Health Care Reform

[Primula Baggins]

If people have health care, they're more likely to be able to provide themselves with housing and food.

I think that people who can't provide these things for themselves should have help. But if more people can be cured of disabilities, or prevented from becoming disabled in the first place, the pool of people who need help with these things will be smaller. If more women can get control over their reproductive lives (as the ACA mandates with access to free birth control), the pool will be smaller still. If more people get preventive care tests such as mammograms and colonoscopies so their illnesses are caught when they're treatable (again as the ACA mandates), the pool shrinks again.

If fewer babies are born prematurely with lifelong disabilities because (ACA mandate) their mothers can get free prenatal care, the pool shrinks enormously. (Not all premature births are preventable. Not all babies born prematurely are disabled even slightly. But this is still a huge source of preventable disabilities.)

Mandates aren't always a bad thing, for individuals or for society.

EDIT: Cross-posted with Anthy. Our former insurance (Mr. Prim's employer and then COBRA) was self-insured. But they did not cover, for example, my colonoscopy at 50, which (being responsible) I went ahead and paid $1500 for. When Mr. Prim got around to it the next year, the ACA had kicked in for that, and his was free. Definitely an additional up-front cost to his insurance. The question is whether it was a cost savings to the whole pool, overall. I suspect it was.

[River]

Yeah, if they were already more or less ACA-compliant I'm missing something too. There's nothing, AFAIK, in the ACA requiring visits to the chiropractor. Is covering contraception for all females who want it going to pile on $16 million?

It might not hurt to ask.

[anthriel]

EDIT: Cross-posted with Anthy. Our former insurance (Mr. Prim's employer and then COBRA) was self-insured. But they did not cover, for example, my colonoscopy at 50, which (being responsible) I went ahead and paid $1500 for. When Mr. Prim got around to it the next year, the ACA had kicked in for that, and his was free. Definitely an additional up-front cost to his insurance. The question is whether it was a cost savings to the whole pool, overall. I suspect it was.

Oh, I wasn't trying to imply that being a self-funded insurance company had anything to do with having comprehensive coverage; my company happens to be both. Colonoscopies, for example, are already covered (with a co-pay, of course). My point was that our insurance coverage is already pretty broad, so having to pay 16M "extra" because of ACA probably wasn't because they weren't already paying for now-mandated coverage.

I think I will ask. They can't make a statement that huge without some serious explaining.

[Voronwë the Faithful]

I'm going to go out on a limb. I think they are lying to you. Sorry. Maybe they will prove me wrong.

[River]

Or maybe it's a result of having to cover people's pre-existing conditions.

You really should ask. Best case, there's a valid reason that you will now understand. Worst case, they are lying like rugs and you will have to decide how much excrement you want to throw at the ventilation.

[Nin]

I don't know how the American system is working in details, but I just wanted to add the perspective of a person like my son, who discovers that he has an very likely uncurable illness at the age of 15, that he will have to be medicated for long years, eventually for life - for something for which no prevention could have helped in any way...

If he is always sure to get medical insurance, despite of his condition: it's an inconvenience, sometimes a handicap, but if the medication works, not necessarily life changing.

On the other hand, it can damage his entire life and work perspective, if insurance is impossible or depends on employment.

He now needs a medication which costs around 10$ daily. The insurance pays 90% of it. (And 100% once we reach a certain amount) I could and would pay it entirely if I had too, but you cannot always be sure that a person actually can pay his or her drugs. Many are much more expensive than his.

With the medication, he is a chance of 60 to 80% of not having seizures. Without, less than 2%. Who costs society more? The patient without seizures on medication - with a more or less normal life in society - or the one who regularly has seizures and therefore very likely cannot work without major impact for long periodes? Yes, the medication is expensive, but the contrary even more.

But health is not all about money. Health is about the society in which we want to live and if this society has a place for the weak and the sick. Freedom makes sense when you have the choice - but for your health, very often, you don't have it and even with the healthiest of lifestyles, people will be sick.

But then, as I said, I don't know the American system - neither now nor before- very well.

[halplm]

It's not a sound organizing principle for a service that can determine whether someone lives or dies. Most societies prefer that their members live. Many people would argue that "life, liberty, and the pursuit of happiness" are rights that can't be exercised unless people are able to be healthy. And working and contributing to society are obligations that can't be met unless people are able to be healthy. Health care is fundamental to a lot of what a society does (or to what an individual needs and wants to do).

The old American principle of "Your right to swing your fists around stops at the end of my nose" is applicable here, I think.

At the risk of entering this discussion, and of not having read everything so I might have missed some stuff, this is missing a major major point.

We currently have the "right" to NOT be healthy. The more the government controls things, the less that exists. When can they tell you you don't get a certain coverage because you smoked... or had that extra glass of wine each night? When do they decide you don't deserve a surgery because you were overweight and should have made better choices?

Universal health care (which this does not provide in any way, but it seems to be what some of you expect), is not universal "good" health care.

[yovargas]

That is a concern I've long had about all types of insurance. We have that classic "Your right to swing your fists around stops at the end of my nose" idea of liberty that many of us try strongly to defend, but when my personal habits cause your insurance premiums to go up, the argument that those personal habits are hitting your nose becomes much easier to make. That is worrisome as it allows more and more for people to vote on how others should live their lives. There's a very real slippery slope to be had here where we can determine all sorts of behaviors that are good for the economy that we slow allow the gov to control (read more often! don't eat sugar! don't have too many (or too few) kids!). (But frankly, we've been on that slippery slope for a very long time now.)

[JewelSong]

When can they tell you you don't get a certain coverage because you smoked... or had that extra glass of wine each night? When do they decide you don't deserve a surgery because you were overweight and should have made better choices?

Many (if not most) insurance companies do that now. Your premiums are affected if you smoke, you get a discount if you join a health club...and if you are overweight, it may very well be that you are denied surgery if your weight is considered too much of a risk factor.

(However, it HAS been deemed that a glass of red wine is actually beneficial to your health!)

[River]

What Jewel said. I think one of the reasons my premiums went down is the university launched a massive wellness initiative on all campuses. They want us all exercising, getting flu shots, and so on. There are incentives. Not sure what they are as I haven't been paying much attention; regular exercise is already part of my routine. The flu shots for myself and my spouse are intriguing, though. They also banned smoking on campus though I suspect that had more to do with keeping marijuana off campus grounds than the new wellness initiative.

[Primula Baggins]

The ACA does not allow insurers to consider your health (past or present) or lifestyle, other than whether you currently smoke. In the exchanges, you're asked your age, whether you smoke, and the zip code where you live. Insurers are allowed to charge 15% more for smokers' premiums, and they can charge older people up to three times the premium they charge younger ones. (It used to be much more than that.) They can't charge you more or turn you down because you're female, which also used to be common.

I think people who have always been covered through employers sometimes don't understand how nasty the old "free" market for individual coverage actually was. Until last Tuesday.

[halplm]

insurance companies did things poorly in many cases, but you always had the choice to NOT HAVE ONE.

ETA: That is to say, with it all tied to the tax code, it's not just about what treatments you get (although that will be a big part of it, and far worse than the insurance companies), but also how many taxes you pay... what you get from the government... etc.

Control removes freedom, there is no way around that. You can claim that more control is better for people, but we will never agree on that one.

[River]

You still do. You'll pay a penalty, but, then again, under the previous system, if you opted not to have insurance you also paid a penalty the minute you ended up in a situation where you needed medical attention. And considering that hospitals charge outrageous prices for things as simple as aspirin tablets and gauze pads, that penalty was/is probably steeper than $95 or 1% of your income, depending on circumstances. In fact, that's part of what was driving healthcare costs through the roof. People would, for one reason or another, opt not to carry insurance. Then they get in an accident, or develop a cough that won't go away, or start mysteriously losing weight, or find a strange lump that just keeps getting bigger. So they go to the doctor and rack up bills they have no hope of ever being able to pay. Bills that if they'd saved every nickel they ever made they'd never be able to pay. So they don't pay. But the money has to come from somewhere, so the bill ends up getting rolled onto everyone else. The person who couldn't pay isn't getting away scot-free either. They've got debts and a bankruptcy hanging over their head, assuming they even lived long enough to file for bankruptcy. No one wins.

[halplm]

those prices are due to lack of competition and exploitation of the insurance system... something obamacare does nothing but exacerbate.

And I don't want to rehash everything all over again, you can find all these arguments out there if you actually want them... I'm sorry I said anything.

[Primula Baggins]

That's probably as well, Hal. You're starting from the assumption that the important thing is being able to choose to be uninsured. I'm starting from the assumption that we're all better off if everyone is insured. Never the twain shall meet.

But I feel confident that my assumption is correct and that within the next several years it will be obvious to everyone—just as it was obvious several years ago that having millions of people uninsured was driving health care prices up insanely and dragging down the economy. We tried the system you prefer. It failed.

[halplm]

There are more choices than what we had, and what you want.

[Frelga]

Well, yes. Some of them have worked quite well all over the civilized world. But we can't have them in the U.S., on purely ideological grounds and not for any logical or practical reasons.

[Primula Baggins]

Yes. Even though we have that kind of single-payer system in place already for people over 65, and it's far more efficient (3% overhead) than private insurance, it's politically impossible (now, anyway) to expand MEdicare to anyone else. Instead we have the ACA, cobbled together to preserve the private insurance system while also sealing up some of the holes millions of people were falling through. Overhead under the ACA is mandated not to exceed 20% of premiums. Before the ACA, some insurers were spending more than 30% of premium dollars on things other than health care.

There's also certainly competition. Competition is why rates have turned out to be lower than expected. The ACA hands the private insurance system millions of new customers, many of them young and healthy, and the insurers are competing on price since they can no longer discriminate in other ways.

[yovargas]

Yes. Even though we have that kind of single-payer system in place already for people over 65, and it's far more efficient (3% overhead) than private insurance, it's politically impossible (now, anyway) to expand MEdicare to anyone else.

There was a key moment for me back when this was a live debate where I heard a Rep. politician rail against government health care programs and then literally in the next sentence express their support of Medicare. I later found that this was a position being taken by many Rep. politicians. That's when I concluded that for these politicians this had little to do with doing the right thing even by their own professed philosophies.

[Primula Baggins]

Having seen Medicare in use from a very close perspective, I'm very impressed with the simplicity of it. My parents both have supplementary insurance, which costs them a couple hundred a month each, but the result is that everything is covered at close to 100%. They occasionally get a bill for $2.87 or $4.69 or something, but that's after being in the hospital for 10 days at a time. And their care has always been excellent. Occasionally Medicare balks at paying for a particular drug, but there's always an acceptable alternative. That's about the limit of the hassle.

We are still paying down my $5,000 bill for four days in the hospital, with insurance that covered 80% after a large deductible. Fortunately hospitals are happy to spread out the payments interest-free.