American Health Insurance Is Upside Down

Writing in The Week, Ryan Cooper shares a chilling story about an Obamacare Gold-level health insurance policy that let its beneficiary down when he needed it most:

Stewart is 29 years old, and was pursuing his Ph.D in American history at Texas Christian University until ill health forced him to withdraw. He lives in Ft. Worth, Texas, with his wife of six years, who is a junior high school teacher in a low-income district. They own their home. Before he came down with complications from cirrhosis caused by autoimmune hepatitis, he says he led a scrupulously healthy lifestyle — he does not drink or do any other non-medical drugs, he says, and was a devoted hiker before disaster struck. And he was insured — indeed, he had a gold plan from the ObamaCare exchanges, the second-best level of plan that you can get.

But now he faces imminent bankruptcy and possibly death.

(Ryan Cooper, “This is How American Health Care Kills People,” The Week, January 14, 2017.)

This exactly the type of catastrophic illness for which insurance should pay. Why does it not? Liver failure is not usually associated with people who live healthy lifestyles – quite the opposite. However, other than a small variation in premium for tobacco use, insurers are forbidden from “discriminating” against those who abuse drugs or alcohol in favor of those who are struck with liver disease for other reasons. (Although not described in the article, this may be a genetic predisposition).

So, insurers do the best they can to limit benefits for liver disease, despite legal and regulatory attempts to prevent them from doing so. Why are laws and regulations not very effective at addressing this perverse outcome?

The proportion of people in circumstances like Stewart’s is very small, not really a powerful political constituency. Instead of allowing a market for health insurance that indemnifies beneficiaries from financially catastrophic costs, politicians prefer to promise citizens “free” benefits which most citizens expect to use relatively constantly. Instead of hard data on health outcomes for expensive and deadly diseases, research produced in support of the health benefits of Medicaid tends to report increased access to dentists and vaccinations, which is self-reported by dependents in telephone surveys.

As long as we allow politicians to design health insurance, the sickest patients will suffer most.

Comments (50)

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  1. Lee Benham says:

    This first thing I thought of when the Country decided to go to guarantee issue was how insurance companies would mitigate risk.

    Let’s assume an insured has a standard BCBS plan. The insured comes down with the illness you described.

    What can BCBS do to mitigate claims?

    1.Use very poor customer service to frustrate the client.

    2.During the next open enrolment have employee (wink-Wink) call client and switch them to another carrier.

    Here is the script: Hello Mr.________ this is so and so from BCBS. We have been monitoring your health status and we are always on the lookout for ways our clients can improve their coverage choices. We are now in open enrolment so you can choose any plan you would like without evidence of insurability. From your claims history it appears that the Aetna plan through the exchange would be a better option for you than your current plan. Would you like me to get you set up on that plan?

    Insurance companies would never do anything like this would they?

    • Ron Greiner says:

      If that call saves the insurance company $400,000 they are going to have someone make that call. If the person is good they should be able to switch several sick people to other insurance companies a day.

      If it’s a sick Medicaid person they will just send them a termination notice.

      John would say that the sick should be able to switch companies as long as they have had his magical “continuous coverage”, his silver bullet.

  2. Barry Carol says:

    Risk adjustment, reinsurance and risk corridors can all help to protect insurers from extraordinarily high claims and thus increase their incentive or at least reduce their disincentive to provide coverage to people who need it the most. Unfortunately, republicans in congress view all three of those types of payments as nothing more than a bailout for insurance companies. They’re wrong.

    • John Fembup says:

      Before anyone had ever heard of Barack Obama, insurance companies had been participating in private reinsurance treaties among themselves that mitigated catastrophic risks by pooling them above some agreed-to level among the companies.

    • Ron Greiner says:

      Barry, read the story again. This Texan didn’t spend the high price for his wife’s employer insurance, the school district’s high cost. Here in Tampa it is $728 a month to add a spouse to the school’s insurance. The HMO on the Obamacare EXCHANGE was cheaper. So he got the dangerous HMO and then got sick and is now going to die.

      The Democrats passed Obamacare without one Republican vote and now you blame Republicans that Obamacare’s Gold Plan, with unlimited lifetime maximums, is killing this cattle herder.

      Barry, deadly Obamacare is the result of Democrats.

    • Allan says:

      The design of the ACA that you supported led to the problem described above. Instead of insurance you are looking for redistribution of wealth. Reinsurance is common in the free marketplace. Instead of using reinsurance for the problem above the ACA focused on redistribution which only made the problem worse. The ACA functioned to protect the so called known high risk patient, but when it came down to the unknown high risk patient (much greater number) the ACA failed, yet you continue to look for the same solutions. Risk corridors are an added confusion that never end because once they do the insurer’s are less likely to insure risk at the same price.

      You blame Republicans, but it was the Democrats and non Democrats that supported this bill that leads to such disasters. You keep telling us how others are wrong, but you were told the reasons the ACA was wrong before it was passed and you refused to recognize those reasons. When are you going to learn?

  3. Bob Hertz says:

    The insurance situation is awful enough, but one thing that would help would be federal regulation of hospital charges for clear emergencies.

    Hospitals should be limited to charging about 125% of Medicare. The charge of $73,000 for 2 days in the ICU is clearly abusive.

    Here is a super-brief survey of some early legislative attempts to deal with this problem…

    “Some states have already acted to protect their residents. California enacted legislation protecting patients who receive out-of-network non-emergency care at an in-network facility. Under the legislation signed by Governor Brown, health plans would pay non-network physicians the plan’s average contracted rate or 125 percent of the Medicare rate, whichever is greater. Californians were already protected from balance billing in emergency situations. Florida passed similar legislation in 2016, which prohibits billing for out-of-network charges for emergency services and billing for out-of-network charges when the services were provided at an in-network facility and the patient did not have a choice of an in-network provider.

    In New Jersey, Assembly Bill No. 1952, which is intended to protect consumers from surprise medical bills, is now under consideration. The proposed legislation places limits on out-of-network charges when emergency services are provided or the out-of-network services are “inadvertent.” Inadvertent services are defined as services that arise when an individual utilizes an in-network facility for covered services and in-network services are not available.”

    This is from Health Affairs Blog.

    One quick note: I do not think we can blame this situation wholly on the ACA. I read numerous HMO horror stories 20 years ago when there was no ACA at all.

    Actually I think that the feds should regulate hospitals and insurers much more. The Obama crew was
    so grateful to expand coverage that they did nothing to restrain the worst kinds of billing abuses.

  4. Lee Benham says:

    Unfortunately Bob the free market will always be one two or even 10 steps ahead of the politicians who think they can regulate business. How did Florida hospitals react to the legislation? By enacting a Cover charge to access their services. Some times as much as $33,000 per occurrence.
    http://www.tampabay.com/news/health/how-hca-turned-trauma-into-a-money-maker/2169280?utm_source=twitterfeed&utm_medium=twitter

  5. Barry Carol says:

    Payers, including the Blues, should negotiate their reimbursement rates as a percentage of Medicare instead of a percentage of some ludicrous list price which can be raised at will to close to infinity by price gouging hospitals that apparently have unlimited greed on the billing side of their operation. For emergency care, I think 125% of Medicare is reasonable.

  6. Bob Hertz says:

    One should ask why the Florida Attorney General is not after the hospitals for their trauma charges. Every state I believe has anti-price gouging laws on the books already, plus anti-trust statutes.

    The problem in part is that the victims of hospital greed are sad isolated individuals. A well-insured state or federal employee almost never has this happen to them.

    Here is an article on point from an editor of the conservative National Review….

    http://www.slate.com/articles/news_and_politics/politics/2015/03/america_s_hospitals_our_system_lets_big_hospitals_charge_exorbitant_prices.html

    • Allan says:

      There is no question in my mind that hospitals are being compensated inappropriately, but the reasons behind such compensation are political and frequently based upon Liberal policies, not conservative or libertarian policies. An additional reason is that politicians on both sides react to big money that all federal departments have floating around.

      From the article you cited “America’s hospitals have become predatory monopolies”. What has the left done? It has incentivized consolidation and monopoly formations. He continues: “To protect these families, many people want the government to pick up a bigger share of our hospital bills. But this just shifts the burden from employers to taxpayers.” In other words our Liberal politicians didn’t solve the problem, they exacerbated it.

      He makes a controversial statement which is true, but poorly interpreted by Liberal minds. As an aside take note of “some [countries like Switzerland) that rely a bit more on private insurance markets than ours”

      “ When you survey the health systems of other rich countries, you’ll find some that rely a bit more on private insurance markets than ours (like Switzerland) and others that rely a bit more on centralized bureaucracies (like Britain), but what you won’t find is a country where hospitals dare to charge such obscenely high prices.”

      What is the problem? Socialism. “ In a competitive market, a provider who jacks up prices risks losing customers to competitors who charge less.” Political muscle is a problem because it can buy its way out of socialistic regulation. He adds “ If you’re not saving money by shopping around for a better deal, … you might as well go to the hospital closest to you.”

      “Yet from 1998 to 2012, the 5,000 or so hospitals in the United States saw 1,133 mergers and acquisitions. The bigger, more dominant you are in a local market, the more you can extract from private insurers and taxpayers.” Barry is one of those that continuously supports such blind consolidation so I will note a later entry in the article, “ we need smaller, more efficient competitors to keep the big hospitals in check and to drive down medical costs for society as a whole.”

      “For example, as Margot Sanger-Katz has reported in the New York Times, hospitals have been buying up doctors’ offices, because doing so allows the exact same offices to charge Medicare higher prices for performing the exact same services, because the government has decided that hospital-based care is intrinsically more expensive than office care.”

      “Curbing the power of the big hospitals isn’t a left-wing or a right-wing issue.”

      Bob, I thought this would be another trashy article we so frequently see, but this is an excellent article and I thank you for providing it for us.

      • Barry Carol says:

        Actually, I don’t support consolidation on the hospital side as there are few economies of scale to reduce costs but plenty of opportunity to enhance market power in order to extract higher prices from payers. I do support consolidation on the insurer side because technology and scale matter more there and there is also more opportunity to work with providers to develop more efficient ways to manage care, especially for the highest utilizers of care. Also, as providers have fewer payers to deal with, there administrative burden should shrink as well.

        • Barry Carol says:

          Correction: their administration burden should shrink, not there…

        • Allan says:

          You have supported the ACA, ACO’s, consolidation, price controls and policy that prevents innovation and new entries into the marketplace etc.

          “I do support consolidation on the insurer side because technology and scale matter more there.”

          That is true only to a point and the numbers needed are relatively small. That by itself forces consolidation of the medical community which incentivizes consolidation by the hospital corporations. You also want singular control over the patient population mandating them to buy only those health delivery products you find appealing.

  7. Barry Carol says:

    I often say only half in jest that when hospitals aren’t killing us with infections, they’re killing us financially. They have a lot to answer for on the pricing and billing side.

  8. Barry Carol says:

    The numbers needed on the insurance side are not small if they are to negotiate satisfactory reimbursement rates with providers, especially hospitals.

    • Allan says:

      What you are creating is a war. Who can be the biggest and who can consolidate the most? That is great. You can essentially end up with 2 monopolies that are too big to fail and scr-w patients and taxpayers.

      Size can create all types of inefficiencies, but you will see to it that government hides those inefficiencies and hides the costs from the public.

  9. Bob Hertz says:

    Two quick points:

    1. I mentioned that attorneys general could be suing hospitals for price gouging.

    Here is a description of additional court cases that could be cited in such lawsuits…..

    http://blogs.harvard.edu/billofhealth/2013/06/25/the-tylenol-debate-can-hospitals-be-sued-for-excessive-markups-on-medications-and-devices

    2. As to the success of Switzerland’s health insurance system:

    In this country a hefty portion of hospital operating expenses is covered by taxes….

    “Switzerland has 186 public and 128 private hospitals (BFS 2010). Hospitals’ operational and investment costs are co-financed by cantonal taxes (55 %) and health insurance premiums (45 %). Hospital financing will translate from per diem to DRG payment by 2012. Cantons are responsible for hospital planning and control. Cantons are setting up hospital lists including public and private hospitals based on a health service performance mandate.”

    In other words, private insurance payments do not need to cover all of a hospital’s costs. This keeps insurance premiums lower but taxes are higher, I suspect.

    • Barry Carol says:

      The taxpayer financing that hospitals in Switzerland receive also makes it possible for them to charge significantly lower prices than they would have to charge if all of their revenue came from insurance payments and patient copayments / deductibles.

  10. Allan says:

    1) “attorneys general could be suing hospitals for price gouging.”

    First you have to be able to define price gouging. Whatever definition you decide to use, making a claim of price gouging will be opinion based where price is not the sole determinant factor.

    You cited a blog where I found a most interesting thing in one of the comments by an individual who seems to be an attorney.

    “The problem is that an individual patient’s charges are rarely high enough to justify an attorney taking the case on a contingent fee basis.”

    In part this is telling you why third party payment is so devastating to healthcare and so costly. The person receiving the care doesn’t have much of a stake in the bill. If third party was not virtually mandated by the favorable tax laws to employers the patient would bargain with the insurer forcing the insurer to keep these prices down.

    2) Switzerland: Take note that according to your recent article from Slate the author writes that some countries rely more upon private insurance markets than ours, Switzerland being one of them. That too points to the freer market as a method of keeping costs down.

    I note that whenever one points to another country to show how their ‘centralized care’ is better than ours they point to the socialistic ideas that seem to make certain things appear better. What they fail to do is to point to the freemaket items being used along with a lot of other variables. Then they draw erroneous conclusions.

    • Barry Carol says:

      One of the big problems in medicine, especially hospital based care, is that there doesn’t seem to be any consensus on how to even define quality, let alone judge how good the care is regardless of whether a third party or the individual patient is paying the bill. It’s not just about how good the doctors are but how well the hospital prevents infections, how diligent the nurses and other patient facing staff are, whether or not the place is adequately staffed, among other things. An independent organization similar to Consumer Reports that could help to provide such information would be enormously helpful.

      • Allan says:

        It’s very hard to differentiate things like quality that have so many variables where so many of the players are in middle relatively close together though portions of their care might swing more radically. Frequently we can figure out the outliers both good and bad.

        Consumers Reports developed in a free marketplace. We don’t have one and haven’t had a totally free one in almost 75 years. I’m not sure what existed before. If you want government to create a Consumer Reports then be prepared for that report to serve government interests not yours. That is the problem when government becomes a player instead of watching out for the people.

        • Ron Greiner says:

          Allan, Consumer Reports funds Consumers Union who is a radical left wing fruitcakes. Look what they said about tax-free MSAs in 1998:

          Consumers Union: Expanding Medical Savings Accounts a “Poison Pill”

          WASHINGTON – The GOP plan to balloon the failed Medical Savings Account (MSA) experiment is a poison pill designed to kill the Patients Bill of Rights, according to Gail Shearer, Director of Health Policy Analysis at the Washington Office of Consumers Union.

          “It is time to recognize Medical Savings Account’s for what they are – a marketplace flop, a mechanism that drains the Treasury and benefits the health at the expense of the sick,” Shearer told a public forum hosted by the House Democratic Working Group on Wednesday. “We strongly urge the Congress to remove poison pills such as expanded Medical Savings Accounts from legislation that is designed to improve the quality of health care provided through managed care.”

          I don’t trust Consumer Report’s brainwashing

          http://flfedleg.tripod.com/crmsa.html

          • Allan says:

            Ron, Consumer Reports is leftist, but one has to learn how to read the information that comes from various sources. I sent a letter to them explaining why their article on HMO’s (I think the first one) was so wrong. I didn’t expect anything from them because the writers have ideologies that usurp their intellectual abilities. The same thing occurs at politifact and other so called commenters on fact or fiction. We have to live with a bit of idiocy everywhere.

    • Bob Hertz says:

      Allan, my point about partial taxpayer funding for Swiss hospitals was this:

      If an American goes to a French or Swiss hospital and is charged $350 for something that costs $7,000 in the USA,
      (and this does happen, at least I read about periodically), this is NOT because these nations have used free markets to reduce medical costs.

      This occurs because these nations use coercive taxes to cover a part (and not a small part) of each hospital’s budget.

      It is like you or I getting the fire department to bring terrific equipment and personnel to our home as needed, and all we pay is a user fee of $250. This is thanks to taxes, not due to free market fire insurance.

      • Allan says:

        There was a lot more to what you said and I responded to those points even in agreement with the expert you wished us to refer to. You should listen to your own expert.

        Understand one thing, taxpayer funding of anything doesn’t reduce the cost. The cost is just paid for differently. We have cost problems and they are created by things like moral hazard that can mostly be corrected with a freer marketplace. We are not Switzerland. We are a much more diverse and less accepting population. Travel to Switzerland and see how expensive it is to live there. If the Swiss taxpayer had to pay the costs of $7,000 instead of $350 there would be a revolt. Then try to imigrate there. They won’t permit you. The Swiss are dealing with a much simpler environment but even with that simpler environment they have had problems and costs are rising.

  11. Bob Hertz says:

    When it comes to hospital care in the ER, I would define price gouging as any charge in excess of:

    a) $1,500 a day; plus

    b) the cost of diagnostic tests, as if they were performed by an independent free-standing lab;

    c) the cost of drugs and equipment as though they were purchased retail from online pharmacies.

    The price-gouging line would be different for a full admission and for intensive care.

    Hospitals might complain that these price levels will make them insolvent. At this point, I have built up a lot of hatred for hospital billing practices, and I am the wrong person to ask if I care.

    (I ran a small business as an advocate for persons wanting help with medical bills.)

  12. Allan says:

    How do you derive the magical figure of $1,500 per day? There are patients that must remain in a room with little active treatment for a number of days. Those days are at almost no cost. Yet, there are others that can generate huge bills that are reasonable. At $1,500 per day the former might well be gouging while the latter might not even recoup its costs.

    Drugs: The cost of the first pill can be tremendously higher in a hospital than the cost of the pills that follow. The cost for a Walgreens is much less since much of the cost has already been paid for.

  13. Bart I says:

    I don’t know if gouging applies to the original story above, considering is involves surgeries and an ICU stay. I suspect the hospital is already giving him a cash price, since the bill is less than six figures.

    The basic problem here is the ACA loophole. The fact that it’s there means that insurers have a strong incentive to exploit it in order to remain competitive.

    I guess it’s time to check the out-of-network copay limits for my own ESI coverage.

    • Allan says:

      I think price gouging is all too frequently a poor description of something that is happening. It is all too frequently a misperception of the person uttering the term who is too emotionally involved with the problem at hand. Sometimes the appearance of gouging merely means the marketplace is quickly addressing the problems of a severe shortage.

  14. Bob Hertz says:

    Bart and Allan, the article described a bill of $73,000 for two days of care.

    I have an admittedly quaint notion that the charge for a service must have some connection to the labor, land, and raw materials required to perform the service.

    So if an auto mechanic bills you $1,200, he would be expected to show that he spend 7 hours under the hood and bought parts that have a retail price that adds up.

    I know that it takes more capital to open up and staff a hospital than it does to build a Midas Muffler shop. A hospital does have fixed costs to recover.

    I have spent a nite in an ICU ward, and I know that 2-4 people had virtually nothing but me in mind. I realize that this has a non-trivial cost, maybe $1,200?

    I know too that surgeons must be paid, and they have precious skills, so they may deserve $5,000.

    It just cannot add up to $73,000 in my mind.

    • Bart I says:

      Bob, I can’t say that you’re wrong. It’s just that my main concern was that regardless of the charges, there should have been some sort of mechanism for maintaining out-of-pocket limits for what clearly looks like emergency care.

      This can’t be a new situation. How would a decent group plan have handled this?

      • Bob Hertz says:

        I cannot answer your question precisely on group plans.

        However, the state of California passed a law almost 10 years ago that protected a wide swath of taxpayers from ER price gouging.

        And there were large successful lawsuits against hospitals, which preceeded this law.

        https://en.wikipedia.org/wiki/California_Uninsured_Patient_Hospital_Pricing_Litigation

        Going from memory, this law might have prevented the sad case in the initial article that we are responding to these posting.

        In general, if all of America had the medical consumer protection laws of CA, IL, NY, MN, the public would be better off. These states may be off track in other areas, but on protecting patients they are dead right.

  15. Allan says:

    Bob, your quaint notion has to include a lot of knowledge about costs and actual payments. I don’t think you have the information to draw a conclusion of greed. However, even on that score I believe you to be wrong because an intense desire or even a selfish desire for wealth is not necessarily bad for society. In fact it might be good for society.

    What we should be looking for is ill gotten gains no matter what the value or how rich the individual is. I don’t hear much of that in your greed comments. Things become rotten when you are forced to pay someone a fee that is higher because the government madated it or someone broke the law. If you aren’t forced then it is a consual agreement.

  16. Bob Hertz says:

    Are you implying that an ER patient or a stage four cancer patient is not being forced to pay what he is billed?

    I come back to the concept of ‘desperate exchanges,” or what might be called ‘Trades of last resot.’

    These are not free market transactions. True they are not naked coercion, but close enough to be regulated, in my view.

    • Allan says:

      There are certain contracts that are considered void.

      One of the two main reasons people carry insurance is to pay for care they can’t afford. But, we also have laws that force emergency care whether the patient can pay or not.

      Bob, don’t you think people should pay for things they receive?

  17. Bob Hertz says:

    Actually, I would rather have emergency care as a tax-funded public function, not unlike fire and police.

    We all pay a little in taxes, so that the service is there when we need it, and no one pays a huge amount.

    You do not need fire insurance to call the fire department, and you certainly do not need a lawyer to contest a $25,000 bill from the fire department.

    Firs departments are effectively socialized in about 98% of American communities, and I do not think this has corrupted us.

    I realize that my change would have to be done with care. Where does emergency care end and regular hospital care begin? If I am admitted with chest pains and that is free to me, what happens if the doctor decides I must have bypass surgery right away, and then must stay 2 weeks in the hospital? Is that free also?

    I do not have a precise answer. But I wanted to answer your question, which was a reasonable one.

    • Ron Greiner says:

      Bob, any problem for you can be cured with Socialism. Hey, my heart attack is an emergency so the government should pay so start raising taxes on young people pronto.

      Bob, move to Cuba and buy yourself a 1956 Chevy.

    • Allan says:

      “I would rather have emergency care as a tax-funded public function, not unlike fire and police. ”

      That is understandable, but how do you prevent the ER from being used for non ER care? The question at hand was “don’t you think people should pay for things they receive?” Today people in need must be treated in the ER whether they pay or not,

      • Ron Greiner says:

        Allan, the NCPA blog has been over run with Socialists. Now we hear Medicare for all. Cruz debated Sanders on Monday night and Cruz is so uninformed that he didn’t say — Medicare only pays 80% so many couples are paying $500 a month for a Medicare supplement. How much would a Medicare supplement cost for a family of 4 — $1,000 a month?

        This blog refuses to discuss the advantages of Republican Reform, it is sad.

        I think the tax credits should be $1,000 for people 20-years-old then increase the credit $100 a year till Medicare eligibility. A 30-year-old would get $2,000, a 40-year-old would get $3,000, a 50-year-old would get $4,000, and a 60-year-old would get $5,000.

        Rand Paul wants $5,000 for any age so my way is a lot cheaper plus Rand wants unlimited HSA deposits which would let professional football players and MDs deposit $10 million a year. I say raise HSA deposits to $5,000 for a single and $10,000 for a family.

        Of course Cruz would learn NOTHING if he read the NCPA blog.

        • Bart I says:

          Ron, it’s funny you can call someone else a socialist when you advocate giving $1000 and up free money to healthy people who should be able to find their own insurance.

          You’re essentially saying that you think everyone is entitled to free health care.

  18. Bob Hertz says:

    Well, I did not expect a warm reception for this idea of mine, but I am not ashamed of it.

    I believe first in the Golden Rule. I want my neighbor or his child to get treated if they break a leg, regardless of the state of their bank account or insurance….and I want the same for myself and my family. A publicly funded emergency medicine system does this.

    (I have seen first hand in relatives the difference between fully-insured treatment of broken bones vs. minimal treatment.)

    Secondly, I believe that medicine should be whenever possible a gift relationship. I was born in a hospital which had nuns as nurses and very low fees…that is fine.
    We cannot run every single medical facility as a charity, but the more the better in my view.

    Finally, Ron, if we fund public health through some form of income taxes, the burden is not on the young. The richer elderly and near-elderly probably pay a near-majority of income taxes.

    • Barry Carol says:

      Bob — I know that your heart is in the right place. The problem, though, isn’t so much financing as how to define an emergency. If I go to the hospital with chest pain and it turns out to be indigestion, in retrospect, it wasn’t an emergency. Should I have to pay for treatment out-of-pocket then if I don’t have insurance? Or suppose it is an emergency and I need bypass surgery but not immediately. Next week will do. Should publicly funded emergency care pay for that too? What about post-op rehab, if it’s needed? What if the publicly funded emergency system is just required to treat everyone whether it’s an actual emergency or not? Everyone will just go to the ER without an appointment knowing that their care will be provided at taxpayer expense there rather than their own expense or an insurer’s expense at a doctor’s office or clinic.

      How to cover everyone with insurance and how to pay for it are separate issues. Yes, I know that providing insurance to someone who is already sick isn’t really insurance. It’s medical welfare or charity or having someone else pay your medical bills but it’s what we would need to do at least at the start of any new ACA replacement system. We could permanently charge more for people who don’t sign up as soon as they’re eligible for coverage which is what Medicare does. The longer they delay, the more they pay. I think that’s a reasonable approach.

    • Allan says:

      Bob there is nothing wrong in what you believe and what you want rather many things enter the picture and make many of your actions a very poor choice.

    • Allan says:

      “I believe first in the Golden Rule. I want my neighbor or his child to get treated if they break a leg, regardless of the state of their bank account or insurance”

      WE all do, but if you feel so strongly you and your friends could pay for that broken leg. That by the way is what one does if they follow the Golden Rule. The Golden Rule doesn’t tell you to take that money from someone else.

      The one with a broken leg should have carried insurance, but if he didn’t his broken leg will be fixed at the hospital whether or not he pays.

      The question is how does he pay the least and get the most? A free marketplace.

      • Bob Hertz says:

        Alan, what you are saying is that if we just let people be uninsured, kind of back to the 50’s, the American people will come up with enough charity so that hospitals can take of the uninsured in a semi-reasonable manner.

        You may be right, especially for prosperous communities. I remember reading that Parkland Hospital in Dallas provide a huge amount of care for the uninsured, and Texas has fewer mandates than almost anywhere.

        I am a little troubled by the fact that charity is uneven. If you are uninsured and break your leg, the ambulance may take you to a hospital that bills the heck out of you and sics lawyers on you to collect every nickel. (some of the hospitals which do this are ostensibly charitable, with names like Sisters of Mercy….see Stephen Brill on this.)

        So I would like to see some limits on your ER bill, in case charity is a little slow this month.

  19. John Fembup says:

    Bob, you say “I believe that medicine should be whenever possible a gift relationship. I was born in a hospital which had nuns as nurses and very low fees…that is fine. We cannot run every single medical facility as a charity, but the more the better in my view.”

    In other words, your “gift” is to confiscate the labor of some people (nuns, doctors) and distribute the proceeds to suit other people – yourself included. If the nuns and doctors will voluntarily work for less than their skills are worth (“charity”) that’s “fine” with you but, even if they won’t, it’s also fine with you for the government to step in and oblige medical staff to accept a level of compensation you deem appropriate. And the more of such “gifts” the better in your view.

    I say this only to clarify your remark, not to persuade you.

  20. Bob Hertz says:

    I would not protest against a flat fee of $150 or $200 to use the emergency room. That would keep out many of the freeloaders that Barry refers to.

    Another option would be to require health insurance policies to have a $150-$200 copay for ER use and no further exposure.
    (The more expensive plans have this already, but this feature is usually tossed overboard when cutting the premium is paramount.)

    I would not seek to dictate the compensation of ER personnel. In fact, the compensation of fire and police emloyees is above average in most cities, and in a few cases is so high (with lavish pensions) that it threatens to make the service unaffordable to the public. Wage suppression does not seem a problem.

    • Allan says:

      What you see with fire service is magnified at the federal level. You have just demonstrated why your preferred way of managing healthcare costs doesn’t work as costs go up.

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