Even though I've been researching with interest, so far I haven't run across much in the American healthcare system that makes me question my decision (as an American) to move to Denmark. My taxes are higher, but my costs are very predictable, and by design cannot ever bankrupt me: I pay a flat 8% of my income to support the national healthcare system. I won't end up with a charge equal to 20% or 50% or 500% of my income in any circumstance, not even if I get cancer or find myself unemployed. So it's guaranteed that I will always be able to pay my healthcare costs without great hardship.
I do hope someday to move back to the USA (mix of language / "feels like home"), and am mildly hopeful that PPACA will make it feasible, by 2014, for an individual to buy private health insurance without worrying about preexisting conditions and rescissions and whatnot. But we'll see. For now, Danish is growing on me. :P
Incidentally, this kind of emergency care would be free even for a tourist in Denmark. Regular use of the national health system is only available to legal residents, but acute emergency care is considered a basic service not subject to billing, like police and fire response.
8% sounds great. US currently spends around 16% of GDP on health care every year. I think the majority of Americans would support a universal health care system that provides far more coverage at half the cost. Instead our total spend is expected to double by 2020.
Worth noting that the US leads Europe in outcomes for serious illnesses (particularly cancer), and the US provides access to specialists in days where other countries often have multi-week or even multi-month delays.
Careful--the US does more early cancer screening than is typically done in Europe. This boosts the US score on 5 year survival rates, but it doesn't necessarily mean we actually get better outcomes. E.g., if an American and a European each get a cancer that will eventually kill them in 7 years, and the American finds out in 1 year and the European doesn't find out for 3 years, then the American will show up in the 5 year survivor statistics, and the European will not.
We do gain some outcome advantage from earlier screening, in that it means we will catch some cancers early enough to treat that Europeans would miss, but the outcome differences aren't nearly as big as the 5 year survival stats lead some people to believe.
As far as seeing specialists goes, the US does do well, although I believe Germany and maybe Japan have us beat--showing that universal affordable coverage can be achieved without having to give up reasonable wait times to see specialists.
The thing that makes me sad about the US system is this. Take the top, say, 10 non-US systems. They have quite a diverse range of approaches, ranging from straight up socialized medicine to highly capitalistic market-based systems. All they have in common is that in most areas they have equal or better outcomes than the US, with universal or near universal coverage, for a lot less cost per patient or as a percent of GDP. Based on the evidence, it doesn't appear hard to design a good healthcare system for a first world country. Only the US seems to be able to botch this. WTF!?
By what measure do European countries have better health outcomes than the US? We're seeing in this thread why the most obvious metrics don't work well:
* Cancer survival rates, because of the 5 year survival heuristic, capture people who's illness is detected early but isn't actually cured.
* Life expectancy captures the fact that people drive more and faster in the US, that the US has more violent crime, and that more people in the US kill themselves
Intuitively, "high cost" plus "shortest wait time to specialist" plus "problematic overprescription" (a problem common to all first-world health systems) plus "earliest cancer detection" just doesn't add up to "worse outcomes than Europe".
But, it does make sense that despite the money we pay, our outcomes are not different enough to justify the expense.
I strongly agree: the way we finance health care in the US, primarily through a system of employer-provided health insurance policies that give way to a single-payer socialized system that kicks in right when patients are most engaged with the health care system, all without giving patients control or a stake in the cost of their care --- this system makes no sense.
Yes, but, europeans generally see a healthcare provider more often and are more often diagnosed before they reach an acute stage. If you look at the graphs [1][2][3] that compare per capita expenditures per country with life expectancy per country. You'll see that they are generally getting equivalent or better outcomes at less than half the cost.
And I can tell you that for my own part, even with health insurance, the deductible is so high that it might as well not exist as far as basic checkups and doctor visits go.
Life expectancy is a poor proxy for health care effectiveness. By some methodologies, once you take out things like auto accidents, the United States snaps right back into first place in those rankings. Meanwhile, in disease-by-disease rankings, the US routinely leads.
We do spend a lot for health care in the US, and we probably aren't realizing comparable value, but it is also probably not true that the actual quality of care in the US lags that of Europe.
Something that wasn't confounded with deaths by suicide and high-speed automobile accidents, both of which are so anomalously high in the US that when you factor them out of life expectancy the rankings are totally different.
Say what you will about the worldwide quality of mental health care, but there's not a whole lot a good hospital can do once you've set out to harm yourself, and that one particular tragically underserved health problem is not what people are thinking about when they suggest "Americans pay more money to get less than what Europeans do". That last notion is dubious at best.
> the US provides access to specialists in days where other countries often have multi-week [...]
This is a view that's strongly distorted by the UK. It's seems to hold there, and the wait times sound terrible, but it's definitely not the case in the majority of countries, by a long shot. As far as I can tell from personal experience, wait times are not an issue in The Netherlands, Sweden, Germany, or France; outside of that I've never heard of really long waits in any country of Europe, with the exception of the UK.
The European systems are all different in sometimes surprising ways, throwing them together into one bucket is an incorrect generalization. E.g. the UK system with the NHS is entirely tax funded, where the Germany system has insurance paid 50/50 by employee and employer, and the Swiss system has 100% privately paid but mandatory and state regulated insurance.
These are really massively different systems, and the effects on e.g. waiting times are huge. They are all state regulated and sometimes state funded, but that's by far not the only interesting characteristic of medical systems.
For procedures that aren't time sensitive, like eye surgery, wait times in France are upwards of 2 months.
I don't know what Germany's wait times are, but Germany isn't a pure single-payer system like France, the UK, and Canada; it's guaranteed-issue mandatory-coverage.
The great thing is that this expense grows at a rate of 9%/year while the economy is stagnant. If GDP miraculously and immediately begins to grow at 5%/year, health care spending will completely eclipse it in 50 years. If it does not, health care spending will completely eclipse it in 28 years.
Should be noted that there is not a direct correlation between tax paid for health care and cost of health care. It's heavily subsidised by the government, from taxes taken elsewhere.
In Norway it's like this:
Senior citizen: 4,7%
Employed: 7,8%
Self-employed: 11%
Last time I checked we spent around 9% of GDP on healthcare.
Having experienced emergency care in both Denmark and the U.S., this is also the main reason I won't relocate to the U.S. until this is sorted out. I had what was thought to be a broken ankle in Denmark thanks to icy conditions and I was so well looked after, and charged nothing, I was awe inspired and wish there had been some way to pay it back. I sliced a finger in the U.S. and was made to feel like a statistic, with a $1000 bill. Thanks to inexpensive travel insurance that cost me just $100, but how I am supposed to feel when my travel insurance is less than quarter of the price that actual insurance would be if I lived there?
(Edit from reading other comments: probably not charged in Denmark because of European health reciprocity, but they never verified this at the hospital).
It's not fair, and not right, but it is a fact that for the most part, most of us here don't have to worry about that.
If you're a software engineer or systems administrator or similar type of professional earning a fair living it's not at all uncommon to have completely free health insurance for yourself, and affordable options to cover your family. I haven't worked for a place with an individual premium in 5 years.
Again, not saying the system isn't broken, but rather that there's a reason all Americans aren't vocally supporting the ACA and the president: this is mostly a lower-middle-class-and-below problem
It's a huge problem if you want to start a company. It's an even bigger problem if you want to hang up a sign and do business as a freelancer.
I agree with your point: the reason the country isn't completely behind health care reform is that they get it from their employer and don't understand how it works. Of course, they're also getting screwed financially in the process.
As others have said, it's a problem for anyone who wants to do work outside of the "middle class employment cocoon".
I'm self employed, and even if I go back to working for a larger company, I would prefer to continue to keep my private insurance. I have private homeowner's insurance. I have private car insurance. I have private life insurance. Why oh why do we demand/insist that employers provide health care, to the detriment of market forces favoring individual purchasing?
Conservatives in this country should be in an uproar that the 'free market' isn't allowed to run its course because of the combined interference of big business, big labor and big govt over the past several decades, but they're not.
> Conservatives in this country should be in an uproar that the 'free market' isn't allowed to run its course
Because unlike cars and homes you only have one life. If you let a profit seeking entity control and dictate what happens to your health, you might not have a chance to go back fix the problem by choosing a better one. You could be dead.
There was just recently a story on Reddit about someone who's relative a was killed by a driver and his dead relative' insurance company effectively provided council for the defendant. That's the kind of stuff you'd be dealing with. You health insurance company would be interested in killing you promptly as soon as you develop a chronic or expensive condition. And they'd all want to do it. All 1 of them after they merge into a giant conglomerate (since you know can't be messing with the free market and stuff, there will be nobody protecting against monopolies).
I agree, and I feel it used to work even better in that respect, when educated Americans typically had lifetime employment. I would guess that's one reason the debate is growing louder lately. The West basically solved the healthcare problem via collective coverage, but in different ways: the European countries did it nationwide, but the US did it with employer group plans. That was almost equivalent, for people with good jobs, as long as people stayed in jobs for life: having the IBM group plan was about as good as having state health coverage, as long as the IBM job was more or less for life.
It's more broken if you're middle-class-or-below (as you mention) or an entrepreneur who isn't either early-20s-and-healthy or raking in huge piles of cash. The part that seems most out of keeping with the American ethos is how anti-entrepreneur it is: you get good collectivized coverage if you work for IBM or Microsoft or Google (because it's socialized across their employee base), but if you start your own company or are trying to buy insurance for a 10-person company's employees, well then you're screwed.
Interesting. I mostly know people trying to buy individual health insurance, whose difficulty really varies, depending on age and health history. Is even a 10-person company big enough that buying it isn't a problem, if you're willing to pay the "10-person company" premium? In particular, do they inquire into the distribution of health among those 10 people? I would've guessed that if 1 of your 10 employees happened to have some disqualifying condition you'd be SOL.
Not entirely a theoretical question, b/c one of my friends has a congenital heart defect, and is himself not 100% sure how his condition would impact a small company. They aren't allowed to inquire into such things when hiring, but could it possibly tank their group health-insurance plan, if 1 of [small-N] members had a major preexisting condition?
You can get group coverage (by which I mean, "insurance plans in which individual members of the team will not need to fill out applications") for teams smaller than 10 people, but probably not much smaller.
In the US, group health coverage is distinguished in part by not "qualifying" patients, so that latter example doesn't really come up. There are horror stories about companies being forced out of their insurance plans by prohibitive cost spikes after major medical events, but I don't have any of them ready to deploy on this thread.
I disagree. It's really common for small software companies not to provide insurance, and of course anyone who wants to strike out on their own, either selling software or contracting, has to deal with the question. I would wager that the average programmer is more exposed to the problem of health insurance than the average.
Exactly what part of an emergency room visit is going to change in 2014, when PPACA is fully implemented? Please be as specific as you can, while limiting the detail you provide to the "amount of time taken to see someone at an emergency room" example you've used in this comment.
I expect the continued growth of socialized medicine to continue the trend of less and less competence among medical professionals, and less and less medical professionals period (particularly doctors--which seem to be in acute shortage already). So, nothing will change overnight, but this certainly isn't going to allow things to get _better_, which would eventually happen in a more free-market medical system.
Americans are exceptionally good at everything the free market touches (consider the tech world). Medicine could, and should, be a lot like going to the vet. Extreme competence, speed, and low price. The difference? There honestly isn't that much of a difference, except veterinary practice is pretty much a free market.
By the way, I've personally been forced to undergo unreasonably waits at the ER (I was kicked out of the building by a security guard because I wouldn't take a seat or stand - I couldn't physically do either, and I went and laid down in a parking lot outside). I've also seen a loved one hurt--potentially very severely over what could have been the case, but who knows--by not getting competent attention during a stroke. And there is at least one other bad story I won't get into here.
By the way, I do think my stories are representative of a larger trend. The above-mentioned incidents occured in different hospitals mixed between the east and west coast. That still isn't enough to prove anything. But I'm hearing complaints from a lot of people. Also, if you talk to someone applying to med school, you'll see that the number of doctors is being artificially restricted.
The public discussion about healthcare is missing a huge component, which is: why is our healthcare so completely shoddy and incompetent today? What can we do to change that? And, why aren't there enough doctors? I'm talking totally independent of the _cost_, which admittedly is also a problem.
"Medicine could, and should, be a lot like going to the vet."
Yeah, and patients whose cures are more expensive than they can afford should be put down painlessly, eh?
There are some aspects of health care where free market mechanisms can improve efficiency, but efficiency is not by itself the ultimate goal a health care system should have.
How much does it cost to treat a dog for the most serious medical problems, like cancer? I bet it's trivial compared to the cost of a human. I bet it's so little, that we could actually think about treating everyone for everything, if we could get human treatment to that level of efficiency.
Seriously, it's the most humane way to go.
In the meantime, I'll be thinking about going to India if I or loved ones need serious medical care.
It seems that most people get confused between ER & "trauma" service. If it was a "real emergency" (chest pain/stroke etc) the patient would go straight to the trauma service. Not so critical emergencies are treated in the ER, and that can involve 3-4 hour wait.
Quite a few hospitals with ERs also have a 'urgent care' or 'express care' clinic attached which are quite effective as they can a lot of things a ER can do, and expedite transfer to the ER if can't be treated there.
What is your legal status in Denmark, and how did you achieve it? Are you a "resident alien" or an immigrant or what? What restrictions/hoops did you have to jump to get permanent residence status? What did it cost?
Unfortunately it's not the most friendly country for immigration, partly as a result of the right-wing coalition that tightened rules over the past few years (Sweden is better, as far as the Scandinavian countries go). But there are some exceptions: it's easy for EU citizens (due to being in the EU), and it's easy if you have a professional-level job offer (no US-style H1B quotas).
I'm a researcher hired by a Danish university, which made for a fairly easy fast-track visa under the "researchers scheme" [1]. In fact the entire process was by mail and took one round-trip: I mailed my passport, offer letter, photos, and application to the NYC consultate, and they mailed back my passport with a visa pasted into it. Most professionals with an offer will also be able to get a visa; it's not nearly as restricted as getting U.S. visas is. If you have an offer that pays more than 375,000 DKK ($63,500), you qualify under the "pay limit scheme" for similarly preferential treatment [2]. Getting permanent residency depends on if you're an EU citizen. If yes, it's just a matter of remaining in the country as a legal resident for at least 5 uninterrupted years. If you're from outside the EU, there are more requirements [3], including that you must be employed for 3 of the 5, and must pass a language exam establishing basic competence in the language (which is unfortunately quite difficult to speak, though the grammar and vocabulary are not particularly difficult).
I must also give them kudos for giving all of this information in not only English, but straightforward, non-legalese English. Dealing with the Danish state is generally not a horrible experience so far, even for someone who speaks no Danish.
I don't entirely understand the permanent residency for EU citizens part. As far as I understand, EU citizens have work permits and no restrictions on residency in all European countries, what would permanent residency get you on top of that?
The "free movement of labor" in the EU isn't a completely free right to live anywhere and be treated as a resident. Every EU citizen has the right to reside in another EU country for up to 3 months for any reason, and to be hired without having to apply for a work permit. But after 3 months they must register, subject to certain restrictions of the host nation, usually that the person must either have employment, be a student, or be able to show that they have sufficient funds to support themselves. In that case they get a temporary residency status that allows them to live in the country and be treated as a resident for certain purposes (such as healthcare).
Permanent residency removes any qualifying requirements, and gives the person the right to remain indefinitely in the country with full social rights (except voting), as if they were a citizen. That means, for example, that they would be eligible for the national healthcare system and state welfare system even if they found themselves long-term unemployed, which isn't normally the case for citizens of other EU countries.
Thanks so much for replying and the links. Actually the third one, permanent residency, is quite encouraging for me as I would be a "pensioner" and thus the 3-year work requirement is waived.
It's almost impossible to get a permanent citizenship in any of the scandinavian countries (besides Svalbard, which is a part of Norway, but really strange case). You either have to be some sort of highly educated person or marry someone with a permanent citizenship, and even then there are some restrictions.
Inside of EU and Schengen you should be able to get a limited work permit. Then you are usually covered by local health care after a couple of months paying tax.
That seems like a pretty low bar for "almost impossible", as I would expect most HN readers are both 1) highly educated and 2) single, and so the two avenues you mention are amongst the most accessible to them.
There are far more difficult places to gain citizenship (e.g. Liechtenstein, China).
Life saving treatment is usually like this all over the world, and in Denmark they will give you a bill unless you're apart of EU, as you'd have the EU health insurance (EHIC), which is free. This card is also valid in countries in the Schengen Area, like Norway, Switzerland and Lichtenstein.
Many countries bill for emergency stays. US emergency rooms definitely send bills, even if it's acute live-saving treatment. Even Canada, which has national healthcare for residents, will bill nonresidents who visit an ER. If you're from another country, you may get away with just not paying one of those bills, because if it's life-saving care they have to provide it before verifying you can pay. But they'll still try to collect on it. That's one reason it's common for people to buy travel health insurance that covers emergency care.
Afaik, Denmark doesn't require the EHIC for acute emergency care. Anyone is eligible for unbilled emergency care, with some exceptions to combat medical tourism (if you're found to have traveled to Denmark for the specific purpose of entering an ER to treat a health condition). The EHIC qualifies you for some additional care, e.g. childbirth. This is actually a big current sore point in Danish politics, because many other EU countries don't extend a reciprocal courtesy.
You're still stuck with a bill, if you're a foreigner. They will treat you, like they will in most of the world. But you're still stuck with a bill afterwards.
Also, unless my memory is totally off, each country has to pay up for EHIC, depending on who used what, and visa versa. So the cost should be evened out.
Edit, because I cannot reply to you later down: I think we have a different view on what emergency medical care is. In most of the world you will get fixed up so that you are no longer in life threatening condition, this is the case in USA, Denmark and Norway. But afterwards you will have to pay, even in Denmark, as long as you're not apart of EU and have the European Health Insurance Card or a citizen of any of the Nordic countries, which has a special agreement.
That isn't the case; Denmark simply does not charge for acute emergency visits, and does not send a bill. In addition, they pay for their own residents who incur such bills within the EU on trips under 30 days [1], which is part of the controversy: a French person who ends up in a Danish ER is not billed, but a Danish person who ends up in a French ER is billed, with the bill paid by the Danish government. Most Danes would prefer that each country provide free emergency care to all, like they do with fire and police.
You're still stuck with a bill, if you're a foreigner.
In the UK you are not, purely because they don't do the accounting that way in the first place as it would cost a lot of extra money to keep track of billing when no-one is being individually billed, so there is no bill to bill.
> Even Canada, which has national healthcare for residents, will bill nonresidents who visit an ER.
Even Canada? Canada by its location would be at acute risk for medical tourism from the US, if it didn't bill for ER treatment. That problem isn't as big for Europe, Australia, etc.
That makes sense, I agree. The "even" was more given its reputation: most Europeans I know are not surprised that the US sends large bills for ER visits, but don't expect the same from Canada.
I could almost imagine a financially manageable system where Canada gave free ER care to anyone except Americans, but that would produce obvious political problems.
If he's still in the hospital and thinks the bill is $23K he's got a surprise coming. The bills will keep coming for months. Many items may be billed multiple times. Writer is going to have to invest several man-weeks in dealing with this, minimum.
I talked to a friend of mine who received some treatment recently. He made sure the hospital was "in network", but apparently someone who came in to give a shot was "out of network" - personally, for herself only - so he received a huge out of network bill for the services of one nurse in giving one shot. He asked the insurer if he was supposed to quiz each medical person in the hospital about whether they were in a particular insurance network before allowing them to provide treatment. The insurer's answer was "yes", with no irony.
Anesthesiologists are the worst offenders. My experience is that none of them are in network. You think you have everything covered and along comes this bill that is as big as everything else.
Woe to you if you are uninsured. I had minor heart surgery nearly two decades ago. The bill was something over $80K. The insurance company disallowed most of it, bringing it down to $20K of which I had to pay $2K. Except for the Anesthesiologist.
Why is it that you can't go to a medical facility and tell the intake nurse or admin person you're not agreeing to any procedure that's not covered by your insurance. Wouldn't that put the onus back on them? Anything not covered instantly becomes a freebie or a lawsuit?
Why do hospitals and clinic get away with this crap when auto mechanics and plumbers can't?
Some shady anesthetologists (and others) often try to bill you out of network. In-network charges are subject to insurance company price controls while out of network charges are not.
Once you make it clear you are paying in-network, as you kindly explained to the receptionist (who told you it was all covered), they back down real quick. It's just a scam they try to pull on the uninformed.
If a law was passed that they have to that's what. If a law was passed that any hospital billing mistake in favor of the hospital should be fined by a 10x fine of the amount on the first offence and a much higher one on subsequent offences. That kind of stuff, stuff that would protect individual citizens when they get sick and are most vulnerable. In a normal country that's what would happen.
The hospital didn't make a mistake in this case; they were indeed covered under the plan. The specialist who is not under the plan is probably not an employee of the hospital. So basically you're saying we should overhaul the way medical billing works. I totally agree, but I don't think that is accomplished by passing a law that levies fines on hospitals.
For complex reasons, I was without insurance for a couple days last week.
I happened to have an appointment schedule. I went into the clinic and, since it was my first time there, I filled out a stack of paperwork. And then they told me my insurance was inactive.
So I figured, whatever, I'll pay it out of pocket and file for reimbursement. I asked how much the specific service I was requesting would cost. And they had no idea. They refused to tell me, other than to say "well, we charge a hundred dollars up front and then you pay the rest of the bill after you are done".
I ask to see their cash price list, because every sane facility I've ever been to has a cash price list with prices that are 1/2 to 1/4 of the insurance price. And they don't have one.
So I ended up leaving. It's amazing just how perverse health insurance has become, that it can so affect the delivery of medical care that the facility cant/wont give an up front estimate.
I wasnt even there for anything complex - just a standard glucose diabetes test. They probably do ten a day.
Last year, my daughter caught a stomach bug and for a few days woke up each morning nauseous. We took her to her pediatrician and were surprised to find out that "waking up nauseous" is a Big Deal; it can be a neurological symptom. We were pretty sure that wasn't it (there were... other symptoms... corroborating our "stomach bug" hypothesis) but the doctor was adamant: if she kept waking up and puking, she'd need to get imaged.
She got better and we cleared her to go on vacation with her grandparents, and were just about to get on a plane to go give a talk at Black Hat, when we got a call from our parents in Michigan telling us she was puking again. We called the doctor, who demanded we retrieve her and scheduled a CAT scan.
We are at this point freaked out for a variety of reasons, some of them logistical (trip to conference, driving back/forth to Michigan, &c) but also from the fact that our doctor knew what an epic inconvenience all was and was absolutely clear "daughter needs CAT scan" --- so in the back of our heads there's gnawing "something could really be wrong" (Adia had seizures when she was 4, which, by the way, GUESS WHAT DING DING DING UNINSURABLE ON PRIVATE MARKET NOW, and now 7 years later I still can't even hear she has a headache without taking an inventory of all other possible symptoms.)
So anyways, we want that CAT scan done now now now yesterday now. We get to the hospital for our appointment and: problem with our insurance card. No big deal, we'll just resched--- fuck that, I'm paying cash.
Head scratching ensues, long story short, very large hospital in Chicago doesn't have any price list for a CAT scan at all. Not even an insurance cost to pass on to me, let alone a cash-basis discounted price. Getting imaging done at a top hospital in Chicago without insurance: unheard of. They ended up just making up a price on the spot; $1000.
I have on a few occasions floated the idea of making it illegal to insure more than 90% (say) of procedure costs -- there would always be a mandatory 10% copayment. No one I mentioned this to ever seemed to understand the point. I don't know that the proposal is actually workable, but I think you can see where I'm coming from. If patients had to know all the prices because they had to pay some fraction of them, the whole system would look very different.
Making up prices is routine. Got my wisdom teeth extracted. They said there would be a $170 X-ray fee. I already had X-rays done from my regular dentist and brought those in. During the checkout they scratched the $170 X-ray fee and then added at the bottom a $170 consultation fee. I thought pissing off people who are about to knock me out and operate on me is probably not a good idea and didn't say anything.
This is what is happening now, when there are still some people who pay cash. Imagine how complex and impossible to understand this system will become once there would be virtually no people paying cash as there would be public insurers of last resort. No 1/4 cash price lists would exist anywhere - anybody who paid 1/4 price now would pay the full price, provided from the public coffers. Of course, there would also be a need for a huge bureaucracy to check all these payments, argue about them for months, send stacks of papers back and forth, etc. These people would have to be paid, provided with nice benefits and pensions - after all, they work very hard.
On the other hand, you will never have to pay out of pocket for it and probably will never ever made to realize there's a payment in there somewhere. You'll pay out of your taxes and you wouldn't even know how much you paid, so nobody would be up for an unpleasant shock of knowing how much all this costs. 23,800 is not going anywhere - these nice people in the hospital still need to be paid, and they don't deserve the pay cut (if anything, many of them consider themselves underpaid and many of them are right), and these machines and medicines must be paid for too. So it still will be paid for. And it's not getting cheaper - remember no more 1/4 prices for anybody at all? Somebody would have to pay for it, or, more precisely, everybody would pay for it, but won't know how much and where it went. Some think it's better this way.
I have also seen these places. Some of them will tell you the doctor has gone to lunch when you tell them you have individual insurance.
There are "direct access" clinics that can perform lots of blood tests without a doctor's help at a low cost -- $5 to $20 per panel. Fill out a form, draw a couple vials, go home and your results come in the next day.
What's frustrating is that you aren't typically told about these options, and so you end up paying five times as much out of pocket to have the doctor be your gatekeeper. So then you're tempted to say screw the doctors and use the internet to perform your own diagnoses.
It's a shame we have such an antagonistic healthcare system, and I don't see how it can get better as long as the medical industry expects to book profits at a faster rate than the growth of the population.
A young coworker had an ATV accident. It was ugly, but not so bad that they weren't on IM within days talking about work.
Total bill: just shy of $100,000.
A friend's son had appendicitis. Uneventful appendicitis.
Total bill: neighborhood of $35,000.
Add to this: tens of millions of people are, despite any debilitating medical conditions or even better-than-even likelihood of incurring anomalous medical expenses at all, actuarially precluded from getting insurance on the private market. There are very long lists of widespread health conditions, most of them "chronic", most of them minor, that will land you on automatic exclusion lists (not "we will cover you but not for this condition", but, "we will not issue a policy for you at all"). Particularly if you are a woman with a functioning reproductive system.
Once again I say: I cannot understand how anybody who runs a software business or who aspires to run a software business could possibly oppose guaranteed-issue health insurance. I dealt with many dramatic problems during the operation of the company I cofounded in 2005, but the only one that was almost intractable was trying to obtain private coverage for my family. Fortunately, my wife Erin got a tech job with group health coverage and we dodged the bullet until Matasano got its own group plan.
Employer-sponsored group health insurance is a terrible system. It increases costs on new businesses and adds uncertainty to their financial planning, while at the same time retarding labor mobility. It introduces a principal/agent problem between the people selecting plans and the people who use them. Because this idiotic scheme is tax-advantaged, it incentivizes the creation of a bizarre slush fund with warped, collusive prices. At the same time, because users of health care never directly pay for it, it encourages people to make dumb decisions about their own care.
People should buy their own insurance. Insurance companies should be forbidden to decline applicants, or to constructively deter them with shady pricing schemes. People should not be allowed to exploit that requirement by waiting until they get sick to apply for coverage. The requirement should be nationwide, so that states that offer sane insurance regulations don't get sabotaged sick refugees from other states without sane insurance regs.
Minus the Medicaid expansion, which I'm ambivalent about, this is what we worked out in 2010.
One solution (which obviously won't for everybody): live in Massachusetts. We have excellent health insurance plans available here: https://www.mahealthconnector.org/ I'm using one now.
That is, oddly enough, basically the model for the current guaranteed-issue reform (scheduled to become operational in January 2014), despite the fact that the governor who passed it doesn't want to take any credit for it.
Why is gambling with citizens health and encouraging predatory and extortionist behavior by hospitals and insurance conglomerates on people who are sick and vulnerable an obvious states issue, while stuff like 'right to have guns in your house' is a federal law.
Well, because the latter was specifically in the constitution, and is key to our ability to protect ourselves from tyranny. The former was not in the constitution. If you don't like it you can feel free to amend the constitution. It's been done, and it will be done again.
Funny, I actually made that point once (when I was feeling particularly sarcastic). It was rather derogatory and went something like this "Hmm interesting... all these people in West Virginia seem to hate voting for better healthcare and love voting to get more guns, so maybe their answer to healthcare problem is rational after all and it is to just put those guns to good use".
Wait, but two post above you said that government involvement is bad because it will turn emergency rooms to DMV. I thought state of Massachusetts runs the DMV, and hence they would be utterly unqualified to give health care? Am I getting something wrong?
why the downvote? there is nothing in the constitution about the federal government providing healthcare. Ergo, based on the 10th amendment it is the right of the states. Massachusetts can do whatever they want. The federal government cannot.
Everybody already knows about the existence of a "states' rights" opinion on health care, and it's not consistent with Republicans' ideology on the subject. You were downvoted accordingly for making statements that have no basis in reality. You should reconsider believing or sharing your own opinions in the future.
What does Republican ideology have to do with my comment? How does that make my comment have no basis in reality. Also, I will not reconsider believing or sharing my own opinions in the future. I'm quite sure my freedom of speech is covered.
Note that my comment has since been upvoted, so at least I'm not the only one on hn who has read the constitution.
Your comment was in reply to one about the Republican candidate's inconsistent behavior when it comes to healthcare reform, defending it as an example of states' rights. But Republicans want government's hands off their Medicare at the state level as well.
Do you understand what "state's rights" means? It means that the states are free to make up their mind on a matter without the federal government interfering.
You are also confusing one person with a whole party. Just because he is running as a Republican, does not in fact mean that every Republican agrees with him on every issue. He is by all account a very moderate Republican.
Some Republicans might support have a state health care law similar to the one in Mass. Clearly Romney did. Many others would not in fact support that. That is their right. It is also somebody else's right to "want government's hands off their Medicare at the state level." That is a perfectly valid opinion, and it can be debated at the state level.
1865 called. Said that States lost.
2006 called. Gov. Romney supports ObamaCare^WRomneyCare.
2012 Supreme Court called as well. Said ObamaCare was constitutional.
I would say 1964 is a bigger milestone. The Civil Rights Act was upheld (under the commerce clause), and its enforcement was successfully carried out with federal troops, once and for all putting down "states' rights", generally for the good.
1865 - Slavery was something that states shouldn't have the right to. They also shouldn't allow stealing, murder, etc. Turns out after the Civil War we didn't in fact repeal the 10th amendment.
2006 - No, as for a state and nationally are 2 different things. But even if he did, why should that matter here. I never said anything about Romeney, I don't really like him, and he most certainly was not my choice in the primaries.
2012 - now that is a pretty good point. I think they were wrong, but that is neither here nor there. For now I'll just have to deal with it, but that doesn't mean I can't support Congress repealing it, which they are perfectly capable of. Alternately, I can hope for a future non-Democrat court to actually read the constitution and overturn this recent decision.
(Alternately we could amend the constitution and actually add language that makes socialist healthcare part of it. while i wouldn't support it, that would in fact be preferable to me.)
Slavery is not an enumerated right, to control or to tax, for federal powers listed in the Constitution. Therefore it should fall to the states, or their respective citizens. A war was fought over this very issue. States lost. Get over it.
Functionally, Massachusetts Health Care Insurance Reform Law is similar to Patient Protection and Affordable Care Act. One is state law, and the other one federal law. Questions were abound if PPACA was constitutional. SCOTUS said YES 5-4.
Quote: "Alternately, I can hope for a future non-Democrat court to actually read the constitution and overturn this recent decision."
Oh, and I believe the swing vote was Chief Justice John Roberts. Wasn't he a conservative justice, nominated by George W. Bush, after William Rehnquist passed? Facts are pesky things, aren't they?
A war was fought over the issue, and we decided to add that particular issue to the constitution through the amendment process that the founders allowed for in the constitution. It turns out, that after the war, we didn't repeal the 10th. That's totally still there - http://en.wikipedia.org/wiki/Tenth_Amendment_to_the_United_S...
Facts are pesky things, aren't they?
And Reagan appointed Kennedy. What's your point?
I see you also skipped over the part where I'd be ok with amending the constitution to add it. I wouldn't support it, but I'd be ok with it if it actually passed.
> Slavery is not an enumerated right, to control or to tax, for federal powers listed in the Constitution.
So? It is not in a paper composed 200+ years ago that we somehow feel the need to worship and treat it like a set of magic tablets given to Moses on a mountain or something.
Aren't the citizens supposed to be able to change and update that as they see fit, isn't that even more in the spirit of Founding Fathers than say just to continuously point a 200+ year old paper
Don't get too caught up in it. Fights over Constitutionally "enumerated" rights are simply code words for ignoring the 9th amendment. i.e. the framers of the Constitution knew that they could not possibly enumerate all rights from the get go and were bound to make mistakes (especially since most of the rights they were enumerating had not been traditionally recognized before).
The Framers did not intend that the first eight amendments be construed to exhaust the basic and fundamental rights.... I do not mean to imply that the .... Ninth Amendment constitutes an independent source of rights protected from infringement by either the States or the Federal Government....While the Ninth Amendment - and indeed the entire Bill of Rights - originally concerned restrictions upon federal power, the subsequently enacted Fourteenth Amendment prohibits the States as well from abridging fundamental personal liberties. And, the Ninth Amendment, in indicating that not all such liberties are specifically mentioned in the first eight amendments, is surely relevant in showing the existence of other fundamental personal rights, now protected from state, as well as federal, infringement. In sum, the Ninth Amendment simply lends strong support to the view that the "liberty" protected by the Fifth and Fourteenth Amendments from infringement by the Federal Government or the States is not restricted to rights specifically mentioned in the first eight amendments. Cf. United Public Workers v. Mitchell, 330 U.S. 75, 94-95. - Justice Arthur Goldberg
In all honesty, I was just arguing with a libertarian with a strong constitutionalist mindset. And he finally got 'it' with the
" In other news, I'm up far later than I want to be debating something I have almost no control over, with someone who describes himself as an idiot."
comment. I was doing this in the middle of designing a platform and motor for my 3d scanner.
Complete aside: I believe I can modify the source for MakerBot Scanner so it can scan rooms as well as individual objects. It'd be really spiffy to print panoramic pictures of a room. Call it an early work in progress. I'll publish soon-ish.
Just because the system is broken, doesn't mean we need socialism, and it doesn't mean that a software developer should support anything in particular. I personally, won't support anything that makes me pay for your health insurance. I pay plenty for mine, I have no desire to pay for yours. We can work to fix the broken system, but keeping everything the same and then taxing us more to have the government foot the bill WILL NOT FIX THE PROBLEM. The government getting involved isn't the solution.
Just think, emergency rooms that function with the efficiency of the DMV. Woo Hoo
note that obamacare isn't socialism by any stretch of the imagination, and that isn't good for those that want socialism. it also isn't good for people who want free-market. it's the worst of both worlds.
that being said...
I never remotely suggested that our current system is good, or working as it should. I think it sucks. I also take note of how bad a job our government does at running...pretty much anything they try to run (possible exception to NASA). I also note the stories from countries that have socialism. Everyone loves it because it pays for the doctor when they have a something minor or chronic. Then I see the stories of the people dying on waiting lists because they can't get the procedure done in time when it would have been done in America. Due to this, I've come to the perfectly reasonable conclusion that I don't want either our system or socialism. There is another option, and that is to actually fix some of the major problems in our system.
It's hard to take comments like this seriously when the private American health care system has worse outcomes and more than double the cost of numerous socialized systems.
You can blindly chant "government isn't the solution" all you want, but it doesn't change the fact that it undeniably is the solution in a large number of countries with functional health systems.
Functional does not in any way mean better. I do not want to wait on a list for my health care. As I noted in another comment - http://news.ycombinator.com/item?id=4466161 - this doesn't just have to be "current shitty system" versus "socialism". I never said that the current system is great. All I said is that I'd rather have it than socialism. So many things we can fix easily about our system without going to socialism. And Obamacare is the worst of all worlds. Halfway socialism while still keeping insurance companies. Please tell me how that makes sense.
> "I personally, won't support anything that makes me pay for your health insurance."
> Um, that's kinda the point of any kind of insurance.
No, the point of insurance is not to buy into or share the risk of others, but to amortize one's own risk over time. An insurance policy can have a single applicant and still function as it should -- the issuer is betting that the applicant won't suffer a loss, the applicant is betting that he will. An actuary sets the rate based on his best guess about the possibility of a claim.
This thesis is proven by the classic alternative to buying insurance -- self-insurance, a scheme in which an individual sets aside his own cushion against loss, or "self-insures" -- accepts risk using his own resources.
Many states will accept an alternative to otherwise mandatory car insurance -- a personal bond against claims. The advantage to the individual is that the bond can earn money as an investment while it stands as proof of personal responsibility.
So the idea that insurance means joining a pool of insured individuals may be true in many cases, but it isn't a requirement for insurance to function. And it certainly isn't "the point".
The model where there are many clients and one policy is the norm, but that doesn't mean the system requires it. If insurers went to the trouble of making it work, you could have individual policies written up for each and every client, and sell the risk to subscribers (as is done with mortgages). Example:
A quote: "America Ferrera is the newest addition to the list of stars who have some of their body parts insured. Famous for her role as Betty Suarez in the top-rating ABC sitcom "Ugly Betty", Ferrera has had her smile insured for 10 million dollars by Lloyds of London."
One person, one smile, one client, one policy.
> Everything you wrote is wrong, sorry.
It's generally thought good form to offer some evidence for your position, as I have for mine.
You're right, my statement was too broad, but I submit that it is still correct for health insurance, when the goal is (I hope) to get affordable health care for everyone. The difference is that if vehicle insurance for your tank is unobtainable to prohibitively expensive, you can choose not to drive that tank. You have no choice in getting type 1 diabetes, or appendicitis, or an MRSA-infected bug bite.
> You're right, my statement was too broad, but I submit that it is still correct for health insurance ...
It's correct because the present system is set up that way. But this doesn't mean it must be that way, or that insurance requires a large pool of clients with the same policy and coverage. That's a coincidence.
From the standpoint of a large publicly-held corporation, many clients with identical policies, or many clients each with unique personal policies, work internally exactly the same way -- it's all about actuaries assessing risk and setting rates.
> I submit that it is still correct for health insurance, when the goal is (I hope) to get affordable health care for everyone.
Regardless of the business model, if health costs cannot be controlled, insurers will refuse to write the policies. This outcome doesn't depend on the assumptions behind the program -- whether there is a large program with many identically covered clients, or a program in which each client has a unique policy and the capital pool is the corporation's stockholders rather than the policy holders.
In both cases, some circumstances are unworkable. It remains to be seen whether health costs can be meaningfully regulated, in order to make a mandatory health insurance requirement politically acceptable. I sincerely hope so, but I don't control health care costs.
> It's correct because the present system is set up that way. But this doesn't mean it must be that way, or that insurance requires a large pool of clients with the same policy and coverage. That's a coincidence.
No, it is not.
> From the standpoint of a large publicly-held corporation, many clients with identical policies, or many clients each with unique personal policies, work internally exactly the same way -- it's all about actuaries assessing risk and setting rates.
The economy exists to serve people, not the other way round. The only acceptable system is one that allows people with chronic illnesses to get coverage like everyone else, and for an affordable price. The only effective way to prevent commercial insurers to refuse coverage to such people is to not allow them to issue personal policies.
>> It's correct because the present system is set up that way. But this doesn't mean it must be that way, or that insurance requires a large pool of clients with the same policy and coverage. That's a coincidence.
> No, it is not.
It is a coincidence, and many insurance companies write policies that apply to only one person. They can do this because a large pool of people, all with the same policy, is not essential for the system to work. Example:
A quote: "America Ferrera is the newest addition to the list of stars who have some of their body parts insured. Famous for her role as Betty Suarez in the top-rating ABC sitcom "Ugly Betty", Ferrera has had her smile insured for 10 million dollars by Lloyds of London."
One person, one smile, one client, one policy.
> The economy exists to serve people, not the other way round.
Please, to discuss that topic, start a new thread. It has precisely nothing to do with present topic, which is how insurance companies work.
the issuer is betting that the applicant won't suffer a
loss, the applicant is betting that he will. An actuary
sets the rate based on his best guess about the
possibility of a claim.
Emphatically: no! The issuer is betting that in the entire group of clients the total loss will be smaller than the rates they set. Almost nobody can ever financially deal with the greatest risk health insurance insures against. Health insurance is almost never about amortizing your own risk. It is about insuring against risks you couldn't possibly deal with otherwise. Almost nobody can pay for a long stay on the IC after an accident, with months of rehabilitation afterwards. When you need the insurance, it's the money of the other clients, that with hindsight never needed the insurance, that pays for your costs.
Of course obligatory health insurance is pure socialism (not in the pure 'political movement' sense of the word, but in the 'common usage' sense of the word, meaning forced sharing of a population's resources for a specific greater good) and thank God for it. I'll take my Western European social democracy over your government any day. I gladly pay taxes to have it this way.
> When you need the insurance, it's the money of the other clients, that with hindsight never needed the insurance, that pays for your costs.
This is the normal approach, but it's a coincidence -- the insurance system doesn't collapse if it's not the model. Insurance can equally be a case of one policy, one client, all depending on what's being insured -- see below.
> Emphatically: no! The issuer is betting that in the entire group of clients the total loss will be smaller than the rates they set.
My point is that system works with one client the same way as with 10,000. It's a matter of accurately assessing the risk of a claim. Insurance doesn't suddenly stop working because there are few clients or only one client.
Multiple clients is the usual case, but it's not required for the system to work. Large insurance houses will very happily write a policy that only applies to one person:
A quote: "America Ferrera is the newest addition to the list of stars who have some of their body parts insured. Famous for her role as Betty Suarez in the top-rating ABC sitcom "Ugly Betty", Ferrera has had her smile insured for 10 million dollars by Lloyds of London."
No, Lloyds of London have huge numbers of clients. There is not one person / group of people who will personally lose a huge amount of money if that pays out. The money will come from someone else's car insurance not paying out.
Then please, for the sake of the public good, do the following:
Don't drive on the roads.
Do put out your own fires if you house catches fire.
Do hire private police for your security.
Don't use public transportation.
Don't use the Internet (including HN).
Don't use, or have your children use public schooling.
Do pay completely, without subsidy or federal grant, for all your higher education.
Pay for a septic tank if available, or do not use public sewers.
Don't drink water from city water.
Better yet, don't drink water at all: EPA endorses cleaner environmental health.
Don't eat food unless you grew it: All food is inspected by FDA.
Better yet, just go buy a boat and live in the ocean. And don't come back.
You're right. Clearly because I don't want socialism it means I want 100% anarchy and no government whatsoever. That doesn't follow at all. You also added several things in there that the government doesn't provide, so I'm just really confused by this comment.
(side note I could probably get by without almost everything on this list except for food and roads. I'm disregarding internet, as the gov't doesn't provide that).
Don't drive on the roads. -do want roads, those the gov't should provide
Do put out your own fires if you house catches fire. - i have a sprinkler system installed so it's unlikely I'll need them. I suspect I could get private insurance to cover this though in a free-market. pay small money into pool (just like taxes) and we can all have firemen without your government. Also, if you don't live in a city, it is very possible that there are no firefighters who will come to your house.
Do hire private police for your security. - Police are nice for keeping things relatively civil, but most of the time they are minutes away when you have a few seconds of need. They come and do paperwork about the thing that happened to you that they couldn't stop.
Don't use public transportation. - i don't
Don't use the Internet (including HN). - since when did the gov't start providing me internet? I should really stop paying charter to provide it for me.
Don't use, or have your children use public schooling. - i think our public schools are pathetic, and I'm seriously considering home schooling.
Do pay completely, without subsidy or federal grant, for all your higher education. - i did. I probably helped pay for yours though with my taxes too.
Pay for a septic tank if available, or do not use public sewers. - no problem. will do.
Don't drink water from city water. - city water mostly sucks. I have to filter it anyways, I might as well filter water from a well.
Better yet, don't drink water at all: EPA endorses cleaner environmental health. - I could do with less from the EPA.
Don't eat food unless you grew it: All food is inspected by FDA. - I could also do with less FDA. Turns out Kroger has a vested interest in not poisoning me. It's likely I'll start going to Publix if they do.
> Turns out Kroger has a vested interest in not poisoning me.
Are you sue? Last time I checked, Kroger had a vested interest in getting your money. If you get cancer in 10 years and your children get born with deformities it doesn't matter for them. They've already got your money and good luck proving it was them doing it and not WalMart.
> I suspect I could get private insurance to cover this though in a free-market.
Make sure to also buy "bring you back from the dead" insurance you might need that too.
> Don't drive on the roads. -do want roads, those the gov't should provide
Why? What's your justification? There are actually private highways and roads in this country and make good money off of people driving on them. They are expensive but usually well maintained. Why roads and not say a rescue squad?
> I could do with less from the EPA.
You make your own lead and pesticide testing kits? Are you going around to every grocery store and test every single product for bio , chemical and radiological safety?
> Police are nice for keeping things relatively civil?
So no police then. Alright. So when you abolish them let me know so my local militia friends can come and raid your house.
"Do put out your own fires if you house catches fire. - i have a sprinkler system installed so it's unlikely I'll need them."
Haha. Sorry. As a Firefighter, you're very wrong. It'll definitely help, no doubt. But most commercial buildings today have sprinkler systems, and they burn.
"I suspect I could get private insurance to cover this though in a free-market. pay small money into pool (just like taxes) and we can all have firemen without your government."
Plenty of places do this. And it's an unregulated market. With sometimes horrific consequences. Grant's Pass, Oregon, for one, with three fire companies. Make sure you do your research - you don't want to get the company that has an engines with insuffient GPM capacity, or doesn't have sufficient tenders/tankers if you don't live in a hydranted community. Make sure their firefighters are all accredited (there is both an art and a science to it). Make sure they have SCBA so they can go inside your burning building (or your neighbors, who might cause a risk to yours). These are things you think should be obvious, but are not.
"Also, if you don't live in a city, it is very possible that there are no firefighters who will come to your house."
Most such areas also have a volunteer firefighter presence.
Hospitals often bill 5x-10x actual costs to make up for the "discounts" that insurance companies force upon them. If you're uninsured and get hit by a huge bill, you need to negotiate with the hospital to bring the amount down. Doubly so, because hospitals have lax tracking of costs, and no one really knows how much your visit really cost. More about this from an actual MD:
http://truecostofhealthcare.org/hospital_billing
I'd be more for using informed consent laws to argue that you would not have proceeded with treatment had you known how much it cost, or the costs related to failure of procedure.
Our medical system is the worst of capitalism, and the worst of socialism. Tell me again: Where are the prices?
This is putting things exactly backwards. The argument is roughly "Treating a minor condition cost $24k, which could wipe people out financially, therefore PPACA is important."
Where is the outrage over this price? What part of PPACA does ANYTHING to reduce this cost? PPACA does essentially 2 things: 1) It makes insurance "affordable" for people who previously couldn't obtain it at all. 2) Drastically increases demand for health care, without adding to supply or controlling costs any other way.
Insurance is simply a distribution of cost over a risk pool. If relatively mundane life happenings cost $24k, and nothing is being done to fix that, we're in real trouble, and I think we are.
Nothing done to increase the pool of doctors. Nothing done to control medical lawsuit costs, which transfer money from the insurance pool to individuals. Nothing done to control the cost of drugs (and in some cases, aggravated by making more expensive drugs "free").
Bring the cost down to $2,400 and "wiping people out" isn't as big a concern.
We probably don't so much need to deal with malpractice insurance, since that fix doesn't (to employ a congenial metaphor) change the exponent in the Big-O cost of health care.
We need to make it simpler to get drugs on the market, but we also need to walk the tightrope of doing that while regulating pharma marketing, particularly to medical practices.
We need to restructure care in the US. We recognize that the E.R. is a terrible provider-of-first-resort and that non-emergency E.R. visits are damaging the system. We need to start realizing that M.D. doctors are also poor providers of first resort, and get a nationwide system of low-cost clinics deployed. That's already starting to happen at places like Walgreens.
We very much need to figure out how to start exploiting the Internet to provide some level of routine care for patients.
These are all things that do need to happen. But they don't have much to do with the problem that insurance problems are randomly bankrupting large numbers of Americans. We need to fix that problem first. Face it: the most expensive cohort of patients in the US, accounting for by far the majority of our exposure to rising medical costs, have had socialized single-payer health care for decades. Access to private insurance and the "cost curve" of health care are simply orthogonal problems.
I think we really would do best to attack the cost explosion problem at the same time we attack the coverage problem. Fixing the coverage problem is mostly a matter of political will (granted that the opposition has been bitter). Getting costs under control requires far-reaching changes to the health care system itself and will take years at best.
It wasn't a minor condition. It was a staph infection. Don't let the term bugbite mislead you. His son wasn't in the hospital for a bugbite. He was in the hospital for a life threatening infection from an antibiotic resistant infection. That is far from minor.
Disclaimer: I'm not arguing for PPACA in any way but if you are going to base you argument on billing for a "minor" condition then make sure it's actually a minor condition.
So... MRSA Staph Infection... what is the cost to correctly diagnose? And what is the cost of the antibiotics?
I'm not a doctor, but most non-boutique antibiotics are dirt cheap.
I didn't intend to trivialize the illness. I more meant that this could happen to _anyone_. And if this is the cost for things that can happen to anyone, we have a real problem on our hands. Much like it's a problem that a basic, no-complications, baby delivery costs $15-20k.
Insurance is math, and the math gets scary quickly unless costs are controlled.
It's more than just diagnoses and antibiotics. It's monitoring the child for 2+ days. And broad spectrum antibiotics than can kill resistant staph infections I imagine aren't cheap either. Not to mention you can't just administer them. You have to monitor their effect continuously to make sure they actually are having an effect.
As to happening to anyone yes in the same way that anyone could get hit by a car. It's a rare occurrence. most people will not be getting staph from a bug bite. It's totally possible that 23k is an egregious amount to bill for his treatment but I think you are going about making that argument from the wrong position.
Are you capable of diagnosing an MRSA Staph infection? What all exactly is involved in diagnosing it? Looking at it? or do you need complicated lab tests? Does it require a consult with someone who specializes in infectious diseases or can just anyone do it? How do you dispose of medical waste from treatment? Are there any complicated regulations that increase the cost there?
All of these questions should be what fuels the debate around medical billing. The fact that you as a patient have very little visibility into all of that is in my mind the issue.
Arguing about how anyone could be hit with life threatening illness or injury is a potent and emotional distraction.
> but most non-boutique antibiotics are dirt cheap
The whole problem with MRSA is that you need boutique antibiotics to treat it! You don't have to be a doctor to know that, by the way; Wikipedia will tell you that part.
Agreed with you on the baby delivery part. Though it only costs that much in a hospital. In states where alternate arrangements involving a midwife are legal (not Illinois!) the cost can be much more reasonable for a no-complications birth.
From the article, at least a two day hospital stay, IV, antibiotics, the time of the nurses checking in on him, the doctor(s) rounding on him, and the orderlies and cleaning staff keeping the place clean. Staying in the hospital is not cheap.
The question no one ever asks is "why is the bill $23,000?". The only question that ever gets asked is "who should pay this $23,000 bill?". I charge $200/hr for my time at a minimum. Did this child really receive an equivalent of 2.8 weeks of my time in services? Or did an unecessary middle man negotiate ridiculous prices with the provider, leaving the consumer out of the equation but responsible for the bill? And yet people seem to think that more unnecessary middlemen will make the situation better.
You can figure try to figure out the "why" for specific cases but it's tedious work and comes down to subjective opinions that can't be generalized to other cases. The theoretical worth of the shadowy middlemen (whether they gov't or insurance companies) and where the blame lies can be debated. All these arguments rely upon theoretical simplifications of very complex systems--meaning they are almost impossible to model.
What's more important is the "what" as in what are our alternatives. Luckily, we have tons of empirical data from other countries and they all tell the same story: America pays more money, with poorer results.
So why not just copy the models of other countries?
After 15min ER due to a strained wrist the bill was $4100 dollars. We demanded detailed itemized bills and send letters to the doctor (billed separately) and the hospital. The doctor dropped his bill from ridiculous $900 dollars (for saying everything was alright and taking 5 mins to open a tiff file on his computer) to $200 after our complaint. His bill and the hospital had up-coded our visit and tried to hide the costs of their ill-managed hospital by billing a piece of cloth (made in Guatemala) with $500, the price of an iPad.
Really? Nobody ever asks? Whenever the subject of American hospitalization comes up, the question of why the bills are so insanely high is pretty much the only question people ask!
I'm a Canadian who owes tens of thousands because I had an emergency operation in a different province (BC) from where I have my health card (Ontario).
Curious. It seems either Canadian healthcare isn't the panacea we Americans think it is or there a number of Canadians who post here that don't know about their plans.
My thought is the situation is analogous to each US state and their safety net medical programs. Means based? Is this correct?
As far as I can tell (some reading, some 2nd-hand stories) Canadian healthcare is not a good model at all. It may be better than the US, but that's faint praise. I'd look to the French, Swiss, or Scandinavian systems for better models.
I'm pretty sure OHIP will cover your health expenses, but at the Ontario-based care rates.. You just have to submit receipts to OHIP. Everything extra would be out of pocket, and I see how that could be pricey.
I lived in Canada for 10 years. I left precisely because of the awful healthcare being denied my son, despite laws stating to the contrary. My son suffers because so-called medical professionals sat on his case (Autism) for more than a year, with excuse after excuse, problem after problem. Some of the people blamed budget issues, others lied, others through sheer incompetence. I'm not exaggerating. There is nothing that will piss you off more than being lied to by multiple people from one of Montreal's "leading" children's hospitals.
My wife is Canadian. She was just as fearful hearing the stories, and loved Canada's health care. Until we needed it, and it failed our son.
He got more help in the first 2 weeks here in Pennsylvania then he got in Canada after more than a year of fighting to get every bit of care he could get. Do you know what it was like being told of the additional challenges he would face because he didn't get help when he was first diagnosed (1 1/2 years). Now my second son is getting tested, as he might be autistic as well. But the process is massively different. He will do much better, and the system is already working for him. The cost to us? Nothing. Not a dime, and not because I have insurance. It's provided, by the state. I pay less now then I was paying before for my health care. Sorry, but the taxes in Quebec are steep, and everything gets taxed.
I've said it before, and I'll say it again: it was nothing more than child abuse. My son suffered because the system failed him willingly. Knowingly. They knowingly harmed him, and others like him (I kid you not, the government mandated what effectively is abuse).
If you choose to have children in Quebec, good luck. If they have special needs, flee. Do not wait and try to work with the system. Leave as soon as you can. Do not wait. I wish someone had told me that.
Edit: At the time (and I imagine it's still the case) the law required he be given help within 3 months. This couldn't happen, because of budget issues we were told. These budget issues were set by the government, in part, because they don't believe in science. The politicians voted to limit the budget for autism cases to, iirc, around $20 million. This is despite the fact that all the research points to early intervention being critical. If he'd gotten help at 1 1/2 years old, or at least within the time dictated by the law, he would be far more along then he is now.
So no. No respect for a government that places government mandated culture ahead of the health and well being of its citizenry.
Canada is a single-payer health care system. A common problem with single-payer health care systems is access to specialty care. It is indeed tragic to care for someone you know is sick while being stuck in multi-week delays waiting for a doctor who can actually help.
It's also true that this is not one of America's big problems. Now, our specialists will bankrupt you, that's true, but you will actually get to see them pretty quickly.
Like Switzerland's system, the PPACA guaranteed-issue/mandatory-coverage system is potentially a best-of-both-worlds solution. The market for health insurance stays private, modulo federal (contentious, bureaucratic definitions of "minimum care" to qualify plans), but consumer costs are predictable.
> It is indeed tragic to care for someone you know is sick while being stuck in multi-week delays waiting for a doctor who can actually help.
It's not even waiting that is the problem. The quality is down right shoddy at best. Doctors flat out lied to us. We had doctors recommending committing our son to a home because "you can get on with your life." At one point, we had our son get approved after waiting 6 months to get into a special program that would help him. That was a wonderful day.
That afternoon, I shit you not, we get a call again from the same place, and they say "Oh, I'm sorry, we can't take him. He has autism, and we don't take children with autism."
I understand their are problems with the US system. I'm not blind to the issues. But people like to prop up Canada's system as something that works.
It was child abuse. It's hard to explain. I firmly believe that Quebec should shut down it's autism support, and stop pretending to care. At least then parents will know they had better leave. Every day makes a difference. If I'd known earlier, if I hadn't waited...
Years. Years of waiting. A system that requires that is a failure, pitiful, evil system.
I'm Canadian but lets be realistic, there are many things that would cause serious financial hardship due to medical costs in Canada. A friend of mine right now is suffering through intense pain from her teeth that aren't being fixed because she doesn't have money/insurance. She's deciding between healthcare and money.
You can also lose your life on a waiting list in Canada. Not much purpose in having $23K in the bank but being dead.
For sure you're not going to get a $23K bill for a bug bite but you will pay $3000/month for chemo, etc. Lots of things aren't covered by medicare, and they're quite expensive. Canada is more like a $23K bill for getting cancer, or other long term/terminal illnesses.
Edit: OP added a ninja-edit to his comment that included the part about teeth-pain... as my link explains, non-emergency dentalcare is not covered by default.
Yes, I'm aware of PharmaCare. Sure, they theoretically cover insulin; but if you read the fine print about which insulins they cover, it's not so helpful.
An example of their craziness: They cover insulin pumps for children under 18, but they don't cover the types of insulin which work in insulin pumps.
You linked to a provincial health service for B.C. residents. That's not Canadian coverage and I don't see where it says that medication is covered.
Most citizens in Canada don't have free (or reduced cost) medication unless they are below the poverty line.
I came out of the hospital with an $800/month medication bill after a diagnosis of colitis, after missing 2 months of work being bed-ridden, while self-employed with no personal health insurance.
In the USA (don't have stats for Canada) there were 4 billion medication prescriptions written by doctors in the USA... in 2011 alone. That equals 13.3 per person (w/ 300 million population) and around $4 billion dollars. Most of those medication bills go to people will serious chronic illnesses and can easily cost >$1000/month.
The effect of paying for medication on a persons financial stability can't be discredited in this discussion.
> You linked to a provincial health service for B.C. residents. That's not Canadian coverage and I don't see where it says that medication is covered.
Your profile says your in Toronto did you recently move from the states? The Canadian constitution divided healthcare into a the provincial area of responsibility.[1]
> Most citizens in Canada don't have free (or reduced cost) medication unless they are below the poverty line.
Might not appear so to you but most are a reduced price. Relevant quote "A Canadian law authorizes a review board to order a price reduction whenever the price of a drug exceeds the median of the prices in six European countries plus the United States."[2]
I think you've misread my comment. I said prescription medication is not covered by Canadian healthcare, except for some provincial policies which cover some low-income families.
Price control for medication != free medication for Canadians or the removal of the burden of paying for medication for people with a serious health condition, which can still be significant. Which was the original point of the OP (in addition to the cost of dental work).
Every time a healthcare discussion comes up and everyone gets derailed on whether (or how much) to socialize things, I wonder the following:
from a technology, taxation, and moral standpoint, what the hell led to a system where some heavy-duty antibiotics cost about 10-15X what they should? More importantly, why do generally intellegent audiences get caught up in arguments over socialism rather than correcting the cost issue first? Is it sue-happy lawyers, is is an anti-competitive marketplace, or is it the pushing of the very concept of insurance that has given us such an unsustainable system?
I truly want to put out a call to geeks: for every healthcare dollar you spend, grill your provider. Haggle them down, and make them justify the price, or we're all screwed, no matter who is paying for things.
The reason is simple. Many folks, myself included, hold the view that it is government intervention that has led to the insane system currently in place. Eliminating the perverse healthcare system forced on us by current policy IS the way to control the cost issue.
Most other industrialized countries have heavy government involvement and pay half what we do with the same outcomes. We just have a hybrid system with capitalism applied in the stupidest way..
This statement sounds totally odd to me on both ends.
First, the US pays more in a lot of markets. By and large, that's because we can.
Second, capitalism isn't applied. That sounds like it's some sort of regulatory tool that just isn't being used correctly. Capitalism is the absence of government force in an economic market with the notable exception of enforcing private property rights. You can say a lot about the US healthcare situation, but "applied capitalism" it is not.
> Most other industrialized countries have heavy government involvement and pay half what we do with the same outcomes.
I lived in Canada for 10 years. I live in the US now. While living in Canada, I paid more to the government then I pay now. My health care costs for myself and my family are much cheaper. In fact, ignoring the costs of insurance (which was effectively the same) and taxes (which were 3 times higher in Canada, and on everything), my costs for equal service I receive now would have been more than $36,000 more in Canada. That's partly a lie though. The services would not have been equal, as we can get home care here, whereas in Canada, we could not.
This also ignores the 1-2 year waiting list for private care we would have had to deal with in Canada. In the US, we had treatment started within 2 weeks of moving here.
Well, if you want dueling anecdotes, I lived in the U.S. for years, and now live in Denmark, and I pay much less for healthcare coverage now. My sole healthcare expense now is 8% of my salary that goes to the flat health-system tax, whereas in the U.S. I not only had to pay Medicare taxes and general income taxes that supported various kinds of healthcare, but also had to pay a large copay. And, my coverage was tied to my employment, which it isn't anymore.
You make an assertion that the heavy duty antibiotics cost 10-15x what they should? How do you know what they should cost?
- How much money did it take to develop them? (Count the failures in your estimate)
- What is the supply vs demand for them? (demand is probably low since you don't want to use these unless you really need to)
- What's the shelf life for them.
- Do hospitals have to toss them if they don't get used?
- Do they have to keep them on hand or can they be Just In Time manufactured and delivered in an emergency?
As others have said here the real problem is lack of transparency into these issues. Speculating about what the cost of antibiotics should be only adds to the cloud of misinformation around medical billing.
I agree though that demanding more transparency is a good thing.
Reminds me of my kid's $6000 bump on the head. Or the time I had and knee operation and they took five minutes extra to clean out something they spotted and added $3500 to the bill. Or the eye operation where they took fifteen minutes extra because there was a detached retina adding $9000 to the bill. (Insurance wouldn't pay that one. They never said why either.)
You are not exactly going to negotiate at moments like these.
Insurance companies make more money if they refuse payment.
I've always liked the old Chinese medicine system. You find a doctor who is willing to take you as a client. You pay the doctor money per month when you are well. If you are sick, you do not pay. Of course, refusing treatment is acceptable to get you disqualified, as are a few other things.
This is why I think even if you are in favor of socialized health care, you really ought to be against the PPAFA. It's not "socialized health care", the glorious ideal you have in your head where everybody takes care of everybody and it's all smiles everywhere. It's an ungodly abomination of a thousand pages of hastily thrown together legislation with a bajillion moving parts, dozens of newly created agencies, what is basically gibberish in terms of who is paying for what driven more by what voters needed to hear than any resemblance to reality, and then after all of that, was brutally beaten by the legislative process until it could barely assemble a coalition to drag it across the finish line in a horrifically compromised state.
Trying to explain why this is a good idea and trying to explain why socialized health care is a good idea are two things that should not be done at the same time. If you think it's bizarre how many people aren't buying into the whole nothing-but-smiles theme now, wait until after a few years of experience with this turd.
The whole "Oh, the monstrous heartless conservatives just want to throw granny over the cliff so they can save a buck" is just a propaganda smokescreen put up so you don't look too much at the actual product you're pitching beyond the catchphrase level. Personally I feel some people are being pretty careless about what will actually happen to real people while they are moving abstract political footballs labelled "socialized healthcare" around without caring what's behind the abstraction. I know the abstract progress may feel good today, but the reality isn't going to stay behind the abstraction boundary.
I don't really support the outcome (I want real socialized healthcare), but as far as I can tell PPACA is at least better than the status quo. It seems like it'll make it possible to buy individual health insurance, which will actually cover healthcare, and won't be jacked up when you get sick. That's at least one improvement over the current system, which is completely broken unless you're in a quasi-socialized health-coverage pool, like those provided by large corporations' group plans.
The US federal government spent more on healthcare last year than the UK government did, despite the fact that federal programs in the US cover 27.8% of the population compared to 100% coverage by the NHS in the UK.
> We’ve got a strategy for dealing with the COBRA expiration, but it’s complicated and requires a lot of hoop jumping and is more than a little silly.
Whatever the author's strategy is, it sounds like he's quite misinformed. There are no hoops required to get HIPAA guaranteed issue coverage when COBRA runs out. All insurers are required to offer it regardless of preexisting conditions. It will cost more, but coverage is automatic with no medical information required.
The usual procedure is to simultaneously apply for underwritten coverage and guaranteed issue. If the underwritten policy is declined, the guaranteed issue takes effect. If you know you'll be declined, you can skip the medical history on the application and apply for guaranteed issue only. You have 60 days after COBRA runs out to apply.
You are also eligible if your insurance ends because the company goes out of business without making COBRA available.
Any insurance company or agent can give you more information, or search for:
I don't think kidney stones are really going to get someone denied for insurance. There is no reason I should have to pay for your healthcare. I pay for my healthcare. You pay for your own damn healthcare. (note that I am self employed and had no problems getting a high deductible health plan).
Now if when you say you are short and stout (or however you worded it) you actually mean you are 500 pounds and obese, then get on treadmill. Absolutely no reason I should have to pay for your healthcare because of your poor life decisions.
Naïve European who'd pay nothing for this here (ok, taxes, but supposedly we still pay fewer % of our GDP overall) with a question:
I’ll have to have to pay less than 6% of that, because I’m lucky enough to still have insurance.
Why? If you have insurance, shouldn't that cover the whole expense? Or is it a bit like an excess on a car insurance policy? Can you get insurance that covers everything?
Did you ever have car insurance or any other kind of insurance? Most insurances have deductibles, and the point of that is that insurance is to prevent catastrophic loss, not every expense. There can be insurance that covers 100% of expenses, but it will be very expensive, especially for health, as it won't be insurance at all.
Imagine that 1000 people pay each $100 into insurance pool. Then if somebody has a problem there's $100000 available for him, and if the chance of this problem is 1/1000, then this works. Now imagine each of these people has $50 in regular expenses that they want to be paid from the same pool. Then to get the same coverage one needs either to pay additional $50 into the pool (which then is not insurance but just a very expensive savings account) or accept that his coverage dropped by half. And that's not counting insurance company's cut, which makes it worse.
Did you ever have car insurance or any other kind of insurance?
Yes. I go with the largest excess possible (what I assume is also called a deductible) because the chance of making a claim is low. But it's only 10-20% more to have no excess at all.
The logic in your second paragraph makes sense on the surface, but the lack of a deductible in many European-style health systems doesn't seem to result in a larger share of GDP being spent on health (which is notoriously high in the US) or the healthcare being of a lower quality.
The difference between medical & car insurance is certainity of small expenses. If your insurance covered regular maintenance of the car, it would be substantially more expensive.
This thread has a lot of socialism vs free-market talk, but the real problem with American health care is the lack of transparency, and the middle-man, be it government or insurance doesn't change that. We have so many pointless things done, and the prices are not known ahead of time. Unless we are talking about life and death, the cost of the procedure you are doing to me should be known before I decide whether I want it or not. The number on the bill also isn't ever really the bill. The insurance company or government negotiating says no I won't pay that amount, this is the real amount you should be charging so we are going to pay this. Doctors and hospitals charge X because that is what insurance companies and government decided they would pay.
If you were negotiating this care for yourself, you could almost certainly get it cheaper (as you have a much bigger vested interest in your savings account than the government etc does), and we would not get nearly as many unneeded procedures done. Most of the time it's not even a question, and it should be. They don't say, we think maybe you should have this done and this is why. They say, we're going to do a X. Maybe they tell you why, if you ask them, otherwise it's just assumed that since I'm sick I should do what they say.
I broke my arm a few years ago playing softball. I had an extra 90 degree angle in my arm. People in the bleachers heard it snap. It was 100% broken no question about it. The hospital wouldn't give me any pain killers until they had an x-ray to see if it was broken or not. Now I suspect getting an x-ray is useful for the guy doing the surgery to fix it, and he did several as well, but there was 0 reason for the x-ray in the emergency room. It cost me (and the insurance company) money, it wasted valuable time for the nurses/doctors who could have been onto the next patient sooner, and most important it made me absolutely miserable for another hour waiting on it when all i needed was some pain killers and nice splint until I could have the surgery.
Socialism doesn't solve this problem. It just makes you pay for my x-ray.
The bill would be much higher if he paid with cash than if he paid with insurance. I'm curious to know how much. I expect would be at least 3x the amount the insurance company must pay.
Im interested how people feel about hacking the ER. I personally have never had to do it but I know quite a few people who will give fake names and social security numbers to avoid such situations. Obviously this makes it more expensive for everyone else and one could argue the Affordable Care Act is a way to fix this security whole as much as anything. Morally if you're stuck between lying to a doctor and losing your child's college fund what is the best choice really?
The people who think the US health care world is A-OK are the people who have never been uninsured nor been uninsurable. As much as I want to build my own company, my life and job revolve around my ability to get insurance because I had the gaul to have surgery once upon a time.
People should not expect something for nothing, but there has to be a better place than we are at now. Because this place sucks!
> an accident or a disease or any of a billion other random, faultless happenstances — isn’t going to send them to the poor house.
What is he talking about? It doesn't make sense. He complains about high costs. Then he praises the health care act but I don't see how health care act controls costs. Not having a single payer option, not having cost controls make it a stupid and broken.
The (big) problem isn't really that there are people who may or may not have insurance to protect them from 24 kilobuck bug bites, its that we've let so much friction build up in our system that it has come to cost this much to treat even simple maladies.
We're so busy worrying about who should pay what we don't ask the big one: why the hell does it cost so much in the first place?
Silly americans... in my country, it's obligatory to have health insurance and if you cannot afford it, the government will pay your insurance, for god's sake. Not even the most conservative and right-wing politicans who see our freedom in danger when we can't keep fully automatic assault rifles at home anymorehere question this system, because it just makes sense.
Can someone please explain to me the purpose of an insurance company when participation in the pool is mandatory? A policy like this seems like it creates a legislated middle-man that just wastes money.
Participation in the automobile risk pool is mandatory in all 50 states, even in states with no-fault accident laws. Nobody questions whether auto insurance companies are really insurers. Similarly, while huge companies aren't required to insure their commercial activities, virtually all of them do.
Mandatory coverage is orthogonal to the question of whether health insurance is a proper insurance scheme, or some kind of social safety net entitlement, or a utility. The sole purpose of the mandate is to make free-riding on the insurance market unlawful; it's a mitigation for an asymmetric information problem.
Oh, so you mean, "only if you don't live and work in one of a prohibitively small number of major metro areas in the US".
For all intents and purposes, auto insurance is effectively mandatory for most Americans. It's for a similar reason that many states revoke driving privileges for parents who don't comply with child support.
You have to own a car, though. The state makes you buy car insurance because you can do a lot of damage to other people and their property with a car. They own the roads, so they're responsible for making sure you can pay for that damage.
Texas, for instance, doesn't actually make you buy insurance. You only have to prove that you can be financially responsible for the damage you could cause [1].
Why is this relevant? You made the claim that "The sole purpose of the mandate is to make free-riding on the insurance market unlawful"
The medically uninsured only pose a financial threat to themselves. It's only through laws that make taxpayers responsible for the medical costs of the uninsured that they pose a threat to the rest of us. This mandate won't change anything in that respect. It will just make the line from taxpayer money to person who can't pay for his medical bills harder to follow.
The laws making the rest of us responsible for the uninsured aren't really optional, so it's probably better to just reason about this problem as if the uninsured were just intrinsically a financial risk to us.
Some kind of organization is going to perform the task of paying money for medical bills: figuring out which medical bills to pay and trying to get lower prices. It can be part of the state or it can a separate corporation; both kinds have historically shown the capacity to waste money.
"Middle man" isn't a dirty word. The health care deals you get in the US are much better with the middle man than without the middle man. Since the insurance companies have so much power, they can (and do) negotiate better rates with health care providers. The cost of paying for your own health care is shockingly high by comparison to the rates the insurance companies would pay on your behalf.
Theoretically, it could produce competition between the insurance companies. Sure, you have to buy insurance from someone, but do you want to buy it from the company which has more doctors close to where you live, or the one which pays for PSA blood tests? Maybe one company only pays for you to visit your GP when you're sick, while another decides that they can save money by encouraging you to get regular checkups and catch problems before they become more serious.
I don't know if this sort of story actually plays out -- I live in a country where the only way to get better health care is to move to a different province -- but it doesn't seem completely implausible.
I believe the theory goes that the administration expenses incurred by the operation of managing healthcare would be incurred either way, i.e. if the insurance companies were not managing distribution of healthcare the government would have to. Given that, allowing the private sector to compete allows capitalist dynamics to drive down the cost.
While both government and private companies are both theoretically incented to drive down costs, practically there is a lot more scope for government to operate the plans in an inefficient way without consequence; on the other hand private companies are primarily incentivised by profit, which does not always correlate with the most efficient way of delivering healthcare.
This is where the nuance kicks in (i.e. big government or small government); a well run government plan would better but leaning on the private sector is a hedge against poor management.
That's exactly what it creates. The obvious strategy here is, "baby steps". The insurance lobby is ferociously powerful. They only accepted the PPACA (with many provisions which hurt their profits) because of the quid-pro-quo with the mandate.
The provision of the law which stipulates companies must spend 80-85% of premium revenues on healthcare expenses are an obvious giveaway: "you're allowed to make only this much money".
The next steps, after this is settled law (i.e., Republicans stop trying to repeal it), are to narrow those margins, then introduce a national healthcare system for everyone which these insurers must compete with.
It makes even more sense than a single-payer system (which eschews the benefits of competition), but you can bet there will be continuing political drama over healthcare for the foreseeable future...
You're subsidizing risk across a large group of people. The chances of something happen to an individual are small, but could be financially devastating. So everyone pools their risk together for affordable premiums.
Not sure if you are joking. Having everyone inside the pool makes up for members with chronical illnesses and other illnesses that need a lot of care. Some still healthy young poeple pay maybe a little bit more but everyone can be treated reasonably well. If you run an insurance without mandatory participation people with problematic illnesses are a risky for the business and that is one reason why the op can't get an insurance in the USA.
I think the point retillit is trying to make is, why even bother with private insurance companies if insurance is compulsory? Which is a good question.
The answer, I think, is partially politics, but also partly whether you think the competition a system like this (in theory) encourages outweighs the cost of profits.
Mandatory participation (of insurance clients) is the necessary other side of mandatory acceptance (of clients by insurance companies).
For health insurance to work as insurance you need the young and healthy to participate and pay more than they'll ever get out of the system, otherwise it's impossible to cover the costs for the old and chronically ill.
I think we have to start with the American Medical Association. It is in their interests to keep prices high and keep doctors in their McMansions. First follow the money, who benefits from high prices? Insurance companies, medical suppliers, and the American Medical Association gets to enforce the medical monopoly.
Even with insurance it cost $1400 for a bug bite? I just had a baby (my wife) and we paid $40 for a private room. This is pretty much why I will never live in the USA. Which is unfortunate because I do like the country and could see myself living there except for this.
Maybe if you're in your 20s and were lucky enough to have no childhood health conditions. In the real world, that isn't the case for many people. How much does individual health insurance cost if you were born with a congenital heart defect? Or if you were diagnosed as a child with autism?
You know what's a huge barrier to entrepreneurship? Needing the insurance that comes with a BigCo job, so you're not ruined financially when your kid gets bit by a bug. I know many people who have this explicit rationale for not founding or joining a startup.
Then they are grossly misunderstanding relative risks and shouldn't be launching their own startup.
And its terrible reasoning. Existing law already provides for cobra, giving them an 18 month window of coverage in which they can retain your employer's insurance (by paying the full premiums). That's more than enough time to validate an idea and secure insurance in the new company, or fail and spend 6 months finding a new job. Or if you are an engineer, 1 month finding a new job.
sure, if you are using the "build a prototype, get investment, move from there" model... that's fine.
Personally, I think bootstrapping, taking no outside investment at all is also a completely reasonable model (and often ends up with a more sustainable business, and can be executed by people that lack the sales skills to get investment)
If you are bootstrapping? 18 months is not a reasonable period of time to get something to the point where you can get group coverage. (In most states, to get group coverage, you need at least two employees on that insurance.)
also, I think it's quite valid to support yourself doing contract work. same problem; if you don't want a body shop to take half your pay, well, you need two employees before you can get group coverage.
My company bootstrapped and we just initiated a group policy 13 months after our doors opened. This is, of course, anecdotal, but I think it's very well in the realm of possibility. Regardless, even in states like CA high-deductible plans (i.e. catastrophic care plans) are very much attainable both by small businesses and by individuals.
Contractors in the US get hit with a fairly sizable self-employment tax. This tax would no doubt go up to fund any sort of universal health insurance.
Regardless, I don't see the need to 'scratch your entrepreneurial itch' as a valid reason to stick you neighbor with your medical bills.
>Regardless, I don't see the need to 'scratch your entrepreneurial itch' as a valid reason to stick you neighbor with your medical bills.
Problem is that with two employees, you can get a group plan, and yeah,you've gotta pay your five hundred bucks per person a month or what have you, it's not cheap, but you can buy insurance.
My problem is that two employee minimum. I mean, am I that much lower of a risk because I work at a company with two employees, rather than just one? sounds unlikely.
By relative risks you mean the possibility that an event occurs that requires medical care?
If so, there are many cases where a founder or their family member has a pre-existing condition that makes them uninsurable. If someone loses the genetic lottery and has a severe case of asthma it can greatly change their calculus. Would you advise someone to start a company if they knew that in 12 months they'd have to hit it big or give up due to the prospect of future medical bills?
No, sir, it's not inappropriate. The cost of health care is a major cost to most businesses. Startups are lucky that the investors bear the cost; but it shows up as a major line item, second only to salaries, in the typical startup's pro forma expense budget. You could probably stretch your first round 15% further timewise if you could get employees without buying them health insurance.
I agree. Normally when this happens, I just comment on the user's blog and then go from there. If they wish to engage in a debate then fine.
Unfortunately, you can't comment on his blog, which makes it even worse. Now people feel like they need to post their political views on HN. Not good IMHO.
In the US there are many community health centers. NYC alone takes care of 450,000 people without any insurance at all through CHCs and other sources. The very poorest generally have Medicaid in NY State, so the uninsured might be people like waiters. At any rate, there are community health centers throughout the country.
One issue that I have with the Obama Affordable Care Act is that they should have put much, much more money into the CHCs.
This country is still suffering from slavery and racism. We would have had socialized healthcare in 1948 were it not for the fucking asshole racists who didn't want to desegregate the hospitals.
Our basketcase of a healthcare system kills 45,000 people per year. That's a 9/11 every 24 days. It's inexcusable.
I do hope someday to move back to the USA (mix of language / "feels like home"), and am mildly hopeful that PPACA will make it feasible, by 2014, for an individual to buy private health insurance without worrying about preexisting conditions and rescissions and whatnot. But we'll see. For now, Danish is growing on me. :P
Incidentally, this kind of emergency care would be free even for a tourist in Denmark. Regular use of the national health system is only available to legal residents, but acute emergency care is considered a basic service not subject to billing, like police and fire response.