US Supreme Court Upholds Affordable Health Care Act

[kandrathe]

Either we are discussing apples and oranges, or you misunderstand the Canadian healthcare system and my opinion on how healthcare should operate in a first-world country. I cannot walk into my doctor's office and demand a free MRI just because "free healthcare". Doctors have the ultimate say on what treatment is administered (as I said more than once in my previous post).

I think it is the apples and oranges thing. Our doctors and hospitals don't work for the government.

For the best explanation we've seen of the real nature of America's health cost problem, read this great investigation by Harvard Medical School professor Atul Gawande. During the tense passage of the 2009 bill, Obama was rarely to be seen without a copy of this article. He cited it frequently and handed out dozens of photocopies to White House staffers. It provides the most direct insight we have into Obama's thinking on health care. It may make uncomfortable reading for many American doctors.

Great article! Thanks for the link.

To preserve a free market system, I think that having the patients experience a portion of the costs for every procedure would encourage them to be more informed about their morbidity and help to bring a balance to the consumer decision. If it is "free", then yes, I'd get whatever I felt like getting. If I had to contribute and make some trade offs, then I have to balance what I'd get with what I would lose. I think the article also describes how changing the market from free enterprise to government payer may not change anything either as long as doctors are paid according to the numbers of patients or procedures they perform. So, not only do patients need more of a financial stake in the process, doctors need to have less of a financial stake. Health care providers need to be given incentives for providing the right care, not more or less of it.

Otherwise, the trend is to remove the market entirely and turn over care and control of care to the government. I think that is what DeeBye is describing, only that under that white coat sits an employee of the Canadian government who is following their guidelines and quotas for treatment.

I don't really have a problem with doctors who serve patients well, getting well paid, but the article indicates that some (or maybe many) doctors are allowing money motives to shape their treatment advice. Higher Fees Paid to U.S. Physicians Drive Higher Spending for Physician Services Compared to Other Countries

In contrast, I'd fear that if our doctors were government employees, we'd be treated as we are at the department of motor vehicles.

For reference on how my perception of government works -- let me describe my recent drivers license renewal which has to be in person for the photo and eye test: I went on a Saturday at just before 11am, and for reference the place closes at 2pm on Saturday. I stood in line for an hour before I got my number. Every form of license was issued from this office, so in the line were anyone from business, to marriage/divorce, boats, immigration applicants, and all forms drivers licenses. The number giver also spent time counseling each person or group on the forms they'd need fill out.

Then I sat in a huge waiting room and watched the bored people watching their children playing (and a horrifying drama where a young toddler kept dropping her lollipop on the carpet, then would return it to her mouth). Because I had received my number just past 12, it was provisional, meaning that if I didn't get called before one, I wouldn't get served that day. Well, that was what happened. Every time the workers would waste time having a little chit chat, or sand bag before calling the next persons it made me a little more frustrated. They missed my number by 2 people.

It wasn't that the workers were overtly negligent, or that having the cut off was a bad thing, so they could wrap up before close. It's just that there is no motivation for anyone to move faster, or serve people better. I went to a different office the following Saturday; this time arriving at 9am. It still took 2 hours for the 5 minute procedure, and I had to pay in cash since some recent kerfuffle between the State and Visa (a personal check, or Master Card is ok, but I don't have that).

Have you seen this article?

The soul-destroying search for a family doctor

[Jester]

In contrast, I'd fear that if our doctors were government employees, we'd be treated as we are at the department of motor vehicles.

They are still, y'know, doctors. Slightly more in the way of professionalism and training than your average DMV functionary, and also bound by powerful and ancient codes of ethics and practice.

-Jester

[kandrathe]

They are still, y'know, doctors. Slightly more in the way of professionalism and training than your average DMV functionary, and also bound by powerful and ancient codes of ethics and practice.

Sure, but that didn't stop some doctors in the article Shadow cited in McAllen from becoming more entrepreneurial, putting profit motives ahead of patient care. To me, the government operates by laws and regulations, and that would be reflected in the system somehow. Operationally, perhaps it's just in the availability of service, or facilities. They wouldn't need to say, "Reduce the number of mammograms you perform.", but merely control the costs by only providing a limited number of machines per facility.

So, other than keeping their government salary and your assumption of their noble self actualization, what motivates the Canadian health care provider to provide better quality?

[LavCat]

In contrast, I'd fear that if our doctors were government employees, we'd be treated as we are at the department of motor vehicles.

In this part of the world I had a different experience. Years ago Motor Vehicles was free enterprise. A private company leased its services to the state. The experience then was much as you describe.

At some point Motor Vehicles was nationalized, or statified, or whatever. The personnel became state employees with opportunity for advancement. A few weeks ago I was in and out quickly, served by pleasant people, and paid by VISA.

[shoju]

In contrast, I'd fear that if our doctors were government employees, we'd be treated as we are at the department of motor vehicles.

In this part of the world I had a different experience. Years ago Motor Vehicles was free enterprise. A private company leased its services to the state. The experience then was much as you describe.

At some point Motor Vehicles was nationalized, or statified, or whatever. The personnel became state employees with opportunity for advancement. A few weeks ago I was in and out quickly, served by pleasant people, and paid by VISA.

We still have to use an ATM that charges a $7 charge on top of whatever the bank charges you to pay with anything other than cash or check.

Yes. SEVEN FREAKING DOLLARS.

[Mavfin]

In contrast, I'd fear that if our doctors were government employees, we'd be treated as we are at the department of motor vehicles.

In this part of the world I had a different experience. Years ago Motor Vehicles was free enterprise. A private company leased its services to the state. The experience then was much as you describe.

At some point Motor Vehicles was nationalized, or statified, or whatever. The personnel became state employees with opportunity for advancement. A few weeks ago I was in and out quickly, served by pleasant people, and paid by VISA.

In my state, the License Bureaus, at least in the larger cities, and in many cases the smaller places, too, are political plums given out by the Executive Branch; i.e. the governor.

The most recent governor instead of passing them out as before, put them up for bid anyplace that there was more entities interested than needed to serve the people there. Service is MUCH improved over what it once was at most of them. Private entities taking care of the public stuff can work, they get a percentage, but, they're motivated to serve, because if they don't do well, they won't get an opportunity next time.

My personal comment on the US healthcare system:

Here's where I see the problem; I had a TIA (mini-stroke) one night, my leg basically refused to work for a few minutes, then I was fine. Two minutes after I fell, I could walk under my own power.

MRI and an 18 hour hospital stay, among other tests, was originally billed at 17.9K. Insurance company wrote off ~16K. So, the insurance paid about 1.5K and I paid the other 400. My issue is if they didn't have to have that other 16K+ if they were dealing with my insurance, why did they bill it at all? I mean, they accepted just over 10% of the total bill as paid in full.

Can someone educate me on that? I've never gotten a straight answer on it. To me, *that* is a big part of the problem. Where is this seeming 9x multiplier coming from? I've seen similar write-offs on every major bill (Four births, my heart issues in 2004, wife's knee surgery, etc) I've seen in the last 18 years, since the birth of my oldest.

Then we need to give doctors incentives to be doctors, treating patients, not revenue streams. And diagnosing things, not just pushing pills.

[DeeBye]

A few weeks ago I was in and out quickly, served by pleasant people, and paid by VISA.

I get my plates renewed at an ATM-style kiosk at a nearby mall. It spits out the stickers. I love it.

[kandrathe]

A few weeks ago I was in and out quickly, served by pleasant people, and paid by VISA.

I get my plates renewed at an ATM-style kiosk at a nearby mall. It spits out the stickers. I love it.

For renewing plates, we do ours through the Internet. The stickers and plates come in the mail.

[Bolty]

My issue is if they didn't have to have that other 16K+ if they were dealing with my insurance, why did they bill it at all? I mean, they accepted just over 10% of the total bill as paid in full.

Can someone educate me on that? I've never gotten a straight answer on it. To me, *that* is a big part of the problem. Where is this seeming 9x multiplier coming from? I've seen similar write-offs on every major bill (Four births, my heart issues in 2004, wife's knee surgery, etc) I've seen in the last 18 years, since the birth of my oldest.

My understanding is that they charge the extra $16,000 as an "insurance" of their own. The logic goes something like:

1) Most people who don't have medical insurance (e.g. poor and/or unemployed) can't afford to pay the ~$2,000 bill for the medical work, so the hospital just winds up eating that loss. Sure, they can bill the person, but if they can't pay it, what's the point...
2) Maybe 1 person out of 10 can actually pay that bill, and just chose not to have insurance for whatever reason.
3) Charge that one person 9x the price in order to make up for the 9 out of 10 people that they don't see a dime from.

The end result of course is that you're enslaved to medical insurance just to be able to afford even basic care. Personally, I'd rather have "catastrophic" medical insurance to cover sudden unexpected huge payments, and then just pay sane rates for basic preventative care. Sort of like having car insurance with a high deductible. That option doesn't exist currently in the United States, because you need those insurance companies to tell the doctors and hospitals that their procedures don't cost what they try to bill for.

It's funny when you look at the history of medical insurance in the United States. It's a fairly recent development having employers provide this, and over the years employers have enjoyed having the extra leverage over their employees that group medical insurance provides. You have to work, because that insurance just costs too damn much on a single policy.

I'll be waiting to see what effect "Obamacare" has on this. If it becomes more viable to purchase medical insurance as an individual due to the exchanges that will be set up, will employer health care plans start to disappear? Individuals would have more freedom and wouldn't be tied to whatever plan their employer decides to choose, which you're currently stuck with.

Time will tell.

[NuurAbSaal]

Individuals would have more freedom and wouldn't be tied to whatever plan their employer decides to choose, which you're currently stuck with.

Excuse my welfare-state communist ignorance, but is this the origin of the sometimes heard phrase "but we have good dental" in American movies?

take care
Tarabulus

[LavCat]

Excuse my welfare-state communist ignorance, but is this the origin of the sometimes heard phrase "but we have good dental" in American movies?

It's the fluorides in our body fluids.

[DeeBye]

They wouldn't need to say, "Reduce the number of mammograms you perform.", but merely control the costs by only providing a limited number of machines per facility.

They could do that, but a politician that is intentionally doing such a thing against public opinion isn't going to be in power very long.

So, other than keeping their government salary and your assumption of their noble self actualization, what motivates the Canadian health care provider to provide better quality?

I struggled with this question, mostly because of the vagueness of the term "quality" when it comes to healthcare. In the end though, it really boils down to what motivates anyone to do quality work.

[kandrathe]

It's funny when you look at the history of medical insurance in the United States. It's a fairly recent development having employers provide this, and over the years employers have enjoyed having the extra leverage over their employees that group medical insurance provides. You have to work, because that insurance just costs too damn much on a single policy.

I'll be waiting to see what effect "Obamacare" has on this. If it becomes more viable to purchase medical insurance as an individual due to the exchanges that will be set up, will employer health care plans start to disappear? Individuals would have more freedom and wouldn't be tied to whatever plan their employer decides to choose, which you're currently stuck with.

Time will tell.

Good point. It might actually be a boon for the self employed, entrepreneurs and small business who don't have huge groups to keep costs low.

[NuurAbSaal]

Excuse my welfare-state communist ignorance, but is this the origin of the sometimes heard phrase "but we have good dental" in American movies?

It's the fluorides in our body fluids.

Hard as it may be to believe, that was actually a serious question . Watching movies as a youngster I for the longest time had trouble figuring out what that phrase was supposed to mean.

take care
Tarabulus

[kandrathe]

Hard as it may be to believe, that was actually a serious question . Watching movies as a youngster I for the longest time had trouble figuring out what that phrase was supposed to mean.

Compared it health care, teeth are fairly predictable, so dental insurance is cheap. Having good dental coverage is pretty normal, although IMHO it's been eroded over the past ten years by money grubbing accountants.

Case in point, I had some pain in a tooth, so I scheduled an emergency visit. My dentist did a minor inspection on the tooth in question, and found a filling was coming loose. No big deal, we scheduled a follow up to have it replaced 3 weeks later. The minor inspection was $100, and the insurance company paid it. During the next visit the dentist did a more extensive inspection of all my teeth this time, and corrected the loose filling. This time, the insurance company wouldn't cover the inspection, since they thought they had just covered one 3 weeks earlier. For lots of reasons, I ended up eating the $100, not the least of which is that it was small enough to not be worth anyone's time to haggle about. The insurance company has "rules" about how often they will pay claims, whereas dental care may not fit easily into their reimbursement check lists. The accountants will congratulate themselves on saving themselves $100, while the dentist and I fume about how hard it is to categorize care.

[Bolty]

Excuse my welfare-state communist ignorance, but is this the origin of the sometimes heard phrase "but we have good dental" in American movies?

I didn't realize you weren't joking. Yes, this is the origin, usually expressed as something like "this job is crap, but at least we have good dental [insurance]." In the US, your health insurance is provided by your employer, who takes advantage of group policy rates along with fronting part of the monthly cost to keep your individual costs down.

As a theoretical example with made-up numbers: if you want to buy your own health insurance, it will cost $2000 a month. If you gain health insurance through your employer, they work out a group policy with the insurance company that reduces that cost to $1000 a month per person, and then the employer themselves pay $800 a month of that, leaving you with a $200 payment (which is then also deducted from your taxable income).

So you go from a $2000 a month bill to $200. You don't ever want to lose your job, because suddenly you incur this gigantic cost. The same thing applies to dental insurance, although the numbers are lower. The examples you hear of that are so painful usually fall along the lines of either:

1) Person loses their job, can't afford to pay their own healthcare, and then has an emergency happen right at the worst moment. They're stuck with millions of dollars of medical expenses they can't pay.

2) Young person foolishly thinks they don't need medical insurance, has some horrible thing happen to them, and is stuck with a medical bill they spend the rest of their lives to pay off.

Add to this the issue that medical expenses are radically inflated under the current system. If you don't have insurance, any medical procedure will cost 10 times what it should. It's economically suicidal to not have medical insurance.

The idea behind Obamacare is that if everyone has to buy in to health insurance, the healthy people pay for the sick. Just as employers can take advantage of group insurance rates because the younger and healthier employees essentially subsidize the older and sicker ones, this is now expanded to the general population.

In theory, it works. In reality...well, we're going to find out pretty soon.

[kandrathe]

I struggled with this question, mostly because of the vagueness of the term "quality" when it comes to health care. In the end though, it really boils down to what motivates anyone to do quality work.

Favorable performance evaluations leading to higher compensation and possible promotion?

But, demoralized health care workers is not anything on my radar.

I think my bigger concern is the erosion of the "paying for it" side of Obamacare. Just as the SCOTUS decision on Medicare and the States, it leaves all the carrots, but removes the stick. There are many different special interests lined up to get their part tweaked, which I fear will result in more benefits with less ability to pay for it. For example, the special 2.5% additional tax on medical devices -- there is a sound argument that it will cost the manufacturers directly, and be detrimental to manufacturing jobs. As people figure out, and with the help of their pocket legislator avoid the costs, ultimately it will become a tax burden or pile onto the debt (taxes later).

A secondary concern of mine is that many employers will realize the penalties for not insuring their workers are cheaper ($2000 "tax" vs. ~$15,000 average employer contribution for health insurance), and so more companies will increasingly choose to pay the "tax" rather than pay the insurance. According to the CBO's latest estimates (pre-SCOTUS ruling) it will put more people in the uninsured category since they won't qualify for government programs and cannot afford the prices on the health care exchange.

[RiotInferno]

FWIW, At the end of the day, I find it hard to believe that a bill that was overwhelmingly influenced by the Health Insurance Lobby has my best interests in mind.

If procedures and coverage were both logically priced, then we wouldn't be having the "healthcare crisis" that we are now.
As much as I want to be a free-market capitalist, the free market doesn't work if there's no real competition.

[kandrathe]

FWIW, At the end of the day, I find it hard to believe that a bill that was overwhelmingly influenced by the Health Insurance Lobby has my best interests in mind.

It makes you wonder.

If procedures and coverage were both logically priced, then we wouldn't be having the "health care crisis" that we are now.

Do we have a "health care crisis" or do we have a "price of health insurance" crisis?

As much as I want to be a free-market capitalist, the free market doesn't work if there's no real competition.

Agreed. I think my question has always been; if the problem is the "price of health insurance", then what is the critical analysis of the factors contributing to higher prices? Some people go without this expense because of the price, which is too high when it's not being supplied by either an employer, or the government. And, the other side of the uninsured would be those individuals who have proven to be expensive to care for (i.e. preexisting conditions).

We can take it as a given that the industry is not in favor of any approach that would reduce the price by increasing the availability of care ( e.g. more hospitals, professionals, etc), because this would mean more competition and lower incomes.

The other factor has been the increase in technology, expressed as new drugs, new procedures, and devices. This, and the increasing needs of the boomer population has driven up the demand for health care. I think we can agree that while we can tamp down on incidence of unnecessary health care (and promote preventative care) that the trend of more demand for care is also a given.

Maybe I'm oversimplifying it, but I really see the issue as one of supply and demand. It's not an issue of who pays for it, other than in the minds of the forces backing "Big Government" or "Big Business". The issue to me is simply that we have more demand than supply.

Ultimately I believe both cost and quantity of care will be reduced by forcing more health care to be paid for by Medicare / Medicaid. Fewer providers will be be willing to provide services at the governments controlled price. Two markets have emerged. Those driven by the reduced price the government will pay, and those driven by the rising price of health insurance paid mostly by employers.

I have a hard time seeing the "for profit" health care industry faring well in the impending government designed "control of price" with a 10% expansion of people covered. So, we are going to try to force more people into Medicare, a program inadequately funded by Congress, and also try to make it more affordable. An average US married couple filing jointly ($89,000) will pay about $114,000 in Medicare taxes over their lifetime -- but would receive an average of $355,000 in Medicare benefits.

And, we are giving companies (with more than 50 employees) the choice to provide their employees $15,000 in health care insurance benefit, or face a $2000 fine tax. Other than the initial "Scrooge" effect, I think I see what the natural forces are here. Am I reading it correctly? More demand, less money, no change in supply.

Health care is an industry that is 18% of the US economy. All things being equal, if we reduce our spending on health care, doesn't that show up in our economy? Perhaps we'd be better off spending that money elsewhere too. I don't know.

[LavCat]

Excuse my welfare-state communist ignorance, but is this the origin of the sometimes heard phrase "but we have good dental" in American movies?

It's the fluorides in our body fluids.

Hard as it may be to believe, that was actually a serious question . Watching movies as a youngster I for the longest time had trouble figuring out what that phrase was supposed to mean.

take care
Tarabulus

There seems to be a longstanding trope that British teeth are terrible and by comparison American teeth are better. Having done a little looking I cannot find the origin of it.

But if it's not obvious, my film reference was to Dr. Strangelove.