Health Care Reform

[Voronwë the Faithful]

I removed the discussion about what is appropriate to post to the Henneth Annûn forum to as to not to derail this otherwise productive discussion.

[vison]

You want to talk gaming the system, look at the scams the insurance companies and big investment houses have been pulling on us all. Any gaming poor people might do is chump change compared to that.

Precisely.

Why did health insurance become an employer/employee issue in the first place? I don't understand that - you don't expect your employer to provide fire insurance on your house, or auto insurance. People look after that sort of thing themselves.

When it comes to union contracts, that's a different thing, in one way. A union contract (or any employment contract) might specify that the employer pays the premiums on medical insurance. But at what point did it make sense for anyone to agree to losing their insurance if they changed jobs? Why isn't insurance portable?

That is the great advantage of the Canadian plan. It's the individual who buys insurance.

[yovargas]

Why did health insurance become an employer/employee issue in the first place? I don't understand that - you don't expect your employer to provide fire insurance on your house, or auto insurance. People look after that sort of thing themselves.

When it comes to union contracts, that's a different thing, in one way. A union contract (or any employment contract) might specify that the employer pays the premiums on medical insurance. But at what point did it make sense for anyone to agree to losing their insurance if they changed jobs? Why isn't insurance portable?

This baffles me too. i don't see why anybody, including insurance cos, would be opposed to changing this.

[axordil]

yovargas--

A lot of health insurers do very well with group sales to companies. It's their bread and butter. It's also an easier market to corner, especially in small states or small communities, which then means they can do whatever they will with the price.

I know this because a lot of small insurers who are clients of the systems I work are unhappy about it...except when it benefits them.

[Primula Baggins]

My husband's company self-insures, meaning they pay the costs for their employees' care and Blue Cross/Blue Shield administers the policies for them. They can do this because they're a Fortune 500 company and thus cover enough people that a few big payouts won't break them. But certainly a policy like that can't be portable.

[Dave_LF]

One reason is just historical. Insurance requires groups and people are already conveniently divided into groups based on employment. IIRC, the first attempts at health insurance were just agreements between doctors and the large companies in the area. It also serves both the insurance companies and the employed people in the pool to limit the groups to individuals with full-time jobs, since holding down a full-time job requires a certain baseline degree of health.

[Voronwë the Faithful]

Here's an article that seems to give a fairly straight-forward description of the history of health insurance in the U.S.

The History of Health Insurance In The United States

Regarding the question of how employer based health insurance came into being, it states (and this is my basic understanding as well:

Employee benefit plans proliferated in the 1940’s and 1950’s. Strong unions bargained for better benefit packages, including tax-free, employer-sponsored health insurance. Wartime (1939-1945) wage freezes imposed by the government actually accelerated the spread of group health care. Unable by law to attract workers by paying more, employers instead improved their benefit packages, adding health care.

The problem with having a system of employer-based health insurance is that it sets up too much a disparity between two groups of people. It simply isn't fair to reward people who work for employers that provided health care benefits so much more than those of us who don't. I am sympathetic to the fact that people like Teremia have come to expect having these benefits without being taxed on them, but I am taxed on the income that I use to pay for my health insurance, though I do get to take a small deduction for it. Is there a rational basis for such a disparity between employees and self-employeed individuals? If there is, I can't see it

[Faramond]

I think the "gaming the system" angle was fixated on as a way of easily attacking some of what I said, but in truth it is a misrepresentation of what I am really saying.

The system cannot work unless people are paying into it all of their productive lives. It is not intentional gaming of the system that concerns me the most. I never said that I opposed health care reform because I was afraid it would cause more gaming of the system. Intentional fraud is something to keep an eye on, of course, but it's not a reason to give up. It is the unintentional kind that worries me, where someone goes 20 years without insurance either by choice or because of employment circumstances and then get sick and then what? Either we let that person die, or we pick up the tab without that person ever paying any of it! The first option is worse but the second option is not sustainable either.

[Voronwë the Faithful]

Which is why there has to be a mandate. Interesting that seems so clear to me now, when it didn't during the campaign. That says something; I'm not entirely sure what, but I'll keep thinking about it until (hopefully) I figure it out

[Primula Baggins]

Faramond is absolutely right. The system is more efficient when everyone is covered. Risk is spread farther; costs for people with health disasters are partly covered by younger, healthier people paying more into the system than they get out of it—for the time being. And if their luck runs out, they're covered.

I wish there were a way to accurately estimate how much would be saved every year if everyone could get basic preventive care, including prenatal visits, well-baby care, and vaccinations. You can't avert every health problem with preventive care, but you can certainly catch them early.

[vison]

It happens here all the time. It's usually a young man who has not bothered enrolling with BC Medical. He wrecks his car or his motorcyle, winds up in a hospital, and needs drastic and expensive care. He is not, of course, turned away.

I'm not sure what should be done, quite frankly. He's the same sort of young man who doesn't bother filing his income tax, who steals cable from the guy upstairs. How can you stop it? I don't know.

People on welfare or disability pensions are covered, the government picks up the tab.

Can you "make" people have insurance? How? By requiring an employer to deduct premiums? That might work. But if the person doesn't work? If he doesn't work, is he collecting welfare?

By requiring proof of premium payments on income tax returns? But what if the person doesn't file a tax return? And if he does file, and it's apparent he hasn't paid for medical insurance, what are you going to do? Fine him?

The thing is, and it is an unpleasant thing, is that there are going to be people who don't pay their share. Whether someone could go 20 years without ever paying, I don't know. But that person is still going to be treated, isn't he? I hear this from Americans all the time: no one is ever refused care, there are public hospitals where you can go if you have no money or insurance. So what will be different?

Maybe public pressure, societal pressure, will eventually have an effect. Most Canadians have insurance, but not all and those who don't are almost always voluntarily not enrolled.

[axordil]

Actually, in some areas there are no public hospitals left (St. Louis comes to mind--there's a "care center" which is not a full-fledged hospital).

[Teremia]

Everybody in California has to have proof of auto insurance, so I don't see why you couldn't mandate health insurance as well.

On the taxing health benefits thing: isn't that a little bit like the old Communist-era joke about "My neighbor has two cows and I have none -- not fair! Let's kill his cows!"

Why take health coverage from the people who have it? (Which is what making it taxable as income would do, since we'd not be able to afford the same coverage.) Why not take out the insurance middle man and cover everybody?

Again, this is related in my mind to the whole pension question, too. I have stayed in my job BECAUSE of the pension and the health insurance. So one could say, "It's not fair that you have health insurance and a pension -- let's take them away," but on the other hand, I gave up other kinds of job possibilities in order to have the pension and health insurance. So taking those things away seems also unfair.

I don't really find myself very hopeful about any positive changes being made.

[vison]

Mandating health insurance is not quite the same as mandating car insurance, though.

The blunt truth is, there are going to be people who don't pay. There always are people who don't pay. There are 2 options: treat them or don't treat them.

Pensions are not as portable as they should be, either. I understand the reasons why some pensions aren't, but the problems can be overcome with some goodwill on the part of employers. And by some employees taking more responsibility for their pension schemes. Particularly in light of the recent financial failures.

The word "fair" always pops up. It's a very American notion, that notion of "fairness". I think life should be "fair", too, but I don't see any way of making it happen.

[Voronwë the Faithful]

On the taxing health benefits thing: isn't that a little bit like the old Communist-era joke about "My neighbor has two cows and I have none -- not fair! Let's kill his cows!"

I think a better analogy would be: "My neighbor and I both have 100 cows but the government takes 10 from me and only 6 from her, so let's even it out at 8 and 8."

Why take health coverage from the people who have it? (Which is what making it taxable as income would do, since we'd not be able to afford the same coverage.) Why not take out the insurance middle man and cover everybody?

Taking out the middle man and cover everybody isn't going to happen at this point. But that doesn't mean that finding a system that is more equitable for all can't happen, or that fixing the inequities had to necessitate taking away decent health care from people that already have it.

[anthriel]

It also serves both the insurance companies and the employed people in the pool to limit the groups to individuals with full-time jobs, since holding down a full-time job requires a certain baseline degree of health.

That's interesting, Dave. I never thought about that before.

[Andreth]

There are some troubling parts in one of the bills specifically regarding end of life care which might be read as endorsing euthansia. I am also concerned about the lack of concience protections. And the overall emphasis on govt input, mandates and orders is a wee bit disturbing.

As I said before, the Congress is using a sledgehammer to reform health care when a more measured shall we say surgical approach might have worked better? I mean, address the private insurance issues in one well-written bill. Address access in one well-written bill. And so on. I know we need reform but must it be this monstrous beast of paper and legalese?

Frankly, I probably really need to read the varous proposals. Kind wish they hadn't made health policy so deadly dull and politicized in school. I might be more informed now.

[Primula Baggins]

It's hard to separate those issues, though, Andreth. Private insurance "issues" include access, for example. Trying to address the problems sequentially might be a little like getting your house repainted from top to bottom, then adding on a couple of rooms, then once that's completely finished and closed up, going in to replace the plumbing, then reopening the walls to update the wiring.

Sometimes the logical way to approach a really big job actually is to make all the changes at once. This may be one of those times.

[Frelga]

I agree with Prim.

A sudden and abrupt change is distressing, but it can also mean "going from one kind of normal to another" as Moist von Lipwig said. A protracted period of gradual change can be really distressing. Besides, to continue Prim's construction analogy, while all of that is going, nothing really works and the house is uninhabitable.

[elfshadow]

There are some troubling parts in one of the bills specifically regarding end of life care which might be read as endorsing euthansia. I am also concerned about the lack of concience protections. And the overall emphasis on govt input, mandates and orders is a wee bit disturbing.

Well, this is going to sound harsh, but enormous amounts of money are spent (sometimes unnecessarily) on end-of-life care. It puts a huge burden on the system. I am in no way saying that we should automatically decrease it, but the issue needs to be given some serious consideration. I, for one, think it makes absolutely no sense to force someone to stay alive on expensive machines when they express a desire to pass peacefully. Again, I know it sounds heartless, but there's a finite amount of money that can be spent on health care--no matter who is providing the resources. I think it's worth determining whether there are resources spent on unnecessary end-of-life care procedures that could be diverted to, say, preventative care. Of course it's a very complicated, troubling moral issue. But I don't think it's unreasonable to give it some sincere thought.