concussion that same year and we ended up in the ER. We just worked out a payment plan with the hospital. They were VERY willing to work with us financially. So I don't know why people are screaming that they can't go to a doctor or ER without health care coverage.

Layne said...

I've known a few people without insurance who have done that same thing--worked out a plan directly with the hospital. I wonder if it costs the same, or if they take less when they don't have to give the insurance companies a cut.

John says part of the problem is that nobody has skin in the game. Most of us have no idea what procedures really cost, because we just worry about our copay.

Did insurance start out as a way to guarantee that people got care for extremely expensive problems? It spreads the risk over a large group of people, so theoretically no one would be financially ruined. Does it still work that way?

beckster said...

I am a nurse, my husband is a physician, and together we have over 80 years of experience in the heath care industry. Hospitals and MDs are paid based on how many tests and procedures are done. If they got paid just to provide quality care (there are good definitions for this), then costs would go down considerably. That is part of what universal coverage would fix. You cannot be turned away from an ER without an evaluation as to whether or not you need emergency care. However, if the MD decides your condition is nonemergent, you can be turned away. If you have insurance, they are generally happy to have you stay for treatment. Yes, you can work out a payment plan with the hospital, but unless you press them for a discount, you will be paying more than any insurance company would pay for the same care. Insurance companies negotiate deep discounts with hospitals, they never pay retail. Talk about kicking somebody when they are already down! And that is just part of the mess at the payment end. My husband and I both truly believe that we need universal HC for essential care. It is simple to medically define essential and preventive care. If you don't get treatment, and it leads to further serious illness or death, it is essential care. Most of the stories that I read about people not getting "timely" care in countries with universal coverage boil down to inconvenience/discomfort on the part of the person seeking care, not true harm. This is the nature of triage. They may seek private care and pay for it themselves if they like. Your husband is right, some countries do not cover major organ transplants, but neither do a lot of insurance companies. Even if you have insurance, it can be difficult to get expensive treatments covered. These arguments overlook the huge numbers of people in the US who routinely do not seek or are refused treatment and suffer and/or die as a result. Eventually, they end up in the ER with an emergency that costs an incredible amount to treat. There are a lot of people who can't pay for care, or must choose between paying the MD or buying groceries. There are solid statistics that all nations that have universal care have greater life expectancy and better overall health and pay less than half of what we pay. These stats are easy to look up, just Google it. Asking people if they are satisfied with their health care is a nebulous question at best. We can only rely on outcomes. We already have universal health care in this country, it is called Medicare, the administrative costs are lower than any insurance company, and I don't know of anyone that really wants to get rid of it, unless it is those people who who believe people should be allowed to die who don't have insurance. I don't want to live in a society where those people are in the majority. MC could use some improvement, no doubt about it. Let's do that! Universal coverage can be better and less expensive. It is not perfect, nothing is. No matter how I look at it, it seems inhumane to choose to live in a country that does not provide basic health care to its citizens. Life can turn on a dime into something you don't recognize, no job, no home, and no health care no matter what kind of person you are. OK, I'll shut up now, let me have it!

Layne said...

No, I agree with your points, which is why I am so uncomfortable when people do choose not to buy health insurance, because I know there will most likely come a point at which they need care they can't afford. To me the conflict lies in my belief that people must govern themselves vs. their accountability to the rest of us when their choices affect the general population.

The point of my post was to get people discussing the issue, hopefully beyond sound bytes and talking points. I want a respectful discourse about it, and it would be great if we all examined our positions and shared our opinions and experiences and came away a little wiser and better informed, even if our opinions aren't changed. So far that seems to be the case, and I appreciate that we can all be civil.

Layne said...

Beckster--what in your opinion is essential care, the stuff that you think should be universally covered? Because this is where I think people like me stop listening and start freaking out about having to pay for things they see as somewhat preventable, like diet-related diabetes or lung cancer from smoking.

I haven't heard the idea put forth that some things would be covered as essential and preventive (I think you were advocating for coverage of preventive things, right?), and coverage for the other things would be optional. Is that what you're saying? If so, that seems like a much easier pill to swallow, to me.

beckster said...

I think that all people should have access to primary care, and often a nurse practitioner and/or a clinic is all that is needed. That's pretty cheap health care. Screening and education is essential. We are woefully ignorant about health in in this society. We confuse health with esthetics. I also think dental care is essential. You would be amazed at how many health problems are caused by poor dentition and abcessed teeth. As to those people who choose to do things that are harmful, well, there is very little we can do about human nature. I've tried my entire career, won some, lost some. I think it is of utmost importance to provide health education from childhood. We need to stop equating health education with morality. I don't think it is debatable, although we still debate, that factual information does not lead people into temptation. People lead themselves into temptation, and are actually less likely to do so if they have some scary facts under their belts. As to coverage, I guess I should explain that I think all elective tests/surgeries should be the responsibility of the individual. Urgent tests/surgeries should be done without question, free of charge. Semi-elective procedures should be placed on the wait list and should meet established criteria of necessity. A lot of this structure already exists. What I think most people don't understand is that you are already paying for all this indigent care, but in a very indirect and inefficient way. We wait until an abcessed tooth becomes a lung abcess and requires expensive, long term treatment. We wait until a hernia repair becomes a colon obstruction and urgent surgery is needed for a gangrenous gut. We wait to diagnose hypertension when someone has a stroke. These people eventually end up in the ER, and the hospital shifts the cost of their treatment to those who have insurance. They have to get paid some way, so they jack up the prices for everyone's treatment to pay for the people who cannot pay. It is a well known phenomena called cost shifting. The insurance companies then pass the cost on to your employers and then you. That's why health care costs so much in this country. Your husband is right, in a way, people don't know they have skin in the game because it is all so complex, but they do. I am convinced by my study and experience that it is cheaper to have a healthy, productive society that is able to obtain reasonable health care when needed. I really wish there were more people like you who wanted to understand the problems. There are so many lobbyists protecting the doctors, hospitals, medical device, and pharmaceutical companies that the public rarely hears the truth.

tipsybaker said...

I wish we had some kind of universal health care and that someone else would just work out the details. We end up paying one way or the other because people don't always govern themselves, can't always govern themselves, and I'm with Beckster, I don't want to live in a society where people are refused basic medical care because they are improvident or merely unlucky.

Layne said...

Oh, Beckster, you are preaching to the choir about teeth. I quite like the plan you have put forth. Let's do it. I will call my congressman.

Tipsy--do you mean improvident poor, or improvident repeatedly makes bad decisions? I am of two minds about that--one side of me says it shouldn't matter how they got to where they are, and the other side of me says that there comes a point at which you are causing more damage by robbing them of the natural consequences to their decisions,--I'm talking adults here. Kids get covered no matter what. I'm basically an unemployed vengeance demon. It's not something I'm proud of, but it's part of me. I hope you don't think less of me, but I've got to think it's not much of a surprise. I pretty much hate people.

beckster said...

Layne, I actually own a misanthrope bracelet, so I understand your point of view. Does it help if I assure you that it is cheaper to provide primary care for the improvident? I honestly think that some people's brains and horrific circumstances lead them to be poor planners, but aside from that, these people end up in the ER eventually. And ER care and hospitalization are so much more expensive than a primary care clinic visit. Jennifer, chime in on this.

tipsybaker said...

When the consequences of poor decision making are inability to afford a house or cable TV, I'm all for letting people suffer. But medical treatment? People have trouble predicting their risks, especially young people. People are silly and unlucky and stupid and crazy and just plain desperately poor and the playing field isn't level and I just think it's decent and right to provide a medical safety net.
And as to kids, what about grown kids? Should responsible parents of a kid who gets sick in his twenties and has somehow failed to get insurance have to bankrupt themselves? Wouldn't they? Wouldn't you? I would. That seems unfair, too.
I don't think most people deserve what they actually get. That includes me, with my good fortune in life. I bought my own catastrophic insurance when I was in my 20s, but my mom taught me to do that. Not everyone had prudent parents who raise them to worry about every horrendous possibility. And if I hadn't been able to afford it, I'm sure she would have paid. Not everyone is so lucky.

Layne said...

I've often said that teenagers are the stupidest creatures alive, and unfortunately that condition seems to extend well into the twenties, and now even the thirties. I know I was supposed to be making decisions for which I was woefully unprepared, so I get that.

Please understand that I think almost exclusively in worst-case scenarios, so it's not that I think these are bad ideas, it's that I worry about what will happen when the irresponsible people outnumber the responsible ones, which I see as a foregone conclusion. Are people compelled to pay into the system? I would assume below a certain income level they wouldn't be, because of the financial strain it would cause them. What happens when those paying into the system can't support the demand? Maybe that won't happen; maybe the robber barons who control our government and economy will realize that the middle class is starting to go the way of the buffalo (which isn't as apt a metaphor as it used to be, but you understand) and they'll ease up on their predation. Maybe they'll stop using their extreme (sometimes undeserved and unearned) good fortune to find ways of not paying into the system. But maybe not. Maybe we'll eventually be crushed under the sheer weight of bureaucracy and need and have to have a revolution, hopefully not like the French Revolution.

So I like these ideas. The good person deep, deep inside me (or maybe only on the surface of me) knows that when people are starving they can't hear anything else. It is the same with basic health care.

What do you think about people contributing to the system in ways other than financial, if they are below a certain income level?

beckster said...

Jennifer explained the humanistic view of why universal coverage should exist much better than I did. I knew she would. Thank you, Jennifer. My husband and I often talk about how we reinforced our good fortune by making sacrifices and good decisions, but we try never to forget that we have had good fortune in our lives. A lot of people just don't. Layne, I am not a financial whiz, so I don't claim to understand the best way to pay for universal care. However, I do think that people forget all the different ways we already pay into healthcare. Employers and individuals presently pay a lot for insurance coverage, we pay Medicare taxes on wages, we pay co-pays and deductibles, etc. The government could divert all the money that is now being spent on Medicaid, federal and state, and Medicare. In other words, we are already paying a LOT of money in many different ways for healthcare in the US. I will have to think about whether or not we would require people who already have so little to do something other than pay money to receive coverage. My first thought is NO, it seems like a punishment for being poor. As to your remarks about being crushed by bureaucracy, that is another subject we need to discuss. We are already crushed by bureaucracy. The government subsidizes everything, it seems. There are 2,179 programs for domestic assistance! And I truly wish we could stop subsidizing corn! Sorry, I digress. Universal coverage is something my husband and I are willing to help pay for because we really believe it is the right, smart, forward thinking thing to do for the country and all the people in it. And I don't believe you hate people. I believe you abhor their poor behavior, as do I, but that's life.

g. lo said...

as another health care provider (for pregnant women--virtually guaranteed Medicaid while pregnant) let me put my 0.02 in...We have been subsidizing healthcare for the less fortunate (or less money-smart) already. Unfortunately, it still doesn't cover the type of preventative care that would lower the total cost--i.e. the dental care that would prevent costlier problems in the future...the fact that certain family planning methods that are long lasting and reversible (i.e. IUD, Implanon)may not be covered, but Medicaid will pay for the subsequent unwanted pregnancy..the list goes on and on. The healthcare system has been broken for a long time in this country, and while mandating insurance coverage my not be the ultimate solution it may light a fire under the people who can effect the change.

Layne said...

Well, as you may have guessed by now, my whole beef is with compulsion. So if, as seems obvious once I think about how things really work, we're already being compelled (only expensively and inefficiently) to pay for things that should have been dealt with a lot earlier, then I suppose I have no philosophical quandary with a plan such as Beckster has suggested.

But I do want to throw this out--I don't feel like giving back to a system from which you've benefited is a punishment. I think it is a vital part of teaching people how to take care of themselves, and it's also tremendously fulfilling. You have to be creative, obviously, but I think it would be nice if the people who were capable could contribute by vacuuming the clinic, or swapping the paper on the exam tables, or going to nursing homes and visiting with the residents, or any number of other services. I know there are people, probably too many for my taste, who wouldn't feel like they owed anyone anything. But I bet there are also a lot of people who would welcome the opportunity to give back. Service is good for us, and it feels good, too. It's not very practical as I have explained it, but maybe you can see what I'm trying to say.

Don't throw things at me!

beckster said...

I won't throw things at you, this is a wonderful civil discourse. I agree that service is extraordinarily valuable to individuals and society, and I think if you want to offer people the opportunity to give back it's great. I just think that it would be much more useful to an indigent person to be given a paying job so that s/he could pay taxes to support the system. g.lo is right, I think, this will be done in baby steps to allow folks to get used to changes in the system. I hope it gets done in my lifetime; I'd love to see it.

Layne said...

A paying job would be best, but until there is one available, it would be good for a person to be out and about, engaging with the world. Plus maybe my starry-eyed idea would teach them skills they could use on the job.

Think, if communes actually worked. From each according to his ability, to each according to his need. But that's a long way off. Even Mormons couldn't make it work the time they tried it.

All8 said...

One of the issues that might arise with the untrained working in dr.'s offices, nursing homes and the like is that they are a liability and there is the greater possibility that costs would increase to compensate for that. And what of those that are using the system because they really aren't able to work or to give?

Of course then there's the whole fun bit of the government being able to be involved in your financial decisions. Meaning, if you're receiving aid, they have the right to have all of your financial accounts checked, whenever. You give up freedom just by asking. It seems that most of the people I know that think that government run health care is a great idea, actually haven't used it and certainly not for any length of time. Oh, the horror stories I could tell you.

Case workers at the DFS are already overworked and completely understaffed. How would we (as a people) pay for the increase of workers, not to mention those that are uninsured, like myself?

Then there's the whole point that the government decided that Ketchup counts as a vegetable in school lunches. Do I want these people to be deciding what it appropriate healthcare for me and mine? Not really.